Providers Denying Services to Medicare Beneficiaries with Open Medicare Secondary Payer (MSP) Records

Published 02/14/2023

It has come to CMS’s attention again that there are some providers, physicians and other suppliers who are denying services to beneficiaries due to an open Medicare Secondary Payer record on the beneficiary Medicare record. Providers and suppliers shall not deny medical services or entry to a SNF or hospital after you discover that there is an open or closed GHP (whether the beneficiary is entitled due to age, disability, or End Stage Renal Disease) or NGHP (Liability (L), No-Fault (NF) or Workers’ Compensation (WC), MSP record found in the HIPAA Eligibility Transaction System (HETS)  270/271, or on CWF. You must continue to see Medicare beneficiaries if a claim that was previously mistakenly denied by Medicare due to an MSP occurrence. These claims may be appealed through the appeal process.

Provider, Physician and Other Supplier Billing 
If services are covered under an open GHP or related to an NGHP MSP accident or injury incident, bill the primary insurer first. There are situations where providers bill for services related to a new accident or injury that are not related to an existing NGHP MSP record found on HETS or CWF. Physicians, providers and suppliers may need to use the same diagnosis codes that are found on the NGHP record in HETS and CWF. You may submit these claims to Medicare after you submit these claims to the appropriate GHP and/or NGHP insurer. The NGHP insurer may deny these claims if the claim is not related to the original accident or injury or the case has not been settled. After you submit these claims to Medicare, Medicare may mistakenly deny these services because the diagnosis codes on the claim are related to the diagnosis codes found on the NGHP MSP record on HETS and CWF. Physicians, providers and suppliers may appeal the inappropriately denied claim with your MAC. Physicians, providers and other suppliers must provide an explanation or a reason code to justify the services aren’t related to the accident or injury on record. Nonetheless, physicians, providers and other suppliers must continue to see or provide services to the beneficiary if claims are mistakenly denied.

A Workers’ Compensation Medicare Set Aside (WCMSA) MSP record is not a reason to deny services, but instead it provides information as to who is the appropriate primary payer for that situation. A WCMSA is an agreement between the CMS and the CMS beneficiary about what value of settlement funds must be spent for care related to all settled WC injuries or illnesses before Medicare begins primary payment for those settled injuries or illnesses. Providers must first verify via the HETS 270/271 transaction whether a “W” WCSA record exists. Where there is an indication showing a “W” MSP WCMSA record exists, the patient should have a WCMSA that may pay for services, and the provider bills the patient, directly. If the WCMSA does not pay for all of the services due to total exhaustion the provider may submit a Medicare bill indicating what the WCMSA paid. Medicare may then pay as a primary or secondary payer, dependent upon the WCMSA status and how much it paid on the claim. The provider submits a bill in accordance with the regular billing procedures indicating occurrence code 24 (insurance denied) and the date of denial in FL 31-36; and a supplementary statement calling attention to the fact that WCMSA denied payment or annotates FL 80, remarks, with the reason.

Billing no-fault, liability and worker’s compensation claims
When providers, physicians and other suppliers render services for beneficiaries whom have an open NGHP found on CWF, and in HETS, they must bills as follows:

  • If the NGHP record shows an indicator of “Y” identifying there is Ongoing Responsibilities for Medicals (ORM), do not bill Medicare. The NGHP insurer should be billed first as they are the proper primary payer for claims related to the accident or injury.
  • If the NGHP record shows an indicator of “N” or “BLANK” identifying there is no ORM, bill the NGHP insurer first. If the NGHP insurer denies the claim and identifies the reason for the denial on the remittance advice, the denial should be placed on your claim to Medicare. This will assist Medicare in determining to make a conditional payment during the promptly payment period.
  • If there is an open employer Group Health Plan record on CWF and HETS, always bill the GHP insurer first even before you bill the NGHP for both ORM and non-ORM claims

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