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: Assess the Beneficiary’s Responsibility
  • The MSP Patient Responsibility Formula:
  • The Beneficiary’s Responsibility on an MSP Claim
• Related Content

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Determine Beneficiary Responsibility on an MSP Claim

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 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.

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Step 1: Review the Remittance Advice

Once Medicare processes an MSP claim, we will 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

You should not bill beneficiaries for amounts that primary payers will apply toward deductible, coinsurance and/or co-payment amounts. The beneficiary is only responsible for any amount that you did not receive up to Medicare-allowed charge (covered charges).

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Step 2: Assess the Beneficiary’s Responsibility

When an MSP claim is submitted, Medicare will determine what beneficiary’s responsibility will be, if any. National Government Services highly recommends that providers not bill the patient for any primary payer or Medicare deductible, coinsurance or copayment amounts until the claim has been processed and the Medicare remittance advice has been received.

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The MSP Patient Responsibility Formula:

• Add the amount the primary payer paid to the Medicare-paid amount
• Subtract that amount from the Medicare-allowed charge for claim
• If the total is zero or negative, the beneficiary does not have any financial responsibility

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The Beneficiary’s Responsibility on an MSP Claim Equals:

• Any noncovered Medicare services (amount not paid for by the primary payer)
• Medicare deductible (if any) not been satisfied by primary payer’s payment
• Medicare coinsurance (if any) not been satisfied by primary payer’s payment

Providers often ask if the beneficiary is responsible for the primary payer’s deductible, coinsurance and/or co-payment amounts. The beneficiary is not responsible for these amounts because you would have billed Medicare for these amounts when submitting the MSP claim.

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Related Content

• CMS IOM Publication 100-05, Medicare Secondary Payer Manual
  • Chapter 3, MSP Provider, Physician, and Other Supplier Billing Requirements, Sections 10.1, 10.2, 40.1 and 40.2
  • Chapter 5, Contractor Prepayment Processing Requirements, Sections 40.7.2 and 40.7.3

Reviewed 10/25/2023