Your Billing Responsibilities
For Medicare programs to work effectively, providers have a significant responsibility for the collection and maintenance of patient information. They must ask questions to secure employment and insurance information. They have a responsibility to identify payers other than Medicare so that incorrect billing and overpayments are minimized. Providers must determine if Medicare is the primary or secondary payer; therefore, the beneficiary must be queried about other possible coverage that may be primary to Medicare. Failure to maintain a system of identifying other payers is viewed as a violation of the provider agreement with Medicare.
Responsibilities of Providers Under MSP
As a Part A institutional provider (i.e. hospitals), you should:
- Obtain billing information prior to providing hospital services. It is recommended that you use the CMS Questionnaire (available in the Downloads section below), or a questionnaire that asks similar types of questions; and
- Submit any MSP information to the intermediary using condition and occurrence codes on the claim.
As a Part B provider (i.e. physicians and suppliers), you should:
- Obtain billing information at the time the service is rendered. It is recommended that you use the CMS Questionnaire (available in the Downloads section below), or a questionnaire that asks similar types of questions; and
- Submit an Explanation of Benefits (EOB) form with all appropriate MSP information to the designated carrier. If submitting an electronic claim, provide the necessary fields, loops and segments needed to process an MSP claim.
The CMS Questionnaire should be used to determine the primary payer of the beneficiary’s claims. This questionnaire consists of six parts and lists questions to ask Medicare beneficiaries. For institutional providers, ask these questions during each inpatient or outpatient admission, with the exception of policies regarding Hospital Reference Lab Services, Recurring Outpatient Services, and Medicare+Choice Organization members. (Further information regarding these policies can be found in Chapter 3 of the MSP Online Manual.) Use this questionnaire as a guide to help identify other payers that may be primary to Medicare. Beginning with Part 1, ask the patient each question in sequence. Comply with all instructions that follow an answer. If the instructions direct you to go to another part, have the patient answer, in sequence, each question under the new part. Note: There may be situations where more than one insurer is primary to Medicare (e.g., Black Lung Program and Group Health Plan). Be sure to identify all possible insurers.
Note: There are programs under which payment for services is usually excluded from both primary and secondary Medicare benefits.
- Veteran’s Administration (VA) Benefits - Medicare does not pay for the same services covered by VA benefits. For further information about VA benefits, contact the VA Administration at 1-800-827-1000.
- Federal Black Lung Benefits - Medicare does not pay for services covered under the Federal Black Lung Program. However, if a Medicare-eligible patient has an illness or injury not related to black lung, the patient may submit a claim to Medicare. For further information, contact the Federal Black Lung Program at 1-800-638-7072.
Medicare is the Secondary Payer when Beneficiaries are:
- Treated for a work-related injury or illness. Medicare may pay conditionally for services received for a work-related illness or injury in cases where payment from the state workers’ compensation (WC) insurance is not expected within 120 days. This conditional payment is subject to recovery by Medicare after a WC settlement has been reached. If WC denies a claim or a portion of a claim, the claim can be filed with Medicare for consideration of payment.
- Treated for an illness or injury caused by an accident, and liability and/or no-fault insurance will cover the medical expenses as the primary payer.
- Covered under their own employer’s or a spouse’s employer’s group health plan (GHP).
- Disabled with coverage under a large group health plan (LGHP).
- Afflicted with permanent kidney failure (End-Stage Renal Disease) and are within the 30-month coordination period. See ESRD link in the Related Links section below for more information. Note: For more information on when Medicare is the Secondary Payer, click the Medicare Secondary Payer link in the Related Links section below.
MSP Retirement Date Policy
CMS developed an operational policy to help alleviate a major concern that hospitals have had regarding completion of the CMS Questionnaire.
During the intake process, what should be reported when a beneficiary cannot recall his/her precise retirement date or that of his/her spouse if formerly covered as a dependent under the spouse's group health plan (GHP)?
When a beneficiary cannot recall his/her retirement date, but knows it occurred prior to his/her Medicare entitlement dates, as shown on his/her Medicare card, hospitals report his/her Medicare Part A entitlement date as the date of retirement. If the beneficiary is a dependent under his/her spouse's group health insurance and the spouse retired prior to the beneficiary's Medicare Part A entitlement date, hospitals report the beneficiary's Medicare entitlement date as his/her retirement date. If the beneficiary worked beyond his/her Medicare Part A entitlement date, had coverage under a group health plan during that time, and cannot recall his/her precise date of retirement but the hospital determines it has been at least five years since the beneficiary retired, the hospital enters the retirement date as five years retrospective to the date of admission. (Example: Hospitals report the retirement date as January 4, 1998, if the date of admission is January 4, 2003)
As applicable, the same procedure holds for a spouse who had retired at least five years prior to the date of the beneficiary's hospital admission. If a beneficiary's (or spouse's, as applicable) retirement date occurred less than five years ago, the hospital must obtain the retirement date from appropriate informational sources; e.g., former employer or supplemental insurer.