Set Up a Beneficiary's Medicare Secondary Payer Record

Table of Contents

• Background: Set Up a Beneficiary’s Medicare Secondary Payer Record
• Step 1: Provider Receives New MSP Information for a Beneficiary
• Step 2: Check for a Matching Medicare Secondary Payer Record for the Beneficiary in the Common Working File
• Step 3: Submit a Claim to the Primary Payer
• Step 4: Prepare and Submit a Medicare Secondary Payer, Medicare Tertiary or Conditional Claim
  • Processing MSP, Medicare Tertiary or Conditional Claims and Setting Up MSP Records
• Related Content

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Background: Set Up a Beneficiary’s Medicare Secondary Payer Record

Providers should not contact the Benefits Coordination & Recovery Center (BCRC) to set up an MSP record for a beneficiary in the CWF. When you learn of new MSP information for a beneficiary, notify us when submitting your MSP, Medicare tertiary or conditional claim. If necessary, we will have an MSP record set up with the BCRC using the information from your claim. The BCRC is responsible for maintaining all MSP records in the CWF.

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Step 1: Provider Receives New Medicare Secondary Payer Information for a Beneficiary

Providers must conduct an MSP screening process with each beneficiary to identify payers that may be primary to Medicare. During this process, you ask the beneficiary questions about his/her current MSP status and check if he/she has an MSP record(s) in the CWF. For details, refer to Identify the Proper Order of Payers for a Beneficiary's Services.

During the MSP screening process, you may learn the beneficiary has another payer that is primary to Medicare based on an MSP provision. This information is considered new if it is not in an existing MSP record or if there is no MSP record for the beneficiary in the CWF. 

When you determine there is a primary payer for a beneficiary’s services, you must bill that payer before billing Medicare. For us to process any MSP, Medicare tertiary or conditional claim, there must be a matching MSP record for the beneficiary in the CWF (a record with the same MSP information as you will report on your claim). If there is not a matching MSP record, we will have one set up with the BCRC using the information from your claim. 

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Step 2: Check for a Matching Medicare Secondary Payer Record for the Beneficiary in the Common Working File

To check if a beneficiary has an MSP record in the CWF, use the provider self-service tools listed under Step 1 of Identify the Proper Order of Payers for a Beneficiary's Services.

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Step 3: Submit a Claim to the Primary Payer

If there is an MSP record for the beneficiary in the CWF, verify with the beneficiary that the MSP record information is current and accurate.

• If it is not, refer to Correct a Beneficiary’s MSP Record.
• If it is, submit your claim to the primary payer in the MSP record. You will later report the same primary payer information on your MSP, Medicare tertiary or conditional claim.  

If there is not an MSP record for the beneficiary in the CWF, submit your claim to the payer the beneficiary informed you of (and that you determined is the primary payer based on an MSP provision). You will later report the same primary payer information on your MSP, Medicare tertiary or conditional claim. 

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Step 4: Prepare and Submit a Medicare Secondary Payer, Medicare Tertiary or Conditional Claim

After you receive a response from the primary payer, prepare and submit an accurately coded MSP, Medicare tertiary or conditional claim using the instructions in the following articles:

• Prepare and Submit a Medicare Secondary Payer Claim  
• Prepare and Submit an MSP Conditional Claim

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Processing MSP, Medicare Tertiary or Conditional Claims and Setting Up MSP Records

When processing your MSP, Medicare tertiary or conditional claim, we compare the MSP information on it to any MSP record(s) in the CWF.

If the claim information matches an existing MSP record’s information, we process the claim. Note: If there is a reason we cannot process your claim, we return it to you and the reason code narrative will advise you of your next steps, if any.

If the claim information does not match an existing MSP record’s information or there is no MSP record, we:

• Set up a matching MSP record using the claim information and a validity indicator “I” (investigational).
  • Note: If your claim does not have all the MSP information we need to set up a matching MSP record, we return it to you to request the missing information.
• Send/transmit the matching MSP record to the CWF so the BCRC can investigate and validate it. When they validate it, they change the validity indicator from “I’ to “Y”, which can take up to 45 days.
• Process your claim (and subsequent claims) while waiting for the BCRC to validate the MSP record.

There are situations in which we are not able to successfully set up an MSP record in the CWF (validity indicator “I”) and send/transmit it to the BCRC. In these situations, we send the BCRC an Electronic Correspondence Referral System request, with your claim information, asking them to set up, investigate and validate a matching MSP record in the CWF. While our ECRS request is pending with the BCRC, we return your claim. Review the reason code narrative to determine if there is anything you need to do and monitor the CWF so you know when the MSP record is set up. When you see the MSP record for the beneficiary in the CWF, return or resubmit your claim to us. You should see the MSP record in the CWF within 45 days of when we returned your claim. 

Please be aware the BCRC may not be able to validate an MSP record. This is usually because they did not receive a response to their investigation within 45 days or they received a response to their investigation within 45 days but determined Medicare is the appropriate primary payer. In these situations, the BCRC deletes the MSP record (validity indicator “I”) we had set up or they do not set up an MSP record in response to our ECRS request.

• If we processed your claim, our MSP or conditional payment is appropriate if we are the secondary payer but may be inappropriate if we are the primary payer. If you learn the BCRC deleted the MSP record (validity indicator “I”) we set up, refer the beneficiary or other party to the BCRC to confirm/negate his/her MSP status and, if applicable, to ask them to set up an MSP record. If the outcome is that Medicare is the primary payer, you may receive notification of a Medicare overpayment, if applicable.
• If we returned your claim, continue to monitor the CWF. If an MSP record does not appear in the CWF within 45 days from the date we returned your claim, refer the beneficiary or other party to the BCRC to confirm/negate his/her MSP status and, if applicable, to ask them to set up an MSP record.  
  • It is possible for the other payer to be the primary payer, but we cannot process your claim until the BCRC sets up the MSP record for the beneficiary in the CWF. Once they do, you may return or resubmit your claim.  
  • It is also possible for Medicare to be the primary payer and you will need to submit a Medicare primary claim instead.

For more information about how we process your MSP, Medicare tertiary and conditional claims, and how MSP records are set up, refer to the CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 5 and Chapter 6.

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Related Content

• CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 5
• CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 6
• Coordination of Benefits & Recovery Contact Page (for BCRC)
• CMS Medicare Secondary Payer web page
• MLN® Booklet: Medicare Secondary Payer
• Identify the Proper Order of Payers for a Beneficiary’s Services
• Correct a Beneficiary’s Medicare Secondary Payer Record
• Prepare and Submit a Medicare Secondary Payer Claim
• Prepare and Submit an MSP Conditional Claim

Revised 10/17/2024