MSP Explanation Form for Secondary Insured Claims

Medicare Secondary Payer (MSP) claims that are submitted on paper are often denied or returned for illegible or missing or invalid information.

The MSP Explanation Form was developed to help health care providers submit accurate, complete MSP claims and can be submitted with any MSP paper claim. This form should be submitted in addition to the Explanation of Benefits (EOB) from the primary insurer. We encourage you to use this form, although it is not mandatory.

Palmetto GBA will accept the following information on the MSP explanation form:

• The name and/or address of the insurance company
• If the primary insurer combines all services into a single service, you may break down the charges for each service. Please provide the submitted charges, allowed amount, paid amount and patient responsibility, if any. 
• If the primary insurer only places column heading on the first page of a multi-page EOB, Palmetto GBA will accept the information as indicated on the MSP explanation form
• A narrative description providing a more detailed explanation of the reason for denial or partial payment that is indicated on the EOB

Palmetto GBA cannot accept the following information on the MSP explanation form:

• The patient's identification, if not on the primary insurer's EOB
• The primary payer's paid amount
• Date of service
• Reason for denial or partial payment if not indicated on the EOB. An exception is if the EOB contains the reason for denial (reason/remark code), but the reason is not clear, a more detailed explanation can be provided on the explanation sheet.

Note: The Administrative Simplification Compliance Act (ASCA) requires that Medicare claims be submitted electronically, including claims for MSP. An exception is paper claims may be submitted when more than one payer is responsible for payment prior to Medicare.

Please see the MSP Explanation Form (PDF, 613 KB) on the Palmetto GBA website.