• Fact: MSP Provisions require certain coverage to be billed before Medicare for a beneficiary’s services. You can determine whether Medicare is the primary, secondary, or greater payer once you determine whether or not the beneficiary has other coverage.

Step 1: Collect MSP Information from the Beneficiary During the MSP Screening Process

During the MSP screening process, you ask the beneficiary questions concerning their most current MSP status. You can use the CMS model MSP questionnaire or an in-house, CMS-compliant form (same content and intent as the CMS model) to conduct your MSP screening.

To view the CMS model MSP questionnaire, refer to the CMS Internet-Only Manual (IOM) Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Section 20.2.1.

The CMS requires hospitals to collect MSP information for every inpatient admission and outpatient encounter of a beneficiary. We suggest that all providers follow this screening process frequency. Obtain documentation that supports your completion of the MSP screening process with each beneficiary.

There are a few exceptions related to the MSP screening process:

1. You are not required to collect MSP information from beneficiaries receiving hospital reference laboratory services because these services are clinical laboratory diagnostic tests and interpretation furnished without a face-to-face encounter between the beneficiary and the hospital.
2. You are only required to collect MSP information from beneficiaries receiving recurring hospital outpatient services once every 90 days. These are identical hospital outpatient services and treatments that the beneficiary is receiving more than once within a billing cycle.
3. You are not required to collect MSP information from beneficiaries who are members of MAO plans unless the beneficiary is also enrolled in Medicare’s hospice benefit. You may have to collect the MSP information if the MAO plan requires you to do so.
4. You are not required to collect MSP information (complete a new questionnaire) from beneficiaries if you have the ability to access MSP information in CWF or send/receive a X12 270/271 transaction. In lieu of asking all of the MSP questions, ask each beneficiary if any insurance information on CWF, or in the X12 271 response, has changed. For details, review  Change Request (CR) 10863 and MM10863.
5. You are not required to collect MSP information (complete a new questionnaire) from beneficiaries if your provider is an affiliated provider-based service and the beneficiaries have already had their information verified by the provider. For details, review Change Request 10863 and MM10863.

Follow these tips to accurately collect MSP information:

• Ensure the questionnaire is dated and matches the beneficiary’s date(s) of service
• Help the beneficiary understand the questions without responding for them
• Document all responses you receive
• Do not leave response fields to any applicable questions blank (if you must, document the reason)
• Document the beneficiary’s and/or their spouse’s accurate retirement dates, as applicable. If the beneficiary and/or their spouse cannot recall their exact dates of retirement, follow CMS’ policy for recording (in your records) and reporting (on your claims) their retirement dates. Refer to the CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Section 20.1, #4
• If the beneficiary is unable to respond, speak to their representative
• Save the completed form for ten years (the beneficiary is not required to sign the form)

For more details about the MSP screening process, refer to the CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Sections 20.1 and 20.2.

Step 2: Check for Open MSP Records for the Beneficiary in Medicare’s Records

Fact: Medicare may have open MSP records for a beneficiary with MSP information in the CWF. This information may not be as current as the MSP information you collect from the beneficiary but you must still check Medicare’s records for MSP information for the beneficiary.

You can use the following provider self-service tools:

• National Government Services IVR system
• Connex online Web application
• CWF via the FISS/DDE Provider Online System
  • HIQA transaction for Part A providers or HIQH transaction for home health agencies in FISS/DDE to access the CWF until these transactions are eliminated per MLN Matters article MM8248
  • CMS will provide a 90-day notice to providers of the termination date for these transactions per MLN Matters special edition article SE1249 Revised
• CMS HETS
  • The MSP record, if any, contains the MSP VC which represents the MSP provision/category that may apply to the beneficiary
  • Within each MSP record, you can find the primary insurer’s effective date, termination date, name and the policy number

Step 3: Compare the MSP Information you Collected from the Beneficiary to the MSP Information in Medicare’s Records

Review the collected MSP information to the MSP information in Medicare’s records to look for similarities and discrepancies. If the beneficiary is no longer at your facility, you may need to contact them to resolve any conflicts.

If the information you collect from the beneficiary can correct the MSP information in Medicare’s records, to make Medicare the primary payer, contact the BCRC to request that they correct the MSP record. You must contact the BCRC, even if you will not submit a claim to Medicare, if you are made aware of information than can correct an MSP record. Refer to correct a beneficiary’s MSP record. If you submit a Medicare primary claim before the BCRC updates the MSP record, National Government Services Medicare rejects the claim for MSP.

If the collected MSP information identifies a payer primary to Medicare and there is no MSP information in Medicare’s records about this payer, contact the BCRC to request that they set up an MSP record. You must contact the BCRC even if you will not submit a claim to Medicare, if you are made aware of an MSP situation for which there is no MSP record in Medicare’s records. Refer to set up a beneficiary’s MSP record. If you submit an MSP or conditional claim before the BCRC sets up the MSP record, National Government Services Medicare suspends your claim and contacts the BCRC to request that they set up the MSP record which can take up to 100 days.

Step 4: Determine Which Payer is the Primary, Secondary, etc. for the Beneficiary’s Services

Follow these general guidelines to determine the proper payer order:

1. Medicare is primary for the beneficiary’s services if a beneficiary has only Medicare and no other coverage is available.
2. If a beneficiary has other coverage, you need to know if the criteria/conditions for any one or more of MSP Provisions been fully met which would make the other payer(s) primary to Medicare for the beneficiary’s services. The other coverage is primary to Medicare for the beneficiary’s services if it meets the criteria/conditions required under any of the applicable MSP Provisions. It is possible for a beneficiary to have more than one type of coverage which may make Medicare the tertiary payer (or greater).

To make the right decision, you must have a working knowledge of the criteria/conditions of the MSP Provisions that make certain other payers primary to Medicare.

Step 5: Document Your Decision Regarding the Proper Order of Payers and Submit Claims Accordingly

• If Medicare is primary for the beneficiary, submit a Medicare primary claim. Refer to prevent an MSP rejection on a Medicare primary claim to avoid any issues that can lead to claim rejection.
• If one payer is primary to Medicare for the beneficiary, submit a claim to that payer before you submit a claim to Medicare.
• If more than one payer is primary to Medicare for the beneficiary, submit a claim to each of those payers, in the appropriate order, before you submit a claim to Medicare.

Related Content

• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.4, Claims From Medicare Advantage Organizations
• CMS IOM Publication 100-05, Medicare Secondary Payer Manual,
  • Chapter 1, Background and Overview
  • Chapter 2, MSP Provisions
• CMS Medicare Secondary Payer web page
• HIPAA Eligibility Transaction System (HETS) User Interface (UI) User Guide
• Medicare Learning Network: Medicare Secondary Payer for Providers, Physicians, and Other Suppliers, and Billing Staff
• MLN Matters article MM8248: Termination of the Common Working File ELGA, ELGH, HIQA, HIQH, and HUQA Part A Provider Queries
• MLN Matters Special Edition article SE1249 Revised: HIPAA Eligibility Transaction System (HETS) to Replace Common Working File (CWF) Medicare Beneficiary Health Insurance Eligibility Queries