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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 insurer's that are primary to Medicare can be found in the CMS MSP Manual, CMS IOM, Pub. 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.

Paper claim submission

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.

If you qualify for a waiver / exception under the Administrative Simplification Compliance Act to submit paper claims rather than electronic claims, send MSP 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

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.

When sending an MSP claim electronically, the primary explanation of benefits should not be sent separately.

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