Step 1: Determine if Medicare Tertiary Claim Must be Submitted to Medicare
Before you can bill Medicare, you are first required to bill the payer(s) you have identified as primary for the beneficiary’s services. Refer to the “Identify the Proper Order of Payers for a Beneficiary’s Services” instructions linked on the left. If there are two payers primary to Medicare, then Medicare is the tertiary payer.
Once you bill and receive payment from the primary payers for the beneficiary’s services, use the following guidelines to determine whether or not to submit a Medicare tertiary claim to Medicare:
- Primary payers partially paid ‒ If the primary payers, together, made payment greater than zero but less than full payment, you are required to submit Medicare tertiary claim (known as a partial-payment claim). The receipt of less than full payment may be due to a variety of other reasons such as the primary payer’s (one or more) application of a deductible, coinsurance, or copayment.
- Primary payers fully paid ‒ Determine if services were inpatient or outpatient
- If the primary payers, together, made full payment and the claim is for inpatient services, you are required to submit Medicare tertiary claim (known as a Medicare full-payment claim).
- If the primary payers, together, made full payment and the claim is for outpatient services but the beneficiary has not yet met the annual Medicare Part B deductible, you are required to submit a Medicare tertiary claim (known as a full-payment claim).
Note: You can submit a Medicare tertiary claim for the beneficiary’s outpatient services even if the beneficiary did not meet the annual Medicare Part B deductible.
- Home health and hospice providers should submit Medicare tertiary full-payment claims regardless of whether or not the beneficiary met their annual Medicare Part B deductible.
Step 2: Prepare Medicare Tertiary Claim
A Medicare tertiary claim lists Medicare as the third payer, rather than as the second payer, as in the case of a MSP claim.
Medicare tertiary claims can be submitted via:
- 837I claim effective 1/1/2016 per CR 8486,
- the FISS DDE Provider Online System effective 1/1/2016 per CR 8486 or
- hardcopy format (UB-04/CMS-1450 claim form) once you obtain an approved ASCA waiver.
Examples of claims for which Medicare is the tertiary payer include, but are not limited to:
- beneficiary has two primary GHPs,
- beneficiary has a primary GHP and a primary non-GHP such as workers’ compensation or
- beneficiary has a primary GHP and a primary non-GHP such as no-fault.
When coding the Medicare tertiary claim, you need to determine the proper order of payers. Refer to the “Identify the Proper Order of Payers for a Beneficiary’s Services” instructions linked on the left. You must follow the same guidelines, depending on the situation, as are followed for preparing MSP claims and conditional claims. Refer to the “Prepare and Submit a MSP Claim and Prepare and Submit an MSP Conditional Claim” instructions linked on the left.
When Medicare is the tertiary payer, you may need to report additional claim coding beyond what is otherwise required if Medicare were the secondary payer. This may involve reporting additional CCs, OCs and dates, MSP VCs and amounts as well as two primary payer names and addresses, etc., since two payers have already processed the claim rather than one (as in the case of an MSP or conditional claim). In filing the claim, move Medicare down to the respective third payer line.
Step 3: Check for MSP Records in Medicare’s Records
Before you submit a Medicare tertiary (or greater) claim, check for matching MSP records for each of the primary payers on the claim. To check Medicare’s records, you can use the provider self-service tools listed under Step 2 in the “Identify the Proper Order of Payers for a Beneficiary’s Services” instruction linked on the left. If there are no such records, contact the BCRC to request that they be set up. Follow the “Set Up a Beneficiary’s MSP Record” instructions linked on the left.
Step 4: Wait for the BCRC to Set Up the Open MSP Beneficiary Records
You will continue to check for the MSP records to be set up. To check Medicare’s records, you can use the provider self-service tools listed under Step 2 in the “Identify the Proper Order of Payers for a Beneficiary’s Services” instructions linked on the left. If the BCRC does not correct the MSP records, you must follow up with them.
Step 5: Once the MSP Record is Set Up, Submit the Tertiary Claim to Medicare
Once the matching MSP record(s) are set up, submit the Medicare tertiary claim. You can submit Medicare tertiary claims:
- Via the 837I (per CR 8486 effective 1/1/2016). Prior to 1/1/2016, providers could not submit Medicare tertiary claims via the 837I claim.
- Via FISS DDE (per CR 8486 effective 1/1/2016). Prior to 1/1/2016, providers could not use FISS DDE to submit (or correct or adjust) Medicare tertiary claims.
- In hardcopy format if you have an approved ASCA waiver. For hardcopy claim submissions, you must properly code the tertiary claim on a hardcopy UB-04/CMS-1450 claim form, attach any supporting documentation including the primary payer’s remittance advice and EOB statement and submit it to the applicable National Government Services Medicare Claims Department. You can find the applicable address on our website under Contact Us.
Medicare’s Processing of Medicare Tertiary Claims
- Claim accepted: If Medicare tertiary (or greater) claims are submitted in accordance with the above instructions, and do not encounter any other editing, they proceed to the payment floor.
- Claim RTP: If Medicare tertiary (or greater) claims fail to meet Medicare’s usual claim submission requirements (technical, medical, and frequency of billing) and/or fail to meet the requirements for Medicare tertiary billing, they are not accepted and you must correct the claims which you may do in the FISS DDE per CMS CR 8486 effective 1/1/2016.
Related Content
Read More
