MSP: Eligibility & Denials

Denial Reason, Reason/Remark Code(s)

  • PR-22: Payment adjusted because this care may be covered by another payer per coordination of benefits
How can I determine when Medicare is the primary or secondary payer?
  • To find out whether Medicare should pay as primary or secondary, use the Palmetto GBA MSP Lookup Tool located on the home page under Tools. Ask your patient a series of yes/no questions and select the answers using our online tool.
  • Verify whether Medicare is primary or secondary for specific patients prior to submitting claims to Medicare through the Palmetto GBA eServices tool or Interactive Voice Response (IVR) Unit
  • If Medicare records do not match the MSP Lookup Tool outcome, refer the patient to the Coordination of Benefits Contractor to have his or her records corrected (more information follows)

Online MSP Verification through eServices

  • All providers that have an EDI Enrollment Agreement on file may register to use this tool. If you haven’t already registered, please consider doing so.
  • Please note: Only one provider administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. The provider administrator can then grant permission to additional users related to that PTAN/NPI.
  • Billing services and clearinghouses should contact their provider clients to gain access to the system
  • Specific instructions for accessing beneficiary eligibility information through eServices are available in the eServices User Manual (PDF, 8.83 MB) 
Coordination of Benefits Contractor (COBC)
  • Patients may contact Coordination of Benefits Contractor (COBC) for primary/secondary determinations at 800–999–1118, from 8 a.m. to 8 p.m. ET
  • Provider may contact COBC to:
    • Report potential MSP situations
    • Address general MSP concerns
    • Report incorrect insurance information
    • Get help completing an MSP questionnaire
  • Contact 800–999–1118 or the CMS Coordination of Benefits website
When is Medicare secondary?
  • Medicare may be secondary in the following situations or to the following plans:
    • Aged Worker — Medicare is the secondary payer when the primary Employer's Group Plan has 20 or more employees
    • Disability — Medicare is the secondary payer when the Employer's group Plan has 100 or more employees
    • Workers' Compensation — When the Medicare Beneficiary states that the illness or injury is work-related (regardless of past or current employment) and the Bureau of Workers' Compensation agrees that they are responsible for the illness or injury, Medicare is the secondary payer.
    • Auto/Liability — When the illness or injury is a result of automobile or liability that was caused by another party or on another's property, Medicare is the secondary payer. Please remember that subrogation can play a part for two years, where Medicare makes conditional payments with the intent of receiving refunds once there is a settlement.
    • Veterans Administration (VA) — Medicare and V.A. are equal entities. Patients without monthly fee bases cards may choose to see his or her regular physician, and those claims should be submitted to Part B. Services rendered in a VA facility must be filed with the V.A.
    • End-stage Renal Disease (ESRD) — When the patient is enrolled with Medicare solely due to renal failure, Medicare is secondary for the first 30 months, known as the Coordination Period
    • Incarcerated Beneficiary — CMS will deny claims for patients who are in custody of a state or local government under the authority of a penal statute at the time the provider rendered the service. This provision was implemented in Regulations 42 CFR 411.4(a) and 411.4(b) respectively.
    • Consolidated Omnibus Budget Reconciliation Act (COBRA) — Medicare is the secondary payer to group health coverage only if the coverage is by virtue of Current Employment Status (CES). The COBRA continuation of benefits law requires employers to continue health coverage for employees and dependents of employees who no longer work sufficient hours to qualify for the employer's health plan. Where the employer is required to provide such coverage, the coverage is considered to be "by virtue" of the COBRA law, rather than by virtue of "current employment status." Therefore, Medicare is primary to such coverage. Medicare is always primary over COBRA, except for a person who is entitled to Medicare based on end stage renal disease and they are in their 30-month coordination period. In this case, if the person has a COBRA plan, it would be primary until the end of the coordination period.

Note: Medicare regulations state that a patient must have both Part A and Part B Medicare for the MSP provisions to apply.

  • Ask patient about eligibility at time of visit; obtain copies of all insurance cards
  • Verify all required information is submitted with your paper claim or electronic submission. For complete MSP claim form instructions on our website.
    • Select Publications on the left side of this web page then Physician/Supplier Guide
    • Select Medicare Secondary Payer Guidelines, and then Claims Filing Requirements and select Medicare Secondary Payer Guidelines, and then Claims Filing Requirements
    • For paper claims, a copy of the primary insurer's EOB must be submitted with the claim form. To determine whether you qualify to submit paper claims, refer to MLN Matters article 3440.
    • Review the implementation guide (IG) for electronic MSP claim submission at https://nex12.org/index.php/codes

Reference: Find the answers to MSP Frequently Asked Questions located in the Self Service Tools on our home page.

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Provider Contact Center: 855-696-0705

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