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This course is designed to provide Medicare Part A ...Nov 30, 2015  · Medicare Secondary Payer....

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This course is designed to provide Medicare Part A providers with an understanding of: The various types of Medicare Secondary Payer (MSP) provisions; How to determine when Medicare is primary or secondary; and A general overview of requirements for submitting MSP claims. Course updated: November 30, 2015 Copyright 2013 Cahaba Government Benefit Administrators, ® LLC
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  • This course is designed to provide Medicare Part A providers with an understanding of:

    • The various types of Medicare Secondary Payer (MSP) provisions;• How to determine when Medicare is primary or secondary; and• A general overview of requirements for submitting MSP claims.

    Course updated: November 30, 2015 Copyright 2013 Cahaba Government Benefit Administrators, ® LLC

  • The Medicare Secondary Payer (MSP) Provisions of section 1862(b) of the Social Security Act protect Medicare funds by ensuring that federal funds are not used to pay for services that are reimbursable under any private insurance plan. These entities include group health plans, workers’ compensation plans, liability insurance, or no-fault insurance. The MSP provisions apply to situations where Medicare is not the beneficiary’s primary insurance.

    Medicare Secondary Payer

    Medicare Secondary Payer: Exceptions to the MSP Requirement

    In most cases, Federal law takes precedence over state laws and private contracts. Even if a state law or insurance policy states that they are a secondary payer to Medicare, the MSP provisions should be followed when billing for services.

  • • Working Aged - Beneficiary is 65 or older• Disability - Beneficiary is under 65• Veterans Administration• Federal Black Lung• End Stage Renal Disease• No-Fault Insurance• Liability Insurance• Workers' Compensation

    MSP Provisions

  • • Has group health plan (GHP) coverage through own/spouse's employer with 20 or more employees

    • When the working beneficiary or spouse retires, Medicare becomes primary.• When billing this provision, use value code 43 and appropriate payer code(s)

    and/or occurrence code(s).

    MSP Provisions: Working Aged

  • • Under age 65 and on Medicare due to disability.• Has group health plan (GHP) coverage through own/ family member’s

    employer• Employer has 100 or more employees to qualify as a Large Group Health Plan

    (LGHP).• When billing this provision, use value code 43 and appropriate payer code(s)

    and/or occurrence code(s).

    MSP Provisions: Disability

  • • Beneficiaries who have VA can choose to have their claims filed to VA or Medicare.

    • Medicare will pay in the following situations:• VA benefits were not claimed;• VA did not cover the service.• When billing this provision, use value code 42 and appropriate payer code(s)

    and/or occurrence code(s).

    MSP Provisions: Veteran’s Administration (VA)

  • • Program provides benefits to coal miners for lung conditions attributable to coal mining.

    • Medicare will reject a claim if BL diagnosis appears anywhere on the claim. Submit to Department of Labor (DOL) first to determine what they will cover.

    • Medicare will pay if service is not covered by DOL.• When billing this provision, use value code 41 and appropriate payer code(s)

    and/or occurrence code(s).

    MSP Provisions: Federal Black Lung (BL)

  • • Has group health plan (GHP) coverage through own/ family member’s current or former employer during 30-month coordination period.

    • 30-month coordination period is the period of time when the GHP will pay first and Medicare will pay second and begins the first month a patient is eligible for Medicare due to kidney failure (usually the fourth month of dialysis).

    • Provision applies to all Medicare covered items and services (not just treatment of ESRD) furnished during coordination period.

    • When billing this provision, use value code 13 and appropriate payer code(s) and/or occurrence code(s).

    MSP Provisions: End Stage Renal Disease (ESRD)

  • Under §1862(b)(2) of the Act, (42 U.S.C. 1395y(b)(1)), Medicare does not make payment for covered items or services to the extent that payment has been made, or can reasonably be expected to be made under no-fault insurance or a liability insurance policy or plan (including a self-insured plan).

    • When billing for the No-Fault provision, use value code 14 and appropriate payer code(s) and/or occurrence code(s).

    • When billing for the Liability provision, use value code 47 and appropriate payer code(s) and/or occurrence code(s).

    MSP Provisions: No-Fault or Liability

  • • Medicare will pay for services in the following situations: WC benefits are exhausted; Conditionally if the WC case is in litigation; If the service is not related to the WC injury, provided no other group coverage

    exists that falls under the MSP provisions.• When billing this provision, use value code 15 and appropriate payer code(s)

    and/or occurrence code(s).• If payment for services cannot be made by WC because they were furnished

    by a source not authorized by WC, such services can be paid for by Medicare.• Medicare remains primary for all medical services not related to the work

    related injury, provided no other group coverage exists that falls under the MSP provisions.

    MSP Provisions: Workers’ Compensation (WC)

  • • Medicare may make secondary payment on claims that are denied by the Primary Payer if the services are covered by Medicare and a proper claim has been filed to the Primary Payer and to Medicare.

    • In these situations, providers must provide information from the Primary Payer stating the claim has been denied. For paper submitters, this would be an Explanation of Benefits (EOB) from the Primary

    Payer stating that the claim has been denied. For electronic submitters, the following information is required: Medicare indicated as

    the secondary payer, insurance type, Coordination of Benefits (COB) payer paid amount, COB allowed amount, claim adjudication date, service line data, line adjudication data, line adjudication information, and any line adjustments(s) with the accompanying line adjudication date(s).

    MSP Payments: When Will Medicare Make A Secondary Payment?

  • A contractual obligation (CO) arises as a result of an enforceable promise, agreement, or contract. If a provider is obligated to accept, or voluntarily accepts, an amount as payment in full from the primary payer, this is a contractual obligation.

    For contractual obligations, use value code 44 and amount.

    • The Obligated To Accept as Payment in Full Amount (OTAF) is the amount the provider agreed to accept as payment in full for a service rendered under the provisions of the primary payer's contract. When a primary payer allows less than the billed amount and the provider is contractually obligated to accept that amount as payment in full, then the allowed amount is the OTAF amount.

    • The difference between billed amount and contractual obligation amount that the primary insurance allowed cannot be billed to the beneficiary.

    MSP Payments: Contractual Obligations

  • Conditional payment is a Medicare payment, conditioned upon reimbursement to Medicare, for services which another insurer is the primary payer and has not paid and cannot reasonably be expected to make payment promptly.

    With regard to no-fault and WC insurance, promptly means payment within 120 days after receipt of the claim. For liability insurance, promptly means payment within 120 days after the earlier of the following:

    • The date a claim is filed with an insurer or a lien is filed against a potential liability settlement; or

    • The date the service was furnished or, in the case of inpatient hospital services, the date of discharge.

    Use the Remarks Field to explain reasons for nonpayment and to justify conditional payments. For Working Aged and Disability, enter employer’s name and address that provides the primary insurance.

    MSP Payments: When Will Medicare Make A Conditional Payment?

  • MSP situations are determined by:

    1. MSP questionnaire conducted by provider at time of admission2. Benefits Coordination and Recovery Center (BCRC)3. Accessing patient information through ELGA

    MSP Situations: Three Ways to Determine if MSP Situations Exist

  • MSP Situations: MSP QuestionnaireProviders, physicians and other suppliers may use a model questionnaire published by the Centers for Medicare and Medicaid Services to collect patient information. This tool is available online in the MSP Manual in chapter 3, section 20.2.1 at:https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/msp105c03.pdf

    https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/msp105c03.pdf

  • The Benefits Coordination and Recovery Contractor (BCRC) was created to centralize and consolidate activities that support the collection, management and reporting of other insurance coverage for Medicare beneficiaries.

    The main purpose/role of the BCRC program is to:• Administer the MSP program more effectively and efficiently by utilizing a single

    contractor entity to operate, coordinate and maintain the MSP processes and generate cost savings through a reduction in mistaken primary Medicare payments.

    • Identify which health benefits are available to a Medicare beneficiary.• Assist in the continuous campaign against Medicare fraud, waste and abuse under the

    Medicare Integrity Program (MIP).

    MSP Situations: BCRC

  • Contact the BCRC to:• Report other insurance coverage information.• Report or provide updated information on a liability, auto/no-fault,

    or workers compensation case.• Ask general Medicare Secondary Payer (MSP) questions/concerns.• Ask questions regarding Medicare Secondary Development letters and

    questionnaire.

    BCRC Customer Call Center• 1-855-798-2627 TDD/TYY 1-855-797-2627• Monday through Friday 8:00 a.m. to 8:00 p.m. Eastern Time (except holidays)

    Specific claim-based issues (including claim processing) should still be addressed to the Provider Contact Center at the Medicare Administrative Contractor.

    MSP Situations: Contacting the BCRC

  • Access ELGA - Page 9 and beyond (if MSP situation exists).

    • ELGA will have one additional page for each MSP record. Page 9 would be MSP record 1, page 10 would be MSP record 2, etc.

    • ELGA provides detailed information including the insurer’s name and address, and the policy number for the insured.

    • Page 9 only appears if an MSP record exists.

    MSP Situations: ELGA

  • MSP Situations: ELGA Screen Information

  • Effective 10/05/2009, initial and/or adjustment MSP claims are no longer accepted into the Fiscal Intermediary Shared System (FISS) via Direct Data Entry (DDE). MSP Claims can be submitted via:

    • An Electronic Media Claim (EMC) using a HIPAA compliant version of ANSI ASC X12N 837 format;

    • PC-ACE Pro32;• Hardcopy UB-04/CMS-1450 (if qualified for a paper exception).

    For more information, review Change Request 6426: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R70MSP.pdf

    For more information on the Administrative Simplification Compliance Act (ASCA) Enforcement of Mandatory Electronic Submission of Medicare Claims, review Change Request 3440: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R450CP.pdf

    MSP Claim Submission

    https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R70MSP.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R450CP.pdf

  • Medicare Secondary Payer Manual (CMS Pub. 100-05),https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html?redirect=/Manuals/IOM/list.asp– Chapter 1 – Background and Overview– Chapter 2 – MSP Provisions– Chapter 3 – MSP Provider Billing Requirements

    MSP Fact Sheethttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MSP_Fact_Sheet.pdf

    Cahaba Educational Material:https://www.cahabagba.com/cahaba-u/part_a/msp/html/index.htm

    Resources: CMS and Other Resources

    https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html?redirect=/Manuals/IOM/list.asphttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MSP_Fact_Sheet.pdfhttps://www.cahabagba.com/cahaba-u/part_a/msp/html/index.htm

  • Click the link below and complete the Medicare Secondary Payer Post-test:

    http://w3.mccg.org/iota/test-medicare-secondary-payer-a.asp

    When the test is successfully completed, you will be prompted to enter information to record your

    results.

    http://w3.mccg.org/iota/test-medicare-secondary-payer-a.asp

    Slide Number 1Medicare Secondary PayerMSP ProvisionsMSP Provisions: Working AgedMSP Provisions: DisabilityMSP Provisions: Veteran’s Administration (VA)MSP Provisions: Federal Black Lung (BL)MSP Provisions: End Stage Renal Disease (ESRD)MSP Provisions: No-Fault or LiabilityMSP Provisions: Workers’ Compensation (WC)MSP Payments: �When Will Medicare Make A Secondary Payment?MSP Payments: Contractual ObligationsMSP Payments: �When Will Medicare Make A Conditional Payment?MSP Situations: �Three Ways to Determine if MSP Situations ExistMSP Situations: MSP QuestionnaireMSP Situations: BCRCMSP Situations: Contacting the BCRCMSP Situations: ELGAMSP Situations: ELGA Screen InformationMSP Claim SubmissionResources: CMS and Other ResourcesClick the link below and complete the Medicare Secondary Payer Post-test:


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