Medicare Secondary Payer (MSP) Educational Series Questions and Answers


Medicare Secondary Payer (MSP) Educational Series

Provider Outreach and Education (POE) A/B Medicare Administrative Contractor (MAC) Collaborative Events


The following questions originated from the above-listed event series. The questions are followed by the appropriate answers and the sources of the information are provided. For additional information or details about MSP claims, please refer to your contractor's MSP web page.

General MSP Questions and Information

Part A only

Yes, the claim is still MSP. Once the claim is processed, beneficiary liability can then be determined.

Part B only

No. If the beneficiary does not have Part B coverage, then a provider would not need to bill for an office visit unless you need the denial stating the beneficiary has no Part B coverage.

Parts A and B

Please contact the Social Security Administration for guidance.

Refer to the Medicare remittance advice notice for the final patient responsibility. However, if the provider has been paid the full Medicare allowed amount between the primary insurance and Medicare, there typically is no additional monies owed to the provider.

Automobile Insurance and MSP

Parts A and B

If you know the claim is an MSP issue, providers are required to bill the primary insurance prior to submitting to Medicare.

Medicare regulations require all entities billing Medicare for services or items rendered to Medicare beneficiaries to determine whether Medicare is the primary payer for those services or items before submitting a claim to Medicare. When another insurer is identified as the primary payer, bill that insurer first.

For more information, refer to Medicare Learning Network® (MLN®) Matters Special Edition (SE) article SE1217 — Guidance for Correct Claims Submission When Secondary Payers Are Involved (PDF, 105 KB).

Yes, if state law permits this.

The MSP provisions do not create lien rights when those rights do not exist under state law. Where permitted by state law, a provider may file a lien for full charges against a beneficiary's liability settlement. The provider may enforce a permissible lien up to the lesser of the amount of the settlement and charges for the services incorporated in the lien. The provider may not charge interest, lien filing, or administrative fees to the beneficiary or against the lien.

Generally, providers must bill liability insurance prior to the expiration of the promptly period rather than bill Medicare. (The filing of an acceptable lien against a beneficiary's liability insurance settlement is considered billing the liability insurance.) Following expiration of the promptly period, or if demonstrated (e.g., a bill or claim that had been submitted but not paid) that liability insurance will not pay during the promptly period, a provider, physician, or other supplier may either:

  • Bill Medicare for payment and withdraw all claims/liens against the liability insurance/beneficiary's liability insurance settlement (liens may be maintained for services not covered by Medicare and for Medicare deductibles and coinsurance); or
  • Maintain all claims/liens against the liability insurance/beneficiary's liability insurance settlement

Source: The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Pub. 100-05, Chapter 2 (PDF, 188 KB), section 40.2 for more details.

When the beneficiary is paid directly by no-fault insurer, payment should be paid to the provider by the beneficiary. Report the amount paid by the primary insurer with appropriate coding on the claim. Medicare will process as secondary payer and the provider will need to contact the beneficiary for the primary payment resolution.

Source: CMS IOM Pub. 100-5, Ch. 3, Section 10.1.1 Right of Providers to Charge Beneficiary Who Has Received Primary Payment from a GHP (PDF, 220 KB).

Billing MSP Claims

Part A only

Condition code 08 should be submitted on claims when the beneficiary would not furnish information concerning the other insurance coverage. The Common Working File (CWF) monitors these claims and alerts the Benefits Coordination & Recovery Center (BCRC). The BCRC will then contact the beneficiary if necessary.

The Part A claim should reject and assign responsibility to the patient. Contact customer service for assistance with the claim.

Part B only

No. The CMS-1500 (or the electronic equivalent) is the Part B claim form, which is used for billing MSP claims as well.

Medicare guidance on completing the CMS-1500 can be found in the CMS IOM Publication 100-04, Chapter 26 (PDF, 592 KB), Section 10.2. Additionally, your MAC may have information available on their website or MSP page.

Yes, except for attaching a primary explanation of benefits (EOB) if billing on paper and if electronic, filling in some fields not found on the CMS-1500.

Where are the instructions for completing the CMS-1500 when billing MSP? Is there another form specific for MSP billing rather than the CMS-1500 to submit MSP claims? No. The CMS-1500 (or the electronic equivalent) is the Part B claim form, which is used for billing MSP claims as well.Medicare guidance on completing the CMS-1500 can be found in the CMS IOM , Section 10.2. Additionally, your MAC may have information available on their website or MSP page. Are MSP claims sent to Medicare the same way as normal Medicare claims?  Yes, except for attaching a primary explanation of benefits (EOB) if billing on paper and if electronic, filling in some fields not found on the CMS-1500.

Parts A and B

Yes, you have one year from the date of service to file the claim.

The MSP rules apply to all entities submitting claims to Medicare.

CARCs can be found on the remittance advice, explanation of benefits or denial letter. In rare situations where a CARC is not provided by the primary payer, check the national website and select the best denial reason.

No; this would not be an appropriate use of an ABN.

Source: Fee-for-service (FFS) ABN.

You must bill to the primary payer first; then to Medicare as secondary.

If a patient or other party refuses to furnish information concerning other insurance coverage, you may submit a Part A claim as Medicare primary with condition code 08 (beneficiary would not furnish information concerning other insurance coverage). The CWF monitors these claims and alerts the BCRC.

If billing Part B, submit the claim to Medicare. Medicare will deny the charge. You can contact the BCRC to verify they have the correct information.

If the patient receives the payment, you may bill the patient.

Yes. If the condition is unrelated to the WC or liability, providers can bill Medicare as primary.

Conditional MSP Payments

Parts A and B

Yes, but remember conditional payments are made subject to repayment to Medicare when the primary plan makes payment. Medicare may make a conditional payment even though payment is expected to be paid by another payer.

Refer to article MM7355 (PDF, 815 KB) for information on conditional payments and promptly situations.

Additionally, please review your MAC's provider website for their MSP webpage, which contains a plethora of helpful information, tools and resources.

Providers can choose the earlier of the promptly situations described below and code appropriately.

For no-fault insurance, "promptly" means payment within 120 days after receipt of the claim. For liability insurance (including self-insurance), "promptly" means payment within 120 days after the earlier of: a) the date a general liability claim is filed with an insurer or b) the date the service was furnished or, in the case of inpatient hospital services, the date of discharge.

For a liability situation, the MSP record is usually posted to CWF after the beneficiary files a claim against the associated liability insurance. In the absence of evidence to the contrary, the date the general liability claim is filed against the liability insurance is no later than the date that the record was posted to CWF. Therefore, for the purposes of determining the promptly period (the 120 days), Medicare contractors consider the date the liability record was created on Medicare's CWF to be the date the general liability claim was filed.

Refer to article MM7355 (PDF, 815 KB) for information on conditional payments and promptly situations.

Additionally, please review your MAC's provider website for their MSP webpage, which contains a plethora of helpful information, tools and resources.

For documentation requirements and claims coding information, refer to article MM7355 (PDF, 815 KB) for information on conditional payments and promptly situations.

Additionally, please review your MAC's provider website for their MSP webpage, which contains a plethora of helpful information, tools and resources.

To make the Medicare trust fund whole, the BCRC will work with the primary insurer if the primary insurer is responsible for the charges. Payments made by Medicare as a conditional payment, providing that you filed the claim initially with the primary insurer and they failed to pay timely, can be maintained during this process.

Not without the necessary information indicating how the primary insurer handled the claim.

If the primary payment went to the patient, you may conditionally bill the patient indicating they may be responsible for the bill if you are not able to obtain necessary information on how the primary insurer handled the claim so that Medicare may be billed. This should be your last resort and communication with the patient or primary insurer should be done first.

Employer Group Health Plan (EGHP)

Parts A and B

The employer will need to provide that to the insurance or the insurer for that employer will have that information.

Eligibility Questions

Part A only

Medicare encourages you to communicate with the patient and inform them it appears the incorrect information was provided. Make note of the discussion and make any necessary corrections to the form.

Parts A and B

If providers have different information about primary or secondary insurances and the beneficiary is unable or unwilling to update their information with the BCRC, send this information to the BCRC and they will perform an investigation and attempt to receive the correct information.

The BCRC address is:

Benefits Coordination & Recovery Center (BCRC)
Medicare — Data Collections
P.O. Box 138897
Oklahoma City, OK 73113–8897

The BCRC is a separate contractor and contact information for the BCRC can be found on the CMS website.

The BCRC handles all TPL records on file.

Providers can contact the BCRC to ask that they investigate whether Medicare is primary or secondary, or if there is contradictory information.

The BCRC is a separate contractor and contact information for the BCRC can be found on the CMS website.

Medicare requires eligibility (including MSP) should be checked for all patients. Ensure to have a standard process in place.

Front office staff should have beneficiaries complete the MSPQ and ask beneficiaries for their current cards at each check-in. The MSPQ is required for Part A.

Providers can check the MSP screen in CWF to ensure the information is accurate before you submit your claim to Medicare. You can access this through your contractor's portal or through a Health Insurance Portability and Accountability Act [HIPAA] Eligibility Transaction System (HETS) transaction.

Have the beneficiary fill out the MSPQ to find out this information.

Providers can check the MSP screen in CWF to ensure the information is accurate before you submit your claim to Medicare. You can access this through your contractor's portal or through a HETS transaction.

Have the beneficiary fill out the MSPQ to find out this information.

Providers can check the MSP screen on the CWF to ensure the information is accurate before you submit your claim to Medicare. You can access this through your contractor's portal or through a HETS transaction.

No. To update CWF, the BCRC would need to be contacted.

The BCRC is a separate contractor and contact information for the BCRC can be found on the CMS website.

Providers should request the reopening within one year of the date CWF was updated.

Part A providers should submit a reopening request on type of bill (TOB) XXQ to identify them as a reopening. This TOB should only be used when the submission falls outside the period to submit an adjustment bill. Also, submit the appropriate R1-R9 reopening condition code and adjustment condition code, adjustment reason code (Direct Data Entry [DDE] users only) and good cause remarks in the proper format. Claims determined to not have good cause will be returned to the provider (RTPd). See article MM8581 (PDF, 84 KB) and SE1426 (PDF, 1.01 MB) for further guidance.

Part B providers should follow the reopening process used by your MAC for historical corrections. This may be achieved using the interactive voice response (IVR) system or the MAC online portal. Consult your MAC's website for further guidance.

Please contact the BCRC for guidance. The BCRC is a separate contractor and contact information for the BCRC can be found on the CMS website. 

To update CWF, the BCRC would need to be contacted. However, they may require the beneficiary to verify certain information before updating the file.

The BCRC is a separate contractor and contact information for the BCRC can be found on the CMS website.

The information concerning exceptions will be on file with the BCRC, and providers should be able to check with the BCRC to obtain the information.

Spouse coverage is appropriate since family coverage is not addressed in the working aged section. For billing purposes, however, domestic partner is assigned a specific patient relationship code.

Yes. When submitting a claim to Medicare, ask the questions to determine the correct primary payer.

Billing for inpatient or outpatient hospital services requires the MSPQ to be completed for every date of service (unless it is for recurring outpatient services; see CMS IOM Publication 100-05, Chapter 3, and Section 20.1).

Federal Black Lung Program (FBLP)

Parts A and B

If a Medicare patient is entitled to FBLP medical benefits, any services unrelated to the black lung condition may be submitted to Medicare as primary with remarks indicating services are not related to black lung diagnosis.

Diagnoses associated with FBLP and non-group health plans, such as WC, liability and automobile coverage, may be obtained from the HETS, or the MAC's IVR and internet portals.

Group Health Plan (GHP)

Parts A and B

The GHP pays primary, Medicare pays secondary.

Liability Insurance and MSP

Parts A and B

You should ask the beneficiary is she plans to file a claim on her friend's homeowner's insurance. If yes, obtain the information and submit a claim to the homeowner's insurance before submitting an MSP claim to Medicare. If not, the claim may be submitted as Medicare primary.

Medicare Advantage (MA) Plans

Parts A and B

Please contact the individual MA plan for billing guidance.

Please contact the individual MA plan for billing guidance.

Medicare Primary in Error

Parts A and B

The provider is responsible to adjust the claim. As you cannot reopen this type of claim, you would need to request an appeal. The provider should submit a primary payer EOB for the MAC to process the duplicate primary payment (DPP). If no EOB is submitted, the MAC will recoup the full primary payment.

If your MAC allows for another way of correcting this situation (like completing an MSP form or a self-service option), you can pursue that option. Be sure to check your MAC's MSP webpage for more information.

The provider may submit the primary payer information to Medicare to recoup the payment. However, the beneficiary is responsible for reporting the accident to the BCRC for the recovery process to take place. If the provider fails to submit the DPP, the BCRC will recover the payment.

Veteran's Administration (VA) Claims

Part A only

Medicare is not secondary to the VA. Both are federal government programs. You must file to one or the other. Claims involving the VA are not considered MSP.

When filing a VA claim primary, should we file a Medicare claim with the condition code 77 showing the VA payment? Medicare is not secondary to the VA. Both are federal government programs. You must file to one or the other. Claims involving the VA are not considered MSP.

Parts A and B

For situations involving VA payments, please refer to MLN article SE1517 (PDF, 54 KB).

Ongoing Responsibility for Medicals (ORM)

Parts A and B

For ORM, please reference the article MM8984 (PDF, 411.36 KB).

Primary Insurance Paid in Full

Part A only

For Part A, submit the claim to Medicare with condition code 77 because it could apply to the Medicare deductible. We instruct providers to submit regardless if deductible was met or not because the primary insurance info could change (e.g., a retro term date).

Parts A and B

Yes.

For inpatient services, if the primary payer made full payment (or an amount considered to be full payment), submit an MSP claim (known as an MSP no-payment claim or an MSP full-payment claim) to Medicare in even though there is no balance due from Medicare. This determines the benefit period.

For outpatient services, it should also be determined when the beneficiary has not met his or her annual Medicare Part B deductible. The bill is submitted to inform Medicare of the charges where the deductible may not yet be met. Although Medicare can make no payment, it can apply the expenses to the beneficiary's deductible. A bill is required for crediting the deductible.

In addition, we recommend all home health and hospice providers submit MSP no-payment (MSP full-payment) claims.

See CMS IOM Publication 100-05, Chapter 3 (PDF, 220 KB), Sections 30.5, 40 and 40.1.1 for more information.

Yes. If the patient has Medicare, you should still submit the claim to us even if there is no balance. No-pay bills should be submitted to Medicare to determine the benefit period, update frequency limitations for services and/or satisfy any unmet deductibles.

In addition, if the primary insurance recoups their payment at any time and secondary coverage becomes primary, it is important the claim is not past the timely filing limits. If the primary payer requests repayment after the timely filing limit and Medicare received the claim, you may be able to request a reopening.

See CMS IOM Publication 100-05, Chapter 3 (PDF, 220 KB), Sections 30.5, 40 and 40.1.1 () for more information.

Yes. If the patient has Medicare, you should still submit the claim to us even if there is no balance. No-pay bills should be submitted to Medicare to determine the benefit period, update frequency limitations for services and/or satisfy any unmet deductibles.

RTP Claims

Part A only

For Part A claims that RTP, verify the patient's eligibility. Then, contact the Provider Contact Center with any additional questions.

Workers' Compensation Claims

Parts A and B

Providers can submit a redetermination of the claim, indicating the services were not related to the WC. If it is not related to an accident, the contractor is able to investigate to see if payment should be made.

For Part A claims not related to the open file, remarks indicating "Not related to XX" will help with the claims processing. If the diagnosis codes match an open WC case, that cannot be bypassed, and the claim will need to be submitted for conditional payment.

You can refer to MLN article SE1416 (PDF, 93 KB) for additional details.

MACs determine the claim relationship based on the information in the patient record. The injury date should be submitted on your claim. Providers can locate MSP information, included the open WC and related diagnoses, in the contractor portal for your jurisdiction.

Medicare should not be billed for future medical services until those funds are exhausted by payments to providers for services that would otherwise be covered and reimbursable by Medicare. See MLN Matters SE17019 (PDF, 81 KB).

To determine if Medicare has any obligation, the provider would need to file the tertiary claim along with the EOB from the primary and WC insurances.

Medicare is the secondary payer to WC benefits when services rendered are related to the injury, illness or disease. If the patient does fall and the condition is unrelated to the WC condition, then you can submit the claim primary to Medicare. We do look at the diagnosis codes. If the new condition is related to the WC, then this should be updated through the BCRC. If you submit the claim to WC and they deny it, then you can submit the claim to Medicare as secondary (need to remark that it was denied by the primary).

Yes. WCMSA funds are used to pay for treatment related to the WC injury/illness until those funds are exhausted.

Please contact the beneficiary's MA plan for billing guidance once those benefits have exhausted.

References 

The Provider Outreach and Education A/B Medicare Administrative Contractor Workgroup developed this material. Our joint effort ensures consistent communication and education so that providers and physicians have the information they need to submit claims appropriately and receive proper payment in a timely manner.





Last Updated: 10/22/2021