MEDICARE SECONDARY PAYER (MSP) Part I. Presented by Noridian Part B Medicare Provider Outreach and Education (POE) July 2016
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1 MEDICARE SECONDARY PAYER (MSP) Part I Presented by Noridian Part B Medicare Provider Outreach and Education (POE)
2 DISCLAIMER This information release is the property of Noridian Administrative Services, LLC (NAS). It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by NAS and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the NAS web site at and the CMS web site at The identification of an organization or product in this information does not imply any form of endorsement. 2
3 Helpful Acronyms Acronym CARC BCRC CWF EGHP ERA IOM MSPRC OTAF PECOS TPA Description Claim Adjustment Reason Code Benefit Coordination and Recovery Center Common Working File Employer Group Health Plan Electronic Remittance Advice Internet Only Manual Medicare Secondary Payer Recovery Contractor Obligated To Accept Payment in Full Provider Enrollment Chain & Ownership System Third Party Administrator 3
4 Agenda MSP Compliance MSP Provisions Provider Supplier Responsibility MSP Questionnaire Benefit Coordination and Recovery Center Billing MSP Claims Conditional Payments Other Information 4
5 Objective Provide knowledge and understanding of the Medicare Secondary Payer regulations Help to understand secondary billing requirements 5
6 MSP COMPLIANCE Are you Compliant? 6
7 MSP Term used when Medicare is not responsible for paying first Private insurance refers to it as Coordination of Benefits Assigns responsibility for first and second payments Medicare is not a supplemental insurance even when secondary Medicare s allowable is the determining factor in patient s liability 7
8 MSP Compliance Required by Medicare regulations Part of agreement to be a participating provider Non compliant In violation of the Mandatory Claim Submission Law Loss of contract to provide service Subjects provider to audits Providers responsibility to determine who is primary and who is secondary or tertiary 8
9 MSP Provisions Check out the differences! 9
10 MSP Provisions Working Aged End Stage Renal Disease (ESRD) Disability Med Pay (Auto/Liability) Liability Worker s Compensation Veterans Administration Black Lung 10
11 Working Aged Beneficiary is age 65 or older Actively employed/spouse actively employed Covered by a Employer Group Health Plan (EGHP) from that employment Works for a company of 20 or more employees (FT/PT) Covered by Part A Medicare 11
12 Working Aged Federal law supersedes State laws Private coordination of benefits provision Retirement plan is primary to an active plan Combined total of retirement plan and active plan constitutes primary payment Medicare is secondary 12
13 End Stage Renal Disease (ESRD) Entitled to Medicare based on ESRD Covered under an Employer Group Health EGHP regardless of number of employees (FT/PT, retired) self or family member 30 month coordination period Includes those covered under Consolidated Omnibus Reconciliation Act (COBRA) 13
14 Consolidated Omnibus Budget Reconciliation Act (COBRA) COBRA law requires employers to continue health coverage for employees and dependents who no longer work sufficient hours to qualify for EGHP This coverage is by virtue of the COBRA law rather than by virtue of current employment 14
15 COBRA Medicare is secondary payer to EGHP by virtue of current employment Patient covered by COBRA Medicare is primary Exception: People entitled under ESRD in their 30 month coordination period Medicare secondary 15
16 ESRD Entitlement begins with the month the beneficiary: Completes a three month waiting period after beginning dialysis Admitted for a kidney transplant Covered from the first month of entitlement Enrolls in a self dialysis training program First day of the month in which training occurs Entitlement terminates Thirty six months after a successful transplant 16
17 Dual Entitlement ESRD Individual entitled to Medicare based on ESRD and also entitled based on age or disability ESRD provision applies exclusively 30 month coordination period in effect Working aged or disability provision not applicable during or after the 30 month coordination period 17
18 Under age 65 Disability Entitled to Medicare on basis of disability (other than ESRD) Covered by a Large Group Health Plan (LGHP) (self or family member) LGHP of 100 or more employees 18
19 Auto Medical/No Fault Insurance coverage paying for all or part of medical expenses for injury sustained in the use of automobile regardless of fault Med Pay policy must be billed prior to Medicare Benefits exhausted Medicare pays primary Injury not fully as result of accident Medicare pays percentage of benefit as primary 19
20 Liability Source providing payment based on legal liability for injury, illness or damage to property Auto liability Uninsured motorist Homeowner s liability Product liability Wrongful death 20
21 Worker s Compensation Injured or illness on the job Payment made from a Worker s Compensation Medicare Set-Aside arrangement or conditional payment Allocate portion of settlement for future medical expenses File Worker s Compensation first 21
22 Veterans Administration Beneficiaries without monthly fee basis card Sees regular physician Submit claim to Part B Sees a VA physician Submit claim to VA No payment under Medicare for service authorized by VA One or the other, not both 22
23 Black Lung Entitled under the Federal Black Lung Program administered by the Department of Labor (DOL) Bill DOL if diagnosis is Black Lung Related Inpatient stay with some Black Lung covered procedures done File all services to DOL Outpatient services with some Black Lung services Bill DOL only for services reimbursable under Black Lung All unrelated services bill to Medicare 23
24 Test Your Understanding Mr. D is 67 years old and retired. He has a retiree plan with his previous employer. His spouse is 55 years old, still working for a large corporation and has EGHP and covers her husband. He decides to get a part time job at McDonalds. McDonalds offers him an EGHP but he declines. 24
25 Question #1 Who is the primary insurance? Who is secondary? What if he did not decline the EGHP coverage from McDonalds. Who is primary then? Who is secondary? Is there a tertiary coverage? 25
26 Scenario #2 Joan is 64 years old and developed end stage renal disease and had to go on dialysis in June of She is still working and has an EGHP with her company. 26
27 Question #2 In what month did her Medicare coverage begin? When Joan becomes 65 in August of 2013, will her primary insurance change? When her 30 month coordination period ends, who will be her primary insurance? 27
28 PROVIDER/SUPPLIER RESPONSIBILITY Were you aware of all these responsibilities? 28
29 Provider Supplier s Responsibility Critical Role Securing health insurance information from patient Update insurance information at each encounter Make a good faith effort to find out who is primary and who is secondary Complete MSP Questionnaire 29
30 Provider Supplier Responsibility Third party payer error Not good cause for reopening a processed Medicare claim Contractor reopening Within one year for any reason standard Providers have the legal obligation to find out the correct primary payer 30
31 BENEFICIARY QUESTIONNAIRE Are you asking all of these questions? 31
32 Beneficiary Questionnaire Medicare beneficiary admission questions Contains questions to ask beneficiaries upon each inpatient and outpatient admission May use as guide to help identify other payers primary to Medicare Admission Questions to Ask Medicare Beneficiaries [PDF] aims/msp/index.html 32
33 BENEFIT COORDINATION AND RECOVERY CENTER (BCRC) Do you know who they are and what they do? 33
34 BCRC Handles the initial development of MSP records Updating and maintaining MSP records in the Common Working File (CWF) Ensure accuracy and integrity of the MSP information 34
35 BCRC Consolidates activities to handle inquiries of potential MSP situations Report employment changes Report liability, auto/no fault or worker s compensation cases Assist patient with MSP Development letters and questionnaires Does not answer claim status related questions 35
36 BCRC To protect the Medicare Trust Fund Recovering Medicare payments made when another entity had primary payment responsibility Under GHP Non GHP Liability Insurance No-Fault Insurance Worker s Compensation 36
37 BCRC Contact the BCRC to Obtain conditional payment amounts Obtain final recovery claim amount Ask questions regarding recovery demand letters Ask questions on repaying Medicare Request a waiver of recovery on MSP debt Request first level appeal on MSP recovery demand letter 37
38 Contacting BCRC Medicare-MSP MSP General Correspondence PO Box Oklahoma City, OK Telephone Number (855)
39 Provider Attempting Update with Beneficiary in the Office First call made update made via phone Subsequent calls need: Proof of information Contact made to insurer or employer or organization that last updated record 39
40 Provider Attempting Update when Beneficiary not in the Office Beneficiary to contact BCRC Contact Beneficiary s insurer to resolve issue Fax or mail proof of information On insurer or employer s letterhead 40
41 Provider with New Information Change to existing records Beneficiary calls to close records Fax or mail proof of information On insurer or employer s letterhead 41
42 Provider Update for Deceased Beneficiary One provider can call in the date of death Subsequent updates Handled by family member with appropriate documentation and death certificate. 42
43 Top Rejections or Denials Paper Claims Remit information is illegible or missing Remit not for this claim No column heading on Remit No reason given on the primary remit for why patient is responsible for charge The word NONE is not in block 11 of CMS 1500 claim form when Medicare is primary 43
44 Top Rejection or Denial EMC Claims Incorrect MSP Type code Claim denied as duplicate Claim requesting additional information Allowed amount and payment amount in wrong field 44
45 BILLING MSP CLAIMS CMS-1500 Paper Claim Form and Electronic Media Claim (EMC) 45
46 Primary Remittance Requirements Certain information from primary payer s RA required on MSP claim Approved (allowed) amount Deductible amount (if any) Primary paid amount OTAF amount (if applicable) 46
47 What Items Involve MSP? Items 4, 6, 7, 10 and 11 = Other Primary Insurance Do not utilize Box 29 47
48 Billing Electronically Don t need copy of primary payer s RA Electronically submitted claims Has special loops/segments for MSP Used for processing and cross-referencing If practice software doesn t support MSP? Electronic Data Interchange Support Services (EDISS) offers FREE PC-ACE Pro32 48
49 Required MSP Electronic Data MSP ANSI Specifications - complete every service line: Equivalents: Items a b c - 11 a b c 2 digit Insurance type (i.e. 12, 47) Correct CARC code COB Payer Paid Amount (primary paid on each line) COB Allowed Amount (amount approved by primary) Claim Contract Information (OTAF) Claim Adjudication Date (see primary EOB) Approved Amount (primary approved) Line Adjudication Information and Date (original billed services) Line Level Adjustments (plus Service Line Adjudication equals total amount charged) Required amounts from Primary RA Approved, Deductible, Co-Insurance, Primary Paid, OTAF 49
50 Electronic Claim Fields Line Level Services Claim Level Information Primary Paid Amount Primary Allowed Amount (OTAF) Loop ID 2430 SVD02 Loop ID 2400 AMT02/AAE (as the qualifier in the 2400 AMT01 segment Loop ID 2400,CN102 CN 101=09 (must be greater than zero) Loop ID 2320 AMT02 AMT01=D Loop ID 2320 AMT02 AMT01=B6 Loop ID 2300, CN102 CN101=09 (must be greater than zero) 50
51 EDI MSP Billing Guides PC-ACE Billing Guides Billing Medicare Secondary Payer (MSP) Claims Electronically (Medicare Part B) Using PC-ACE Pro32 msp.pdf 51
52 Filing MSP Tertiary Claims 52
53 What to do when Medicare is Third Submit a claim to Medicare electronically as Medicare primary Claim will deny for MSP information Submit the MSP form with both primary payers remittance advice Claim will be reprocessed using multiple calculations MSP Form 525/ /Medicare+Secondary+Payer+Form/ a1a17bd9-31ac-4f27-a000-f2782fb06cd5 53
54 MSP Form 54
55 WHAT IS A CONDITIONAL PAYMENT? Definition 55
56 What is a Conditional Payment? Payment made when the primary insurance does not pay promptly within the timeframe Payment made to prevent the beneficiary from having to make a payment out of pocket Made with the intention of reimbursement 56
57 CONDITIONAL PAYMENTS Coverage Guidelines Group Health Plan (GHP) 57
58 Group Health Plan (GHP) Primary Coverage File primary plan first No Medicare conditional payment when primary plan available Primary filed and denied Medicare pays as primary Physical or mental incapacity of beneficiary preventing filing of a proper claim to the GHP 58
59 CONDITIONAL PAYMENT Coverage Guidelines Accident and Workers Compensation 59
60 Group Health Plan/Liability/No-Fault Automobile accident Primary coverage under Group Health Plan, Liability Insurance or No-Fault Insurance File primary plan first No Medicare conditional payment when primary plan available Primary filed and denied Medicare pays as primary Physical or mental incapacity of beneficiary preventing filing a proper claim to the GHP 60
61 Conditional Payment for Accident and Workers Compensation Medicare pays conditionally Insurer will not pay promptly Within 120 days from initial claim submission Insurer rejects or denies claim in full Must bill primary for rejection 61
62 No Conditional Payment for Accident and Workers Compensation Medicare will not make conditional payment Insurer applies entire payment to deductible, coinsurance or co-payment Patient has exhausted no-fault/auto benefits 62
63 CONDITIONAL PAYMENT Billing Instructions Accident and Workers Compensation 63
64 Billing Conditional Payment for Accident and Workers Compensation Include remarks to indicate the reason you are requesting a conditional payment Pull directly from the primary payer s EOB. Liability cases Date should be at least 120 days past date of service 64
65 CONDITIONAL PAYMENT Recovery Process Accident and Workers Compensation 65
66 Recovery Process No-Fault Insurance/Liability/Workers Comp Benefit Coordination and Recovery Center (BCRC) uses a two step process Issues a pre-demand letter to No Fault insurer Beneficiary s name and Medicare number Date of accident Itemized list of Medicare conditional payments made to date Any other additional information 66
67 Recovery Process No-Fault Insurance/Liability/Workers Comp If benefits exhausted No fault insurer Must provide itemized amounts of benefits paid and to whom Inform BCRC of any claims we listed that are not related to the accident Within 30 days of receiving the pre-demand letter BCRC If no response received» Issue a formal demand letter for recovery 67
68 Recovery Process No-Fault Insurance/Liability/Workers Comp Settlement/Judgment/Award Beneficiary or representative must send award documentation to the BCRC identifying Date of settlement Settlement amount Amount of attorney s fees and other procurement costs BCRC Will identify related claims Issue a formal recovery demand letter 68
69 Recovery Process No Fault Insurance/Liability/Workers Comp Demand letter Advise debtor of primary payment responsibility Beneficiary s name and Medicare number Date of accident Summary of conditional payment made by Medicare Total demand amount Information of applicable waiver and administrative appeal rights (beneficiary only) 69
70 Recovery Process No Fault Insurance/ Liability/ Workers Comp Debtor is insurer or Workers Comp carrier Dispute its obligation to repay Benefits already paid to beneficiary or provider» Provide explanation of benefits or record of payment» Identify service» Amount of payment» Date of payment» Date of service» Name of payee 70
71 Recovery Process No Fault Insurance/Liability/Workers Comp Checks made payable to Medicare BCRC-NGHP PO Box Oklahoma City, OK
72 REFUND SITUATIONS What Forms Should I use? 72
73 MSP Form Noridian MSP team responsible for processing MSP general and post pay correspondence Includes most MSP front-end related correspondence Send MSP primary/secondary claim inquiry Don t send as Reopening or Redetermination NOTE: If specific patient EOB information is not provided, unable to process request appropriately 73
74 JF MSP Voluntary Refund Form To send refund check voluntarily, use this Part B MSP Voluntary Check Form Utilized for any MSP request pertaining to Primary or Secondary payment Include form with every voluntary/unsolicited refund check 74
75 JE MSP Voluntary Refund Form To send refund check voluntarily, use this Part B MSP Voluntary Check Form Utilized for any MSP request pertaining to Primary or Secondary payment Include form with every voluntary/unsolicited refund check 75
76 Upcoming Part B Webinars Date Time (CT/PT) Webinar Title 7/6/16 1:00 PM/11:00 AM Medicare Secondary Payer 7/7/16 1:00 PM/11:00 AM Medicare Secondary Payer Calculations 7/8/16 11:00 AM/9:00 AM Ambulance Basic 7/12/16 3:00 PM/1:00 PM NCCI & MUE 7/13/16 1:00 PM/11:00 AM Ambulance Documentation and CERT 7/14/16 11:00 AM/9:00 AM CMS 1500 Claim Form Training REGISTER NOW! JE JF 76
77 CEU Reminder Attend entire workshop to earn CEU(s) Take short polling survey Pops up after closing out of webinar CEU ed 3 days after presentation Earn 1.5 CEUs today No password/index number needed for AAPC PDF presentation ed again with CEU Q/A posted after 30 business days 77
78 Questions? Thank you!
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