Prepare and Submit a Medicare Tertiary Claim

Table of Contents

• Prepare and Submit a Medicare Tertiary Claim
• Step 1: Determine When a Claim(s) Must be Submitted to Medicare
• Step 2: Check for MSP Insurer Information in Medicare’s Records
• Step 3: Prepare and Submit Medicare Tertiary Claim(s)

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Prepare and Submit a Medicare Tertiary Claim

When multiple payers are involved in making a primary payment, please follow the steps below before submitting a tertiary claim to National Government Services Medicare Part B.

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Step 1: Determine When a Claim(s) 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 Determine if Medicare is Primary or Secondary for a Beneficiary’s Services.

Once you bill and receive payment from the primary payer for the beneficiary’s services, use the following guidelines to determine whether or not to submit a Medicare Tertiary Payer claim to Medicare:

1. Primary payers partially paid ‒ If the primary payer(s) made payment greater than zero but less than full payment, you are required to submit an MSP claim (known as an MSP 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 application of a deductible, coinsurance, or co-payment.
2. Primary payers fully paid ‒ For Medicare Part B services, providers are strongly encouraged to submit an MSP claim when the primary payers have made full payment.

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Step 2: Check for MSP Insurer Information in Medicare’s Records

Check Medicare’s eligibility files via NGSConnex or the IVR to determine if there’s other insurance primary to Medicare.

Submit claim-based information obtained via Model Admission Questions to Ask Medicare Beneficiaries.

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Step 3: Prepare and Submit Medicare Tertiary Claim(s)

A Medicare tertiary claim indicates that Medicare is the third payer, rather than the second payer, as in the case of a MSP claim.

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
• Beneficiary has a primary non-GHP such as no-fault and a primary GHP

Medicare tertiary claims cannot be submitted electronically; however, they must be submitted within one calendar year from the date of service using the current paper CMS-1500 claim form. You must properly code the MSP claim on a hard-copy CMS-1500 claim form 02/12 version, attach any supporting documentation such as the primary payers’ remittances and/or EOB statements and submit it to the proper National Government Services Claims P.O. Box, depending on the state in which your practice/office is located.

Once the tertiary CMS-1500 claim is properly prepared, submit the claim to Medicare for processing.

Revised 10/25/2023