Medicare Secondary Payer (MSP)

Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have primary payment responsibility. In this situation, another entity has the responsibility for paying on a claim before Medicare. Medicare remains the primary payer for beneficiaries who are not covered by other types of health insurance or coverage. 

The CMS guidelines governing these processes can be found on the CMS website under:

Other CMS reference material:

Palmetto GBA is committed to helping providers understand the MSP process. For more information and the options available to you, please select the link below for additional information regarding the MSP process.

Topic
Brief Description
This tool is designed to help you determine if Medicare is the primary or secondary payer by walking you through a few simple questions.
In certain situations Medicare will pay claims for eligible beneficiaries as a secondary payer to the beneficiary’s primary plan. 
The BCRC consolidates the activities that support the collection, management, and reporting of other insurance coverage for Medicare beneficiaries.
This reference page will assist providers in understanding the various MSP billing processes for Palmetto GBA, including the eight types of MSP situations: Working Aged, Disability, ESRD, Liability, No-Fault, Workers’ Compensation, Public Health Services (PHS) and the Federal Black Lung program. 
The information on this tip sheet is designed to assist providers in understanding when Medicare will make a conditional payment for Medicare covered services.
The information on this tip sheet addresses common MSP billing situations.
The 'working aged' are employed people age 65 or over, and people age 65 or over with employed spouses of any age, who have group health plan (GHP) coverage because of their own or their spouse's current employment.
Medicare cannot make payment for covered items or services when payment has been made or can reasonably be expected to be made promptly by auto medical/no-fault or liability insurance.
Payment under Medicare may not be made for any claims if payment has been made or can be made under a Workers' Compensation (WC) law or plan of the United States or any State.
The Medicare Secondary Payer provisions state that Medicare may be the secondary insurer for a beneficiary under the age of 65 years who is eligible for Medicare solely on the basis of End Stage Renal Disease (ESRD).
Payment under Medicare may not be made for any claims if payment has been made or can be made under the Federal Black Lung Program.
Medicare claims where Veteran’s Affairs (VA) liability may be involved. Claims involving the VA are NOT considered MSP.
The regulations provide that a person has CES even if he or she is not actively working and/or if he or she is receiving disability benefits from an employer for up to six months.
What should you do when a claim has been rejected with reason code 30928?
There are times when a provider will receive a primary payment from another insurance company after Medicare has paid as primary. When this happens, it is assumed that Medicare should be the secondary payer. If you receive two primary payments, you should refund Medicare's payment in full.
A Medicare Secondary Payer (MSP) overpayment can occur when Medicare has processed and paid a claim as the primary payer, but should have paid as secondary. 
  • In order to report an MSP overpayment to Medicare without submitting a payment, the MSP Inquiry Form must be submitted along with the primary insurer EOBs. 
  • If you are submitting a payment along with the disclosed overpayment, the appropriate MSP Voluntary Refund form must be submitted along with the primary insurer EOBs. 
Information about the primary insurer and primary payment are required for all MSP claims.  The OTAF amount is equal to the amount of the primary payer's payment plus any patient responsibility

MSP records are maintained by the BCRC.  Medicare contractors are unable to update a patient’s insurance information with the BCRC by phone. The BCRC can accept MSP change information from providers in some situation. In others, the BCRC may ask providers to fax or mail proof of insurance information, or require the beneficiary to call to report the change. 

Providers can also reference the Medicare Learning Network (MLN) Special Edition Article SE1416 – Updating Beneficiary Information with the Benefits Coordination & Recovery Center.

 

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