Last Modified: 4/24/2022
Location: FL, PR, USVI
Business: Part A
First Coast, as your MAC, understands Part A billing can be confusing. Situations when Medicare is the secondary payer (MSP) can be even more challenging. In fact, many of our top claim rejects each month for Part A facilities are related to MSP. We've prepared this article to help you and your facility avoid common MSP claim rejects.
When billing claims to Medicare, providers are responsible for determining whether Medicare is the primary payer for a beneficiary or not, as well as billing for the services and supplies provided to Medicare beneficiaries. Per Medicare regulations, providers must make a good faith effort to figure out who is primary and who is secondary. This begins with verifying a beneficiary's eligibility.
Upon patient registration and prior to submitting the claim, ask the beneficiary to complete the MSP questionnaire
located in the CMS MSP IOM Pub. 100-05, Chapter 3, section 20.1.2.
• Obtain a copy of Medicare card, or better yet, ask to see all their insurance cards.
Check and confirm the beneficiary's eligibility. Click here
• Note: Customer service representatives cannot assist you with eligibility information and are required by CMS to refer you to the interactive voice response (IVR).
Remember, it's your responsibility to determine insurance information for the beneficiary, including primary and secondary payers, and to bill accordingly.
• If you determine Medicare is primary:
• Submit Medicare primary claim with explanatory billing codes
• If you determine another payer is primary:
• Submit claim to:
• The primary payer first
• Medicare second, after receiving adjudication from the primary insurance, with correct billing codes
• Do not bill the primary payer and Medicare simultaneously
• If you determine more than one payer is primary:
• Submit claim to:
• The primary payer first, then the secondary payer next, and so on
• Medicare as tertiary, etc. with correct billing codes
• Do not bill primary payer(s) and Medicare simultaneously
If you do not receive payment from the primary insurance in a timely manner, be sure to follow up as Medicare's one-year timely filing rule
still applies in MSP situations.
What are the reject reason codes you may receive?
Refer to Part A reason code lookup
for a detailed description associated with the Medicare Part A reason code(s). Enter a valid reason code into the box and click the submit button.
Common MSP reject reason codes:
• 34140 -- Auto/No fault insurer
• 34145 -- Workers' compensation
• 34293 -- Working elderly (Employer group health plan [EGHP])
• 34295 -- Disability (EGHP)
• 34304 -- Liability insurer
• 34381 -- Liability insurer
• 34539 -- End-stage Renal Disease (ESRD) (EGHP)
• 34544 -- Auto/No fault insurer
• 34545 -- Workers' compensation
You may receive one of these reason codes when the beneficiary has coverage under another insurance (type shown) for the date(s) of service which is primary to Medicare.
Steps you can take to correct and avoid these rejects:
• Note: Customer service representatives cannot assist you with eligibility information and are required by CMS to refer you to the IVR.
• If the information is valid:
• File the claim to the primary insurance listed on the beneficiary's records and then to Medicare for secondary payment consideration
• If the information is invalid:
The provider or the beneficiary must contact the Benefits Coordination & Recovery Center (BCRC)
at 1-855-798-2627, to have the record updated. Once the record is updated, refile the claim to Medicare for primary payment consideration.
What to do if Common Working File (CWF) is updated
• If your claim was rejected ("R" status), you should be able to adjust the claim and resubmit through your electronic software.
• If the claim was returned to provider ("T" status), you should correct the errors and resubmit through your electronic software.
Remember you can only void/cancel a paid claim.
Steps to avoid MSP claim rejects:
• Verify beneficiary's benefits at admission or check-in
• Collect full beneficiary health insurance information upon each office visit, outpatient visit, and hospital admission
• Every 90 days for recurring outpatient services furnished by a hospital
• Verify Medicare is secondary
• Contact BCRC if there is a conflict with files, benefits information is invalid or needs to be updated
• Contact BCRC: (855) 798-2627
• Submit claim to primary payer prior to submitting claim to Medicare
• Review documentation from primary insurer
• Submit MSP claims when required and code accurately
• Prepare MSP claim accurately
• Report all appropriate coding
• Verify matching record on CWF -- #1 issue we see is wrong value codes
• Review MSP resources thoroughly
• Use available resources online
• Develop and implement policies that ensure provider's MSP responsibilities are met
• Share information with staff
Amongst other required elements, hospitals should audit patient records to ensure they contain:
• MSP information for the beneficiary, and
• A copy of the MSP Questionnaire
• It is required for each inpatient admission and all outpatient services provided in the hospital.
• If there are no changes or updates to the beneficiary's insurance, for auditing purposes, providers must make a notation that all questions were not asked upon admission, or during the telephone interview/screening, based on the beneficiary's statement that their insurance information has not changed or does not require updating. The Medicare contractor shall request this notation and confirmation during its hospital review.
• For reoccurring outpatient services, the MSP information should be verified once every 90 days. When auditing the record, you should verify the information is no older than 90 calendar days from the date the service was rendered.
• NOTE: A Medicare beneficiary is receiving recurring services if he/she receives identical services and treatments on an outpatient basis more than once within a billing cycle.
Hospitals must be able to demonstrate they collected MSP information from the beneficiary or his/her representative, which is no older than 90 days, when submitting bills for their Medicare patients. Acceptable documentation may be the last (dated) update of the MSP information, either electronic or hardcopy.
The questionnaire must be retained for 10 years after date of service. If the provider's admission questions are retained online, online data may not be purged before then. Should a hospital choose not to retain this information for up to 10 years, it does so at its own risk.
The following First Coast resources can be beneficial to determine MSP and eligibility for a patient. Use these resources to help avoid MSP claim rejects.
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.