Medicare Secondary Payer (MSP) Contractor Fact Sheet
The Centers for Medicare & Medicaid Services (CMS) has embarked on an important initiative to further expand its campaign against Medicare waste, fraud and abuse under the Medicare Integrity Program. CMS awarded the Medicare Secondary Payer (MSP) contract to consolidate the activities that support the collection, management and reporting of other insurance coverage of Medicare beneficiaries.
- The MSP Contractor provides many benefits for employers, third party payers, attorneys, beneficiaries and federal and state insurance programs
- All Medicare Secondary Payer (MSP) claims investigations are initiated and researched by the MSP Contractor. This is no longer the function of your Medicare Contractor.
- Implementing this single-source development approach will greatly reduce the number of duplicate MSP investigations. This will also offer a centralized, one-stop customer service approach for all MSP-related inquiries, including those seeking general MSP information, but not those related to specific claims or recoveries that serve to protect the Medicare Trust Funds.
- The MSP Contractor provides customer service to all callers from any source, including, but not limited to, beneficiaries, attorneys or other beneficiary representatives, employers and insurers
- Medicare generally uses the term Medicare Secondary Payer (or MSP) when the Medicare program is not responsible for paying a claim first
- The MSP Contractor will use a variety of methods and programs to identify situations in which Medicare beneficiaries have other health insurance that is primary to Medicare. In such situations, the other health plan has the legal obligation to meet the beneficiary's health care expenses first before Medicare.
- The table below describes a few of these methods and programs
|Initial Enrollment Questionnaire (IEQ)||Beneficiaries are sent a questionnaire about other insurance coverage approximately three months before they are entitled to Medicare.|
|IRS/SSA/CMS Data Match||Under the Omnibus Budget Reconciliation Act of 1989, employers are required to complete a questionnaire that requests Group Health Plan (GHP) information on identified workers who are either entitled to Medicare or married to a Medicare beneficiary.|
|MSP Claims Investigation||This activity involves the collection of data on other health insurance that may be primary to Medicare based on information submitted on a medical claim or from other sources.|
|Voluntary MSP Data Match Agreements||Voluntary Agreements allow for the electronic data exchange of GHP eligibility and Medicare information between CMS and employers or various insurers.|
Provider Requests and Questions Regarding Claims Payment
- Medicare Contractors will continue to process claims submitted for primary or secondary payment. Claims processing will not be a function of the MSP Contractor.
- Questions concerning how to submit claims for payment (e.g., value codes, occurrence codes) should continue to be directed to Palmetto GBA. In addition, continue to return inappropriate Medicare payments to Palmetto GBA.
- Checks should not be sent to the MSP Contractor
- Questions regarding Medicare claim or service denials and adjustments should continue to be directed to Palmetto GBA
- If a provider submits a claim on behalf of a beneficiary and there is an indication of MSP, but not sufficient information to disprove the existence of MSP, this will be investigated by the MSP Contractor
- The goal of MSP information gathering and investigation is to identify MSP situations quickly and accurately, thus ensuring correct primary and secondary payments by the responsible party
- Providers, physicians and other suppliers benefit not only from lower administrative claims costs, but also through enhanced customer service to their Medicare patients
Medicare Secondary Payer Auxiliary Records in CMS's Database
- The MSP Contractor is the sole authority to ensure the accuracy and integrity of the MSP information contained in CMS's database (e.g., Common Working File). Information received as a result of MSP gathering and investigation is stored on the CWF in an MSP auxiliary file.
- The MSP auxiliary file allows for the entry of several auxiliary records, where necessary
- MSP data may be updated, as necessary, based on additional information received from external parties (e.g., beneficiaries, attorneys, third party payers). Beneficiary, spouse and/or family member changes in employment, reporting of an accident, illness or injury, federal program coverage changes or any other insurance coverage information should be reported directly to the MSP Contractor by the beneficiary.
- CMS also relies on providers and suppliers to ask their Medicare patients about the presence of other primary health care coverage and to report this information when filing claims with the Medicare program
Termination and Deletion of MSP Auxiliary Records in CMS's Database
- Medicare Contractors will continue to terminate records on the CWF where the provider has received information that MSP no longer applies (e.g., succession of employment, exhaustion of benefits)
- Termination requests should continue to be directed to your Medicare contractor. MSP records on the CWF that are identified as invalid will be reported by the Medicare contractor to the COB contractor for investigation and deletion.
Continue to call Palmetto GBA regarding claims-related and recovery questions.
- Customer service representatives are available to assist you from 8 a.m. to 8 p.m., Monday through Friday, ET, except holidays
- Clip and post this section in a handy place for access by your office and billing staff
The form to submit an inquiry to Palmetto GBA: Medicare Secondary Payer Inquiry Form (PDF).