Identify the Proper Order of Payers for a Beneficiary's Services

Identify the Proper Order of Payers for a Beneficiary's Services
Step 1: Check for Open MSP Records for the Beneficiary in Medicare’s Records
Step 2: Collect MSP Information from the Beneficiary During the MSP Screening Process
Step 3: Compare the MSP Information you Collected from the Beneficiary to the MSP Information in Medicare’s Records
Step 4: Determine Which Payer is Primary, Secondary, etc. for the Beneficiary’s Services
Step 5: Document Your Determination Regarding the Proper Order of Payers and Submit Claims Accordingly
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Identify the Proper Order of Payers for a Beneficiary's Services

A Medicare beneficiary may have insurance/coverage in addition to Medicare. Medicare providers must determine, based on the MSP provisions, if Medicare is the primary (or secondary) payer for a beneficiary’s services. It is possible for a beneficiary to have more than one type of insurance/coverage primary to Medicare in which case Medicare may be the tertiary payer. If a beneficiary has insurance/coverage you determined is primary to Medicare per the MSP provisions, you must bill the payer(s) before billing Medicare.

To determine if a beneficiary has other insurance/coverage in addition to Medicare, you:

Must check for open MSP records in Medicare’s records and
May need to collect MSP information from the beneficiary during an MSP screening process.

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Step 1: Check for Open MSP Records for the Beneficiary in Medicare’s Records

A beneficiary may have one or more open MSP record(s) in the CWF. An open MSP record is one that provides insurance/coverage information about a payer that may be primary to Medicare per the MSP provisions and is not deleted or does not have a termination date prior to the claim’s DOS. To check for open MSP records in the CWF for each beneficiary, use the following provider self-service tools:

National Government Services IVR system
NGSConnex online Web application
CMS HETS (X12 270/271 transactions)
- MSP records contain the MSP VC or the Primary Payer code (Payer Code ID) which represents the MSP provision (refer to chart below) and additional information as applicable such as the primary payer’s effective date, termination date, name, policy number, patient relationship, etc.

MSP VC	MSP Provision	Primary Payer Code (Payer Code ID)
12	Working Aged, age 65 and over, EGHP, 20 or more employees	A
13	ESRD with EGHP in coordination period	B
14	No-Fault (automobile and other types including medical-payment insurance/coverage) or No-Fault Set Aside	D or T
15	WC or WC Set-Aside	E or W
16	Public Health Services; research grants	F
43	Disabled, under age 65, LGHP, 100 or more employees	G
41	Federal Black Lung Program	H
47	Liability Insurance or Liability Set-Aside	L or S

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Step 2: Collect MSP Information from the Beneficiary During the MSP Screening Process

In addition to checking for open MSP records in Medicare’s records for a beneficiary, you may need to collect MSP information from the beneficiary during your MSP screening process. To do so, ask him/her (or his/her representative) questions regarding his/her current MSP status. You may use the CMS’ model MSP questionnaire (CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Section 20.2.1) or your own compliant form (same content and intent as that of the model).

The CMS requires hospitals to collect MSP information for every inpatient admission and outpatient encounter of a beneficiary. We suggest all Part A providers (those that bill Medicare on a UB-04/CMS-1450 claim form, an 837I claim or in FISS DDE) follow the same frequency.

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

You are required to collect MSP information from beneficiaries who:
- Receive recurring hospital outpatient services, however, only once every 90 days.
  - These services are identical hospital outpatient services and treatments rendered more than once within a billing cycle (these may or may not be repetitive services).
You are not required to collect MSP information from beneficiaries who:
- Receive hospital reference laboratory services.
  - These services are clinical laboratory diagnostic tests and interpretation furnished without a face-to-face encounter between the hospital and beneficiary.
- Are members of MAO plans.
  - However, we suggest you do collect MSP information if the MAO plan member elected Medicare’s hospice benefit and/or if the MAO plan requires you to do so.
- Receive services at/by an affiliated provider and the provider with whom you are affiliated conducted an MSP screening process.
  - Example: A beneficiary receives services from a transfer ambulance service affiliated with a hospital. If the hospital conducted the MSP screening process with the beneficiary for the services, the affiliated transfer ambulance does not need to do so.
- Have an MSP record in the CWF but advised you the information has not changed and there is no other reason to collect additional MSP information.
  - If you have the ability to access MSP information in the CWF (or to send/receive X12 270/271 transactions) and you determine a beneficiary has an open MSP record, ask him/her if the record information has changed.
    1. If it has changed, administer a new MSP questionnaire/form
    2. If it has not changed, you do not need to do so. However, you may still need to collect information from the beneficiary regarding insurance/coverage not in the MSP record(s). For example, if there is an open GHP MSP record that has not changed (per the beneficiary) but the services are accident related and there is no accident MSP record, then ask the beneficiary the accident MSP questions.

Follow these tips to accurately collect MSP information:

Ensure your MSP questionnaire/form is dated and the date matches the claim’s DOS
Help the beneficiary understand the questions without responding to the questions for him/her
Document all responses you receive
Do not leave response fields to any applicable questions blank (if you must do so, document the reason)
Collect and record the beneficiary’s and/or spouse’s accurate retirement dates, as applicable. If the beneficiary and/or spouse cannot recall exact retirement dates, follow the policy in the CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Section 20.1, #4 for recording (in your records) and reporting (on your claims) retirement dates. The CMS’ model MSP questionnaire does not contain retirement date questions so you may record this information anywhere within your records.
If the beneficiary is unable to respond, speak to his/her representative
Save the completed MSP questionnaire/form for ten years (the beneficiary is not required to sign it)

For 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.

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

Review the MSP information you collected from the beneficiary and compare it to any MSP record(s) to look for similarities and discrepancies so you can discuss them with the beneficiary. It is beneficial to conduct this step before you render services to the beneficiary (pre-registration) or while the beneficiary is at your facility (registration). If the beneficiary is no longer at your facility, contact him/her to resolve any conflicts. Note: You may ask the beneficiary, the beneficiary’s representative, a family member, an insurance company, an employer or an attorney to contact the BCRC if there is a conflict between the open MSP record and the information you collected from the beneficiary or if there is MSP information the BCRC is not aware of based on the absence of an open MSP record. However, Medicare providers should not contact the BCRC. Rather, you will report any applicable information on the claim you submit to us. Refer to Step 5 below for more information.

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

To make the appropriate determination as to whether Medicare is the primary, secondary, or even tertiary payer, base your decision on the MSP provisions. Thus, after you compare the MSP information you collected from the beneficiary to any MSP record(s) and resolve any conflicts, determine if the criteria/conditions of any one or more of the MSP provisions have been met.

Follow these general guidelines to determine the proper payer order of payers for a beneficiary’s services:

Medicare is primary for the beneficiary’s services if they:
1. Has only Medicare and no other insurance/coverage is available.
2. Has other insurance/coverage but it does not meet the criteria/conditions of an MSP provision.
3. Had other insurance/coverage that met the criteria/conditions of an MSP provision, but it is no longer available, and no additional insurance/coverage is available. For example, Medicare is primary for a beneficiary’s automobile accident-related services if such services were rendered after any no-fault or medical-payment insurance/coverage exhausted, the beneficiary is not also filing a claim with a Liability insurer and no other insurance/coverage is involved.
Medicare is secondary (or possibly tertiary) for the beneficiary’s services if he/she
1. Has other insurance/coverage that fully meets the criteria/conditions for any one or more of the MSP provisions.

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

Once you determine the proper payer order of payers for any insurance/coverage the beneficiary may have in addition to Medicare, document that determination in your records and submit claims accordingly.

If you determine Medicare is primary for the beneficiary’s services, submit a Medicare primary claim. On that claim, report the reason(s) Medicare is primary using the appropriate CCs, OCs and/or Remarks. Unless the beneficiary or another party has contacted the BCRC to correct any open MSP record(s) that would cause the Medicare primary claim to reject for MSP, we may need to contact them with the information you reported on your claim. Review Step 3 above and:

If you determine one payer is primary to Medicare for the beneficiary’s services, submit a claim to that payer before you submit a claim to Medicare. Or, if you determine more than one payer is primary to Medicare for the beneficiary’s services, submit a claim to each of those payers, in the appropriate order, before you submit a claim to Medicare. When submitting the MSP, Medicare tertiary or conditional claim to us, report the insurance/coverage information described in our claim submission instructions below. For an MSP, Medicare tertiary or conditional claim to process, there must be a matching open MSP record in the CWF. Unless the beneficiary or another party has contacted the BCRC to set up any applicable open MSP record(s), we may need to contact them with the information you reported on your claim. Review Step 3 above and:

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Identify the Proper Order of Payers for a Beneficiary's Services

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