In a recent Special Edition MLN Matters Article (SE1217), CMS reminded providers of their responsibilities under the Medicare Secondary Payer (MSP) Rules. Under the MSP Rules, Medicare is secondary to certain other payers in the following circumstances:
- Workers’ compensation (WC) plans, for employment-related injuries or diseases
- No fault (NF) insurance, if available, for non-employment related injuries, regardless of whether the insurance plan stipulates it is secondary to Medicare
- Third party liability (L) insurance (e.g., med pay) or self-insurance plans for covered illnesses or injuries
- Employer group health plans (GHPs) of employers with at least 20 employees, for employees who have Medicare by reason of age and are covered under that GHP based on their, or a spouse’s, current employment with that employer
- GHPs of employers with at least 100 employees, for employees who have Medicare by reason of disability and are covered under that GHP based on their, or another family member’s, current employment with that employer
- GHPs during the 30-month coordination of benefits period, for employees who have end stage renal disease (ESRD), and are either entitled to Medicare initially based on ESRD; or by reason of age or disability
- Government research programs, for services that are part of the research program
- The Department of Veterans’ Affairs, for services they authorize at a non-VA facility
Under the MSP Rules, the primary responsibility of providers is to determine whether other coverage is available for each visit or admission and, if so, whether Medicare is primary or secondary to that other coverage. The model hospital admissions questionnaire, published by the CMS, may be used as a guide to collect this information from beneficiaries. This tool is available online in the Medicare Secondary Payer Manual (100-05), Chapter 3, Section 20.2.1. This questionnaire may also be used by physicians and suppliers to gather relevant MSP information.
Once these coverage determinations are made, providers should first bill the primary payer for related services. If a payer other than Medicare is primary, providers may bill Medicare as the secondary payer (if appropriate) after receiving the primary payer remittance advice. If a patient is seen for multiple services, each service should be billed first to the primary payer, and then to any secondary payers, as appropriate.
When billing services subject to the MSP Rules, providers (hospitals, in particular) should be sure to report applicable MSP-related information using situation specific codes (primarily condition, occurrence and value codes) on the UB-04 and 837I claims formats.
CMS provided the following specific tips on billing for accident-related claims when a beneficiary has open MSP WC, NF, or L coverage and/or open GHP MSP coverage.
- Providers should bill the WC, NF, or L, as primary insurer, first for related services. If the insurer denies the claim, then bill Medicare for payment, including all necessary MSP payment information, as found on the primary payer’s remittance advice (e.g., claim adjustment reason code specifying reason for denial), on the claim sent to Medicare. If the L, NF, or WC insurer did not make payment for the accident related services, Medicare will need this information to process the claim accordingly. If Providers follow these procedures, they do not need to wait 120 days to submit a claim to Medicare for payment.
- If the beneficiary has both GHP MSP coverage and WC, NF, or L coverage, providers are required to submit a claim to the GHP insurer and the WC, NF, or L insurer before submitting the claim to Medicare. Once they receive the GHP remittance advice, they should include the GHP information along with the remittance advice information from the WC, NF, or L insurer with the claim to Medicare. If the claim is sent to Medicare without the GHP information, and there is an open GHP MSP record on file, Medicare will deny the claim.
- In situations where there is no WC, NF, or L accident or injury, but the beneficiary has employer GHP coverage that is primary to Medicare, providers must submit the claim to the GHP insurer first before submitting the claim to Medicare for secondary payment.
CMS offered additional guidance about what providers should do if they believe a claim was improperly denied. They also encouraged providers to contact the Coordination of Benefits Contractor at 1-800-999-1118 to update a beneficiary’s MSP record.
If you have any additional questions that remain unanswered after reviewing the MLN Article, check the Medicare Secondary Payer Manual (100-05), which is available from the CMS website.