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Medicare Secondary Payer (MSP) Overview

Medicare Secondary Payer Manual (CMS Pub. 100-05)External Website

Medicare is a secondary payer when the beneficiary is covered by group insurance, Workers' Compensation, or if other third-party liability (no-fault, liability, Federal Black Lung Program) applies. For detailed information on CMS's Medicare Secondary Payer, refer to the CGS web page, CMS Guidelines and Resources for Medicare Secondary Payer (MSP), for links to the various CMS MSP regulations.

IDENTIFYING MSP RECORDS: Check the beneficiary's eligibility using ELGA, the CGS IVRPDF, or myCGS, to determine if a beneficiary has an MSP record. When your claim has dates of services that fall within the Effective and Termination dates of an MSP record, the claim must acknowledge the MSP record by reporting appropriate MSP coding on your claim. Refer to the Checking Beneficiary EligibilityPDF (Chapter 2) of the Direct Data Entry (DDE) Manual for information on using ELGA to identify MSP records that may impact your Medicare billing.

SUBMITTING MSP CLAIMS TO MEDICARE: Claims that include MSP information must be submitted either electronically (ANSI ASC X12N 837 format) or by entering the MSP claim directly into the Fiscal Intermediary Standard System (FISS) via Direct Data Entry (DDE). For more information, refer to the Submitting Medicare Secondary Payer (MSP) Claims and Adjustments web page. Effective January 1, 2016, paper UB-04 claims can only be submitted if your agency meets the small provider exception, (CMS Pub. 100-04, Ch. 24 §90), or if the services are related to Black Lung.

MSP BILLING RESOURCES: Specific data elements are required on an MSP claim to ensure correct processing and payment. Some of these data elements include occurrence codes, value codes, payer codes, and insurer information. CGS offers the following tools to assist providers with billing appropriate MSP claims.

SUSPENDED MSP CLAIMS: Claims/adjustments with MSP information may require Medicare staff intervention and suspend for more than 60 days. Providers may call the Provider Contact Center if their MSP claim has been in the same "S MXXXX" status/location for longer than 60 days.

MSP Resources from the Centers for Medicare & Medicaid Services (CMS)

CGS Resources

Posted: 02.06.19

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