Last Modified: 2/5/2010
Location: FL, PR, USVI
Business: Part A
Medicare secondary payer (MSP) indicated on claim, no direct match on auxiliary record iteration, or if there is a match and the originating contractor is coordination of benefits contractor (COBC) and the incoming claim has a cost avoid 'X'.
Frequently identified issues:
• Billed with insurance codes other than auto, with auto accident occurrence code present on the claim.
• Billed as disabled ‘G’ payer identification (ID), value code 43 with BENE REL (beneficiary relationship) 01, Beneficiary is under age 65, Medicare should be billed as primary.
• Common working file (CWF) has termed the MSP file prior to the claim dates of service.
• CWF reflects end stage renal disease (ESRD) MSP file effective and term dates outside of claim dates of service. The intermediary is unable to resolve MSP conflicting information.
Providers should review the payer ID and value and occurrence codes.
Tips
Verify if Medicare is primary or secondary prior to submitting your claims. There are several ways to obtain this information:
• Ask the beneficiary if his or her spouse is currently working and has insurance through their employer.
• If the answer is yes, the claim must be submitted to the employer group health plan first.
• If the answer is no, the beneficiary and/or the provider will need to contact the Coordination of Benefits Contractor (COBC) at 1-800-999-1118 (Monday-Friday from 8:00 AM to 8:00 PM, ET) to have the file updated. Once the file is updated, the claim can be re-submitted to Medicare as primary.
• Direct data entry (DDE) users can access eligibility information by using the ELGA (eligibility A) or HIQA (health insurance query A) screens.
• Verify eligibility by contacting the interactive voice response (IVR).
• 
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Source: FCSO Education Action Team
, sections 30, 40, and 50.
U6802