- Determine if Medicare is Primary or Secondary for a Beneficiary's Services
- What is Medicare Secondary Payer?
- Identify the Proper Order of Payers for a Beneficiary's Services
- Set Up a Beneficiary's MSP Record
- Prevent an MSP Rejection on a Medicare Primary Claim
- Correct a Beneficiary's MSP Record
- Prepare and Submit an MSP Claim
- Prevent an MSP Rejection on a Medicare Primary Claim
- Collect and Report Retirement Dates on Medicare Claims
- Prepare and Submit a Medicare Secondary Payer Claim
- Prepare and Submit a Medicare Tertiary Claim
- Prepare and Submit an MSP Conditional Claim
- Determine if Medicare Will Make Payment on an MSP Claim
- Determine Beneficiary Responsibility on an MSP Claim
- Correct or Adjust a Claim Due to an MSP-Related Issue
- Determine if Medicare will Make an MSP Payment
- Correct or Reopen a Claim Due to an MSP-Related Issue
- Populating MSP Insurance Type Code on Electronic Claims
- Determine Beneficiary Responsibility on an MSP Claim
- Medicare Overpayments Are Not Redeterminations
- Medicare Secondary Payer: Don’t Deny Services & Bill Correctly
Determine Beneficiary Responsibility on an MSP Claim
Table of Contents
- Determine Beneficiary Responsibility on an MSP Claim
- Step 1: Review the Remittance Advice
- Step 2: Ensure the Primary Payer’s Payment Satisfied the Medicare Deductible and Coinsurance Amounts
- Step 3: Assess Beneficiary’s Responsibility
- Related Content
Determine Beneficiary Responsibility on an MSP Claim
- Fact: Medicare beneficiaries are responsible only for the amount applied to the claim for the Medicare deductible and Medicare coinsurance as well as for any noncovered Medicare services. When Medicare is secondary, this is still true. However, the primary payer’s payments are first used to satisfy the beneficiary’s responsibilities under Medicare.
Therefore, for an MSP claim, the beneficiary is responsible for the amount of the Medicare deductible and Medicare coinsurance applied to the claim as well as for any noncovered Medicare services that were not paid for by the primary payer.
Step 1: Review the Remittance Advice
Once National Government Services Medicare processes an MSP claim, we generate a remittance advice. On that remittance advice, you can find the amount of Medicare’s secondary payment on the claim, if any, as well as any amount that remains of the beneficiary’s responsibility.
Note that the amount of MSP payment that Medicare makes, if any, has no effect on the amount for which the beneficiary may be responsible.
Step 2: Ensure the Primary Payer’s Payment Satisfied the Medicare Deductible and Coinsurance Amounts
- On the primary payer’s remittance advice, you can find the amount of the primary payer’s payment. On the Medicare remittance advice, you can find the amounts that Medicare applied, if any, toward the Medicare deductible and/or coinsurance.
- If the primary payer’s payment (from the primary payer’s remittance advice) is equal to or greater than the amounts that Medicare applied toward the Medicare deductible and/or coinsurance, then the primary payer’s payment satisfied the Medicare deductible and Medicare coinsurance amounts.
- The beneficiary has no responsibility for the MSP claim unless the primary payer’s payment is less than the amounts that Medicare applied toward the Medicare deductible and/or coinsurance and/or there are noncovered Medicare services that were not paid for by the primary payer.
Step 3: Assess Beneficiary’s Responsibility
The beneficiary’s responsibility on an MSP claim equals:
- Noncovered Medicare services (amount not paid for by the primary payer) and
- Medicare deductible (if any) and
- Medicare coinsurance (if any) minus
- the primary payer’s payment amount
The beneficiary is not responsible for the primary payer’s deductible, coinsurance and/or copayment amounts. You would have billed Medicare for these amounts when submitting the MSP claim with the VC 44 and the OTAF amount Medicare may or may not make a secondary payment on the MSP claim but whether Medicare does or does not, this does not impact the beneficiary’s responsibility for the MSP claim.
Related Content
- CMS IOM Publication 100-05, Medicare Secondary Payer Manual,
Reviewed 10/25/2023
Helpful Resources
Helpful Resources
Note: Providers should not call the BCRC to request they set up new or make corrections to existing MSP records. In addition to reporting such information on Medicare claims, when applicable providers may refer beneficiaries and other entities to the BCRC
BCRC Contact
1-855-798-2627
TTY/TDD: 1-855-797-2627
FAX: 405-869-3307