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Last Modified: 2/11/2021 Location: FL, PR, USVI Business: Part A, Part B
The following questions originated from the "Medicare Secondary Payer (MSP) Educational Series." The questions are followed by the appropriate answer and the sources of the information are provided.

Medicare Secondary Payer (MSP) Educational Series -- Questions and Answers

Provider Outreach and Education (POE) A/B MAC Collaborative Events

The following questions originated from the above-listed event series. The questions are followed by the appropriate answer and the sources of the information are provided. For additional information or details about MSP claims, please refer to your contractor's MSP webpage.

General MSP Questions and Information

Part A only
1Q: If, prior to the hospital billing Medicare, a liability insurer settles and makes payment directly to the patient, do we still submit a claim as MSP? Will the claim deny for us to bill the patient for the allowed amount?
1A: Yes, the claim is still MSP. Once the claim is processed, beneficiary liability can then be determined.
Part B only
2Q: If a beneficiary only has Part A hospital coverage, do we have to bill Medicare if it is primary and the patient was seen in-office?
2A: No. If the beneficiary does not have Part B coverage, then a provider would not need to bill for an office visit unless you need the denial stating the beneficiary has no Part B coverage.
Parts A and B
3Q: What documentation is needed to correct the patient's date of death?
3A: Please contact the Social Security Administration external link for guidance.
4Q: A group health plan (GHP) pays primary and leaves a $100 copay, then Medicare as secondary pays $100 on the claim but indicates there is $185 patient deductible. Are we allowed to bill the patient for the unpaid Medicare deductible?
4A: Refer to the Medicare remittance advice notice for the final patient responsibility. However, if the provider has been paid the full Medicare allowed amount between the primary insurance and Medicare, there typically is no additional monies owed to the provider.

Automobile Insurance and MSP

Parts A and B
5Q: We have a patient who fell asleep at the wheel and hit a tree. She stated she did not want us to file a claim with her auto insurance. What should we do when a patient does not want us to bill their auto insurance, although the care they seek is related to the auto accident?
5A: If you know the claim is an MSP issue, providers are required to bill the primary insurance prior to submitting to Medicare.
Medicare regulations require all entities billing Medicare for services or items rendered to Medicare beneficiaries to determine whether Medicare is the primary payer for those services or items before submitting a claim to Medicare. When another insurer is identified as the primary payer, bill that insurer first.
For more information, refer to Medicare Learning Network® (MLN®) Matters Special Edition (SE) article SE1217 -- Guidance for Correct Claims Submission When Secondary Payers Are Involved external pdf file
6Q: Can a provider not bill Medicare and hold the balance on an attorney lien for car accident treatment?
6A: Yes, if state law permits this.
The MSP provisions do not create lien rights when those rights do not exist under state law. Where permitted by state law, a provider may file a lien for full charges against a beneficiary's liability settlement. The provider may enforce a permissible lien up to the lesser of the amount of the settlement and charges for the services incorporated in the lien. The provider may not charge interest, lien filing, or administrative fees to the beneficiary or against the lien.
Generally, providers must bill liability insurance prior to the expiration of the promptly period rather than bill Medicare. (The filing of an acceptable lien against a beneficiary's liability insurance settlement is considered billing the liability insurance.) Following expiration of the promptly period, or if demonstrated (e.g., a bill or claim that had been submitted but not paid) that liability insurance will not pay during the promptly period, a provider, physician, or other supplier may either:
Bill Medicare for payment and withdraw all claims/liens against the liability insurance/beneficiary's liability insurance settlement (liens may be maintained for services not covered by Medicare and for Medicare deductibles and coinsurance); or
Maintain all claims/liens against the liability insurance/beneficiary's liability insurance settlement.
7Q: We have a patient who was in an auto accident, but they received the full med pay payment. What should we do?
7A: When the beneficiary is paid directly by no-fault insurer, payment should be paid to the provider by the beneficiary. Report the amount paid by the primary insurer with appropriate coding on the claim. Medicare will process as secondary payer and the provider will need to contact the beneficiary for the primary payment resolution.

Billing MSP Claims

Part A only
8Q: What is the proper use of condition code 08?
8A: Condition code 08 should be submitted on claims when the beneficiary would not furnish information concerning the other insurance coverage. The Common Working File (CWF) monitors these claims and alerts the Benefits Coordination & Recovery Center (BCRC). The BCRC will then contact the beneficiary if necessary.
9Q: When filing a claim with condition code 08 when the beneficiary is not cooperating, how do we prevent these from returning to the provider?
9A: The Part A claim should reject and assign responsibility to the patient. Contact customer service for assistance with the claim.
Part B only
10Q: Where are the instructions for completing the CMS-1500 when billing MSP? Is there another form specific for MSP billing rather than the CMS-1500 to submit MSP claims?
10A: No. The CMS-1500 (or the electronic equivalent) is the Part B claim form, which is used for billing MSP claims as well.
Medicare guidance on completing the CMS-1500 can be found in the CMS IOM Publication 100-04, Chapter 26, Section 10.2 external pdf file. Additionally, your MAC may have information available on their website. See First Coast's Part B MSP webpage for more information.
11Q: Are MSP claims sent to Medicare the same way as normal Medicare claims?
11A: Yes, except for attaching a primary explanation of benefits (EOB) if billing on paper and if electronic, filling in some fields not found on the CMS-1500.
Parts A and B
12Q: Is there timely filing requirements for MSP claims?
12A: Yes, you have one year from the date of service to file the claim.
13Q: Does it matter if it is a rural health clinic claim?
13A: The MSP rules apply to all entities submitting claims to Medicare.
14Q: Where can we find information about which Claim Adjustment Reason Codes (CARCs) to use on the claims?
14A: CARCs can be found on the remittance advice, explanation of benefits or denial letter. In rare situations where a CARC is not provided by the primary payer, check the national website external link and select the best denial reason.
15Q: As a provider, are we able to provide patients with a Medicare Advanced Beneficiary Notice of Noncoverage (ABN) form to show the MSP listing to treat a patient prior to the MSP closing out? So, in the case that Medicare does deny, can we transfer to patient responsibility?
15A: No; this would not be an appropriate use of an ABN.
16Q: Who do we bill first since Medicare is secondary to liability claims?
16A: You must bill to the primary payer first, then to Medicare as secondary.
17Q: How do we bill if the responsible party does not respond to our requests for the accident information? For example, a patient gave us her niece's name, but the niece does not respond to our requests. Do we hold the patient responsible or bill MSP with the condition code 08?
17A: If a patient or other party refuses to furnish information concerning other insurance coverage, you may submit a Part A claim as Medicare primary with condition code 08 (beneficiary would not furnish information concerning other insurance coverage). The CWF monitors these claims and alerts the BCRC.
If billing Part B, submit the claim to Medicare. Medicare will deny the charge. You can contact the BCRC to verify they have the correct information.
18Q: If the third-party liability (TPL) pays the patient and won't tell us how much they paid the patient, are we allowed to bill the full amount to the patient?
18A: If the patient receives the payment, you may bill the patient.
19Q: If a patient has workers' compensation (WC) or a liability insurance as primary, but are coming in to see us for a completely different concern, we can still bill Medicare as primary, correct?
19A: Yes. If the condition is unrelated to the WC or liability, providers can bill Medicare as primary.

Conditional MSP payments

Parts A and B
20Q: It was said that after 120 days ("promptly" period), if no response is received from an automobile insurance, we can bill Medicare for conditional primary payment. So, I can file this claim as primary to Medicare but use the conditional payment codes on the claim?
20A: Yes, but remember conditional payments are made subject to repayment to Medicare when the primary plan makes payment. Medicare may make a conditional payment even though payment is expected to be paid by another payer.
Refer to article MM7355 external pdf file for information on conditional payments and promptly situations.
Additionally, please review your MAC's provider website for their MSP webpage, which contains a plethora of helpful information, tools, and resources. Be sure to check First Coast's MSP webpage (Part A and Part B) for more information.
21Q: If there is an open no-fault and an open liability and we do not receive prompt response from no-fault or liability, which MSP coding do we use to file for conditional payment – no-fault policy or the liability?
21A: Providers can choose the earlier of the promptly situations described below and code appropriately.
For no-fault insurance, "promptly" means payment within 120 days after receipt of the claim. For liability insurance (including self-insurance), "promptly" means payment within 120 days after the earlier of: a) the date a general liability claim is filed with an insurer or b) the date the service was furnished or, in the case of inpatient hospital services, the date of discharge.
For a liability situation, the MSP record is usually posted to CWF after the beneficiary files a claim against the associated liability insurance. In the absence of evidence to the contrary, the date the general liability claim is filed against the liability insurance is no later than the date that the record was posted to CWF. Therefore, for the purposes of determining the promptly period (the 120 days), Medicare contractors consider the date the liability record was created on Medicare's CWF to be the date the general liability claim was filed.
Refer to article MM7355 external pdf file for information on conditional payments and promptly situations.
Additionally, please review your MAC's provider website and its MSP webpage, which contains a plethora of helpful information, tools and resources. Be sure to check First Coast's MSP webpage (Part A and Part B) for more information.
22Q: When liability insurance does not pay within the 120-day prompt pay period, what documentation is needed to file a conditional claim? Does the liability plan need to send written documentation of the delay or is oral communication accepted? Also, since there is a delay in payment and not a denial, the CARC codes would not be appropriate on conditional claims, correct?
22A: For documentation requirements and claims coding information, refer to article MM7355 external pdf file for information on conditional payments and promptly situations.
Additionally, please review your MAC's provider website for its MSP webpage, which contains a plethora of helpful information, tools and resources. Be sure to check First Coast's MSP webpage (Part A and Part B) for more information.
23Q: So, if the other payer never pays, then is the provider allowed to keep the conditional payment?
23A: To make the Medicare trust fund whole, the BCRC will work with the primary insurer if the primary insurer is responsible for the charges. Payments made by Medicare as a conditional payment, providing that you filed the claim initially with the primary insurer and they failed to pay timely, can be maintained during this process.
24Q: If we bill the large group health plan (LGHP) for working age policy, but the EOB goes to patient and patient is not willing to provide a copy of EOB, can we bill Medicare conditionally?
24A: Not without the necessary information indicating how the primary insurer handled the claim.
If the primary payment went to the patient, you may conditionally bill the patient indicating they may be responsible for the bill if you are not able to obtain necessary information on how the primary insurer handled the claim so that Medicare may be billed. This should be your last resort and communication with the patient or primary insurer should be done first.

Employer Group Health Plan (EGHP)

Parts A and B
25Q: How would we know how many employees an employer has?
25A: The employer will need to provide that to the insurance, or the insurer for that employer will have that information.

Eligibility Questions

Part A only
26Q: If the MSP Questionnaire (MSPQ) was originally completed based upon what the patient informed the registration clerk but now the claim is denying for wrong insurance type code, do we have to call the patient again to update the form with the correct insurance type code? Or can we refer to the CWF and correct the MSPQ based upon it without involving the patient?
26A: Medicare encourages you to communicate with the patient and inform them it appears the incorrect information was provided. Make note of the discussion and make any necessary corrections to the form.
Parts A and B
27Q: Many patients believe Medicare Advantage (MA) is Medicare but they don't have cards and/or have lost them. We also find on several occasions the MSP information isn't showing in the contractor's portal. If the beneficiary is unable to correctly give us the information, what action can we take?
27A: If providers have different information about primary or secondary insurances and the beneficiary is unable or unwilling to update their information with the BCRC, send this information to the BCRC and they will perform an investigation and attempt to receive the correct information.
The BCRC address is:
Benefits Coordination & Recovery Center (BCRC)
Medicare -- Data Collections
P.O. Box 138897
Oklahoma City, OK 73113-8897
The BCRC is a separate contractor and contact information for the BCRC can be found here external pdf file.
28Q: Does the BCRC take care of Medicare on Medicaid third-party liability (TPL)?
28A: The BCRC handles all TPL records on file.
29Q: Medicare shows another insurance as primary, but the other insurance shows Medicare is primary. Should the patient contact the BCRC or can we contact the BCRC on the patient's behalf?
29A: Providers can contact the BCRC to ask that they investigate whether Medicare is primary or secondary, or if there is contradictory information.
The BCRC is a separate contractor and contact information for the BCRC can be found here external link.
30Q: What is the best practice to obtain MSP benefits and eligibility? Should we provide the patient with the MSPQ only if MSP is listed on the portal, or just in general for every patient? Is it appropriate to see the patient for one visit and await outcome if the patient states MSP is not related?
30A: Medicare requires that eligibility (including MSP) be checked for all patients. Ensure to have a standard process in place.
Front office staff should have beneficiaries complete the MSPQ and ask beneficiaries for their current cards at each check-in. The MSPQ is required for Part A.
Providers can check the MSP screen in CWF to ensure the information is accurate before you submit your claim to Medicare. You can access this through your contractor's portal (First Coast's Secure Provider Online Tool [SPOT]) or through a Health Insurance Portability and Accountability Act [HIPAA] Eligibility Transaction System (HETS) transaction.
31Q: How do we determine if the injury is related to our claim when Medicare is secondary to WC?
31A: Have the beneficiary fill out the MSPQ to find out this information.
Providers can check the MSP screen in CWF to ensure the information is accurate before you submit your claim to Medicare. You can access this through your contractor's portal (First Coast's SPOT) or through a HETS transaction.
32Q: What if patients don't remember any information about open liability files? How are we to obtain the information if the BCRC can't tell us who it is?
32A: Have the beneficiary fill out the MSPQ to find out this information.
Providers can check the MSP screen on the CWF to ensure the information is accurate before you submit your claim to Medicare. You can access this through your contractor's portal (First Coast's SPOT) or through a HETS transaction.
33Q: Is there a form that can be completed online to have the CWF updated with the primary information such as GHP information or auto information?
33A: No. To update CWF, the BCRC would need to be contacted.
The BCRC is a separate contractor and contact information for the BCRC can be found here external pdf file.
34Q: We have been denied for timely filing after the CWF is updated with the correct primary information or termination date of the commercial insurance. How long do we have to reopen a file with Medicare if the beneficiary's coverage is updated?
34A: Providers should request the reopening within one year of the date CWF was updated.
Part A providers should submit a reopening request on type of bill (TOB) XXQ to identify them as a reopening. This TOB should only be used when the submission falls outside the period to submit an adjustment bill. Also, submit the appropriate R1-R9 reopening condition code and adjustment condition code, adjustment reason code (Direct Data Entry [DDE] users only) and good cause remarks in the proper format. Claims determined to not have good cause will be returned to the provider (RTPd). See article MM8581 external pdf file and SE1426 external pdf file for further guidance.
Part B providers should follow the reopening process used by your MAC for historical corrections. This may be achieved using the interactive voice response (IVR) system or the MAC online portal (First Coast's SPOT). Consult your MAC's website for further guidance.
35Q: What documentation is needed to show there is no accident coverage?
35A: Please contact the BCRC for guidance. The BCRC is a separate contractor and contact information for the BCRC can be found here external link.
36Q: Can a provider call the BCRC and update any auto insurance information if it is not showing on the CWF and the benefits have been exhausted?
36A: To update CWF, the BCRC would need to be contacted. However, they may require the beneficiary to verify certain information before updating the file.
The BCRC is a separate contractor and contact information for the BCRC can be found here external link.
37Q: How do providers know if someone has a small employer exception (SEE)?
37A: The information concerning exceptions will be on file with the BCRC, and providers should be able to check with the BCRC to obtain the information.
38Q: How should the MSPQ be answered when someone is covered as a domestic partner? Does this count as family or spouse coverage?
38A: Spouse coverage is appropriate since family coverage is not addressed in the working aged section. For billing purposes, however, domestic partner is assigned a specific patient relationship code.
39Q: Do we need to ask the MSP questions when providing a lab draw or a non-face-to-face service?
39A: Yes. When submitting a claim to Medicare, ask the questions to determine the correct primary payer.
Billing for inpatient or outpatient hospital services requires the MSPQ to be completed for every date of service (unless it is for recurring outpatient services; see CMS IOM Publication 100-05, Chapter 3, and Section 20.1 external pdf file)

Federal Black Lung Program (FBLP)

Parts A and B
40Q: If the patient has coverage under the FBLP but the diagnosis is not black lung related, can we bill Medicare as primary?
40A: If a Medicare patient is entitled to FBLP medical benefits, any services unrelated to the black lung condition may be submitted to Medicare as primary with remarks indicating services are not related to black lung diagnosis.
41Q: Is there a list of the covered black lung diagnosis codes available?
41A: Diagnoses associated with FBLP and non-group health plans, such as WC, liability and automobile coverage, may be obtained from the HETS, or the MAC's IVR and internet portal (First Coast's SPOT).

Group Health Plan (GHP)

Parts A and B
42Q: If a provider wants to bill for a disabled beneficiary covered by a group health plan, and the diagnosis on the claim is not related to the disability, would the claim be billed to Medicare as primary?
42A: The GHP pays primary; Medicare pays secondary.

Liability Insurance and MSP

Parts A and B
43Q: If a patient falls at a friend's house, and states she just lost her balance and it was no one's fault, are we to pursue the homeowner's insurance to see if there is med pay available?
43A: You should ask the beneficiary is she plans to file a claim on her friend's homeowner's insurance. If yes, obtain the information and submit a claim to the homeowner's insurance before submitting an MSP claim to Medicare. If not, the claim may be submitted as Medicare primary.

Medicare Advantage (MA) plans

Parts A and B
44Q: If the patient has a MA plan but also has Health Reimbursement Account (HRA) funds available through the GHP, would the GHP be primary or would the MA plan be primary?
44A: Please contact the individual MA plan for billing guidance.
45Q: I've read instructions that the MA plan is not required to report MSP. Is that correct? In other words, does there have to be an open MSP when billing the MA plan secondary?
45A: Please contact the individual MA plan for billing guidance.

Medicare Primary in Error

Parts A and B
46Q: If we billed Medicare as secondary but the claim was processed by Medicare as primary, would we need to resubmit claim or do a self-reopening to add MSP type?
46A: The provider is responsible to adjust the claim. As you cannot reopen this type of claim, you would need to request an appeal. The provider should submit a primary payer EOB for the MAC to process the duplicate primary payment (DPP). If no EOB is submitted, the MAC will recoup the full primary payment.
If your MAC allows for another way of correcting this situation (like completing an MSP form or a self-service option), you can pursue that option. Be sure to check First Coast's MSP webpage (Part A and Part B) for more information.
47Q: A provider is unaware charges are related to an automobile accident or liability and submits a claim to Medicare. Medicare pays primary, but after Medicare paid, the other insurance pays the claim. Who is responsible for reimbursing Medicare for the payment made to the provider -- the beneficiary or the provider?
47A: The provider may submit the primary payer information to Medicare to recoup the payment. However, the beneficiary is responsible for reporting the accident to the BCRC for the recovery process to take place. If the provider fails to submit the DPP, the BCRC will recover the payment.

Veteran's Administration (VA) claims

Part A only
48Q: When filing a VA claim primary, should we file a Medicare claim with the condition code 77 showing the VA payment?
48A: Medicare is not secondary to the VA. Both are federal government programs. You must file to one or the other. Claims involving the VA are not considered MSP.
Parts A and B
49Q: Are we allowed to bill Medicare for any part of the claim that VA does not cover? If so, what are we allowed to bill Medicare for specifically? Are the rules different for inpatient versus outpatient claims?
49A: For situations involving VA payments, please refer to MLN article SE1517 external pdf file.

Ongoing Responsibility for Medicals (ORM)

Parts A and B
50Q: How do we fix any claims that have the ORM attached?
50A: For ORM, please reference the article MM8984 external pdf file.

Primary insurance paid in full

Part A only
51Q: When you are a Part A facility and billing an outpatient claim paid in full, are we to bill Medicare secondary using condition code 77?
51A: For Part A, submit the claim to Medicare with condition code 77 because it could apply to the Medicare deductible. We instruct providers to submit regardless if deductible was met or not because the primary insurance info could change (e.g., a retro term date).
Parts A and B
52Q: Do we file an MSP claim when there is no deductible or co-insurance showing due per the eligibility verification?
52A: Yes.
For inpatient services, if the primary payer made full payment (or an amount considered to be full payment), submit an MSP claim (known as an MSP no-payment claim or an MSP full-payment claim) to Medicare in even though there is no balance due from Medicare. This determines the benefit period.
For outpatient services, it should also be determined when the beneficiary has not met his or her annual Medicare Part B deductible. The bill is submitted to inform Medicare of the charges where the deductible may not yet be met. Although Medicare can make no payment, it can apply the expenses to the beneficiary's deductible. A bill is required for crediting the deductible.
In addition, we recommend all home health and hospice providers submit MSP no-payment (MSP full-payment) claims.
53Q: Do we still submit a claim to Medicare when the primary payer (e.g., WC, auto or GHP) or private insurance pays the claim in full?
53A: Yes. If the patient has Medicare, you should still submit the claim to us even if there is no balance. No-pay bills should be submitted to Medicare to determine the benefit period, update frequency limitations for services, and/or satisfy any unmet deductibles.
In addition, if the primary insurance recoups their payment at any time and secondary coverage becomes primary, it is important the claim is not past the timely filing limits. If the primary payer requests repayment after the timely filing limit and Medicare received the claim, you may be able to request a reopening.
54Q: If a patient is paid for a liability claim and we bill the patient, would we still bill Medicare after the patient pays?
54A: Yes. If the patient has Medicare, you should still submit the claim to us even if there is no balance. No-pay bills should be submitted to Medicare to determine the benefit period, update frequency limitations for services, and/or satisfy any unmet deductibles.

RTP claims

Part A only
55Q: If we have questions when MSP claims go into "T" status, who can we contact to get assistance?
55A: For Part A claims that RTP, verify the patient's eligibility. Then, contact the Provider Contact Center with any additional questions.

Workers' Compensation claims

Parts A and B
56Q: Our claims continue to deny as MSP, even though the diagnosis does not correspond to MSP listed. Most of these patients are in their 90s and cannot call to coordinate their benefits, (a lot of times, they are in assisted living) and these visits are clearly not WC-related. How can these be resubmitted/paid as primary?
56A: Providers can submit a redetermination of the claim, indicating the services were not related to the WC. If it is not related to an accident, the contractor is able to investigate to see if payment should be made.
For Part A claims not related to the open file, remarks indicating "Not related to XX" will help with the claims processing. If the diagnosis codes match an open WC case, that cannot be bypassed, and the claim will need to be submitted for conditional payment.
You can refer to MLN article SE1416 external pdf file for additional details.
57Q: If a patient's record shows an open WC case, how do we determine if our service relates to the workers' compensation case? Does the patient record contain the diagnosis codes?
57A: MACs determine the claim relationship based on the information in the patient record. The injury date should be submitted on your claim. Providers can locate MSP information, included the open WC and related diagnoses, in the contractor portal for your jurisdiction (First Coast's SPOT).
58Q: After the WC Medicare set-aside arrangement (WCMSA) amount has been met, do we bill Medicare as secondary?
58A: Medicare should not be billed for future medical services until those funds are exhausted by payments to providers for services that would otherwise be covered and reimbursable by Medicare. See MLN Matters SE17019 external pdf file.
59Q: When Medicare is tertiary, can Medicare be billed, and will they pay after WC and primary insurance has paid?
59A: To determine if Medicare has any obligation, the provider would need to file the tertiary claim along with the EOB from the primary and WC insurances.
60Q: If a patient had WC for a neck injury then months later falls at home and has neck pain, how can we bill this to Medicare as primary?
60A: Medicare is the secondary payer to WC benefits when services rendered are related to the injury, illness, or disease. If the patient does fall and the condition is unrelated to the WC condition, then you can submit the claim primary to Medicare. We do look at the diagnosis codes. If the new condition is related to the WC, then this should be updated through the BCRC. If you submit the claim to WC and they deny it, then you can submit the claim to Medicare as secondary (need to remark that it was denied by the primary).
61Q: Patient has a closed WC case and WCMSA funds for medical related to the injury. The patient is now enrolled in MA plan, but since he sees us in relation to WC injury, is he responsible for paying for visit until the set-aside funds are exhausted?
61A: Yes. WCMSA funds are used to pay for treatment related to the WC injury/illness until those funds are exhausted.
Please contact the beneficiary's MA plan for billing guidance once those benefits have exhausted.

References

The Provider Outreach and Education A/B Medicare Administrative Contractor Workgroup developed this material. Our joint effort ensures consistent communication and education so that providers and physicians have the information they need to submit claims appropriately and receive proper payment in a timely manner.
Provider Outreach and Education (POE) A/B MAC Collaboration Group
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.