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What is Medicare Secondary Payer (MSP)?

Medicare Secondary Payer (MSP) is the term used when Medicare considers payment after a primary insurance company makes their payment determination.

The primary payer is required to process and make primary payment on the claim in accordance with the coverage provisions of its contract. If, after the primary payer processes the claim, it does not pay in full for the services, Medicare secondary benefits may be paid for the services.

If a beneficiary is covered under any of the following insurance plans, Medicare would be considered a secondary payer:

Group Health Plan (GHP)

Working AgedExternal PDF (age 65+) – GHP coverage is through the beneficiary's or spouse's current employment and the employer has 20 or more employees.

End Stage Renal DiseaseExternal PDF (ESRD) - – GHP coverage is through the beneficiary's or family member's current or former employment, including COBRA coverage. Medicare is secondary for a 30 month coordination of benefit period.

Large Group Health Plan (LGHP)

DisabilityExternal PDF (under age 65) - LGHP coverage is through the beneficiary's or family member's current employment and the employer has 100 or more employees.

Liability Insurance

Liability insuranceExternal PDF means insurance (including a self-insurance plan) that provides payment based on the policyholder's alleged legal liability for injury or illness or damage to property. It includes, but is not limited to homeowners' liability insurance, malpractice insurance, product liability insurance and general casualty insurance.

No-Fault Insurance

No-fault insuranceExternal PDF is a form of insurance that pays for medical expenses for injuries sustained on the property or premises of the insured, or in the use, occupancy, or operation of an automobile regardless of who may have been responsible for causing the accident.

Workers' Compensation (WC)

Payment under Medicare may not be made for any items and services to the extent that payment has been made or can reasonably be expected to be made for such items or services under a Workers' CompensationExternal PDF (WC) law or plan of the United States or any State.

Black Lung (BL)

Where it appears that a beneficiary is entitled to medical benefits under the Federal BL Program, and the services being provided are related to BL, the provider must bill the Department of Labor (DOL) before billing Medicare. The BL- related diagnoses are (500-508).

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