The front line for Coordination of Benefits (COB) in the insurance industry is the institutional providers, such as hospitals. As part of their Medicare participation agreements, they are required to collect MSP information from the beneficiary pr beneficiary’s representative to determine if another primary payer exists. The COB Contractor contacts these providers directly with questionnaires to gather information about the potential for other insurance in addition to Medicare where information on the claim conflicts with information that Medicare has on file. Medicare Secondary Payer (MSP) information acquired during the hospital intake process ensures that Medicare pays in the appropriate order of financial liability.

There are many insurance benefits a patient could have and many combinations of insurance coverage to consider before determining who pays first. Depending on the type of additional insurance coverage, if any, a patient has, Medicare may be the primary payer for a beneficiary’s claim(s) or considered the secondary payer.

There are programs under which payment for services is usually excluded from both primary and secondary Medicare benefits.

• Veteran’s Administration (VA) Benefits - Medicare does not pay for the same services covered by VA benefits. For further information about VA benefits contact the VA Administration at 1-800-827-1000.
• Federal Black Lung Benefits - Medicare does not pay for services covered under the Federal Black Lung Program. However, if a Medicare-eligible patient has an illness or injury not related to black lung, they may submit a claim to Medicare. For further information, contact the Federal Black Lung Program at 1-800-638-7072.

 Medicare is the Secondary Payer when beneficiaries are:

• Treated for a work-related injury or illness. Medicare may pay conditionally for services received for a work-related illness or injury in cases where payment from the state workers’ compensation insurance is not expected within 120 days. This conditional payment is subject to recovery by Medicare after a workers’ compensation settlement has been reached. If WC denies a claim, or a portion of a claim, a claim can be filed with Medicare for consideration of payment.
• Treated for an illness or injury caused by an accident and liability and/or no-fault insurance will cover the medical expenses as the primary payer.
• Covered under their own employer’s or a spouse’s employer’s, group health plan (GHP).
• Disabled with coverage under a large group health plan (LGHP).
• Afflicted with permanent kidney failure (End-Stage Renal Disease (ESRD)) and are within the 30-month coordination period.

 Use the “MSP Questionnaire” to determine the primary payer of the beneficiary’s claims. It consists of six parts and lists questions to ask Medicare beneficiaries during each inpatient or outpatient admission, with the exception of policies regarding Hospital Reference Lab Services, Recurring Outpatient Services, Medicare+Choice Organization members, and when a beneficiary cannot recall his/her retirement dates. Further information regarding these policies can be found in Chapter 3 of the MSP Online Manual (See Related Links Inside CMS below). Use this “questionnaire” as a guide to help identify other payers that may be primary to Medicare. Beginning with Part 1, ask the patient each question in sequence. Comply with all instructions that follow an answer. If the instructions direct you to go to another part, have the patient answer, in sequence, each question under the new part. Note: There may be situations where more than one insurer is primary to Medicare (e.g., Black Lung Program and GHP). Be sure to identify all possible insurers.

The Trauma Development process begins when trauma/injury diagnosis codes submitted on a Medicare claim or information received alert the COB Contractor that an accident or traumatic injury may have occurred and the possibility of an MSP situation that warrants development. Use of the “MSP Questionnaire” can provide you with the correct information before the claim is submitted.

Downloads
Other Insurer Intake Tool
Related Links Inside CMS
There are no Related Links Inside CMS
Related Links Outside CMS
There are no Related Links Outside CMS

Page Last Modified: 12/14/2005 12:00:00 AM
Help with File Formats and Plug-Ins