Determine if Medicare Will Make Payment on an MSP Claim
This information applies when you have filed a proper claim (one that meets all filing requirements specified by the primary payer) with the primary payer before submitting the claim to Medicare as secondary.
Step 1: Determine if Medicare will Make an MSP Payment
An MSP payment may be made if:
Primary payer’s payment for Medicare covered charges is less than your charges for those services and less than the total payable by Medicare in the absence of the primary payer’s payment, and
You do not accept and are not obligated to accept the primary payer’s payment full payment for the services
No MSP paymentis made by Medicare if:
Primary payer’s payment for Medicare covered charges equals or exceeds your charges for those services or the Medicare total payment (without regard to deductible or coinsurance), or
You accept, or are obligated to accept, the primary payer’s payment as full payment for the services, and you receive this amount
Note: If you are fully paid by the primary payer, National Government Services recommends you still submit an MSP claim to Medicare in order to document services rendered.
Step 2: Determine the Amount of Secondary Benefits
The amount of secondary benefits payable to you is the lowest of the following:
Actual charge by the physician/supplier (or the amount the physician/supplier is obligated to accept as payment in full if that is less than the charges) minus the amount paid by the GHP
Amount Medicare would pay if services were not covered by a GHP
Higher of the Medicare fee schedule or other amount that would be payable under Medicare (without regard to any Medicare deductible and/or coinsurance amounts) or the GHP's allowable charge (without regard to any co-payment imposed by the policy or plan) minus the amount actually paid by the GHP
Billing Reminders Which Can Affect your Medicare Payment
Report your actual charges, not what you’ve estimated is due from Medicare, as Medicare payment calculations are based on the total charges.
If you are under an obligated to accept payment as payment in full (OTAF) contract or obligation, you must ensure that report that situation on the claim form or the electronic equivalent.
For electronic claim submissions (837P claims) of MSP (and conditional) claims, you must report the CARCs and claim adjustment group codes from the primary payer’s remittance advice. Medicare uses this information to determine the amount, if any, of Medicare’s secondary payment.
Do not enter an amount in Items 29 (Amount Paid) or 30 (Balance Due) or their electronic equivalents for MSP claims. Amounts listed in these Items will result in incorrect MSP payment amounts and may cause a check to be mailed to the patient instead of to your office.
