Medicare secondary payer (MSP) billing
What you need to know
The MSP provisions apply to situations when Medicare is not the beneficiary’s primary health insurance coverage. Physicians, non-physician practitioners, and suppliers are responsible for gathering MSP data to determine whether Medicare is the primary payer by asking Medicare beneficiaries questions concerning their MSP status.
Information on the types of insurers that are primary to Medicare can be found in the CMS MSP Manual, CMS Internet Only Manual, Publication 100-05, Medicare secondary payer, Chapter 2.
MSP billing
When Medicare is the secondary payer, submit the claim first to the primary insurer. The primary insurer must process the claim in accordance with the coverage provisions of its contract. If, after processing the claim, the primary insurer does not pay in full for the services, submit a claim via paper or electronically to Medicare for consideration of secondary benefits.
It is the provider's responsibility to obtain primary insurance information from the beneficiary and bill Medicare appropriately.
The normal Medicare claims timely filing rules apply. Claim filing extensions will not be granted because of incorrect insurance information.
Paper claim submission
If you qualify for a waiver/exception under the Administrative Simplification Compliance Act (ASCA) you may submit paper claims to Medicare rather than electronic claims.
When submitting a paper claim to Medicare as the secondary payer, the CMS-1500 (02-12) claim form must indicate the name and policy number of the beneficiary's primary insurance in items 11-11c. For additional instructions on completing the CMS 1500 (02-12) claim form, please refer to the CMS-1500 (02/12) data element requirements.
The paper claim MUST include a copy of the primary insurer's explanation of benefits (EOB). The EOB should include the following information:
- Name and address of the primary insurer
- Name of subscriber and policy number
- Name of the provider of services
- Itemized charges for all procedure codes reported
- Detailed explanation of any denials or payment codes
- Date of service
If any of the above information is not included with the claim, it may result in a delay in processing or denial of the claim.
If there is more than one insurer primary to Medicare (e.g., a working aged beneficiary who was in an automobile accident), the explanation of benefits statement from both plans must be submitted with the claim.
Providers must submit a claim to Medicare if a beneficiary provides a copy of the primary EOB. The claim must be submitted to Medicare for secondary payment consideration with a copy of the EOB. If the beneficiary is not cooperative in supplying the EOB, the beneficiary may be billed for the amount Medicare would pay as the secondary payer.
Providers must bill both the primary insurer and Medicare the same charge for rendered services. If the primary insurer is billed $50 for an office visit and they pay $35, do not bill Medicare the remaining $15. Medicare must also be billed for the $50 charge, and a copy of the primary insurer's EOB must be attached to the completed claim form.
Send MSP paper claims to one of the appropriate addresses below.
Florida:
First Coast Service Options
Part B Claims and Claims ADR FL
P.O. Box 2009
Mechanicsburg, PA 17055-0709
U.S. Virgin Islands/Puerto Rico:
First Coast Service Options
Part B Claims and Claims ADR PR/VI
P.O. Box 2004
Mechanicsburg, PA 17055-0704
Electronic claim submission
To submit MSP claims electronically, please refer to Electronic filing of Medicare Part B secondary payer claims (MSP) in the 5010 format. This article includes information required in an electronic file as well as links and helpful billing tools.
Claim adjustment reason codes (CARC)
In addition to the above, CARCs are required. These codes drive the payer code based on the information in the code. A list of CARCs is available on the X12 External Code Lists website.
References