Medicare Secondary Payer
These slides cover how to complete the Medicare Secondary Payer portion of the CMS-1450 and 837I forms.
Medicare Secondary Payer Data Elements
In Medicare Secondary Payer (MSP) claims situations, CMS requires you to report certain data elements when applicable. These data elements include:
- Condition codes related to MSP
- Occurrence codes and dates related to MSP Value codes and amounts related to MSP
- Insured’s name for primary payer information
- Patient relationship to insured
- Employment status code for working aged, ESRD, or disability
- Employer name for WC, working aged, ESRD, or disability
- Employer location for WC, working aged, ESRD, or disability
- Primary payer information
- Applicable claim level and line level adjustments
For more details on MSP billing requirements, visit the Medicare Secondary Payer Manual.
When Medicare is the Secondary or Tertiary Payer
When you list Medicare as the secondary or tertiary payer in FL 50 A-C, MSP rules apply. MSP provisions apply to situations when Medicare isn't the patient's primary health insurance coverage. These provisions ensure that Medicare doesn't pay for services and items that another insurer is primarily responsible for paying.
For more information, reference:
- Medicare Secondary Payer booklet
- Medicare Secondary Payer (MSP) Computer Based Training (CBT) Curriculum
- Medicare Secondary Payer webpage for MSP laws and CMS data collection on insurance primary to Medicare
- Medicare Secondary Payer: Don’t Deny Services & Bill Correctly fact sheet
Note: Group Health Plan Recovery and Non-Group Health Plan Recovery are now separate and have their own webpages.
- The provider must first submit the claim to the primary payer
- The primary payer must process and make primary payment on the claim under the coverage provisions of its contract, including:
- MSP statutory laws
- Regulations
- Policy
- Operational instructions
- The primary payer can’t decline to make primary payment on the grounds that its contract calls for Medicare to pay first
- If the primary payer processes the claim and doesn’t pay in full for the services, Medicare may pay secondary benefits for those services as prescribed in the Medicare Secondary Payer Manual
Medicare Secondary Payer Priority
Payers that may pay primary to Medicare include:
- Group Health Plans for employed patients and spouses aged 65 or over
- Group Health Plans for patients entitled to benefits solely on the basis of ESRD during a period of up to 30 months
- Large Group Health Plans (LGHPs) for disabled patients
- An auto-medical, no-fault, or liability insurer
- WC including Black Lung (BL)
For rules on submitting MSP claims for inpatient services, MSP claims for outpatient bills, Part B Inpatient Services, and HHA bills, review the Medicare Secondary Payer Manual, Chapter 3.
Medicare Secondary Payer Payment
- Another payer pays some of the charges and Medicare is secondarily liable for the rest
- Another payer denies the claim
- You’re requesting conditional payment for an accident- or injury-related service when the accident-related insurer won’t make a prompt payment
Enter the name of the person who has coverage through the insurance. If that person is the patient, enter Patient.
- You can’t accept any copayment, coinsurance, or other payment from the patient when you render services
- You must follow the MSP rules and bill Medicare as the secondary payer after the primary payer has made payment
After Medicare makes its payment, we'll tell you on the remittance advice how much, if anything, you can collect from the patient.
Conditional Payments
Providers of Part A services can request conditional non-group health plan (NGHP) payments by using the correct insurance value code (14, 15, or 47) and zero as the value amount only after you send the claim to the no-fault, liability, or workers' compensation insurer first and the payer doesn’t make a payment. But if a group health plan (GHP) is a payer, you must also send the accident claim to the GHP insurer first.
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