Determine if Medicare is Primary or Secondary for a Beneficiary's Services

Table of Contents

• Determine if Medicare is Primary or Secondary for a Beneficiary's Services
• Step 1: Collect MSP Information from the Beneficiary During an MSP Screening Process
• Step 2: Check for Open MSP Records for a Beneficiary in Medicare’s Records
• Step 3: Compare the MSP Information you Collected to the MSP Information in Medicare’s Records
• Step 4: Determine Which Payer is the Primary Payer, Secondary Payer, etc. for the Beneficiary’s Services
• Step 5: Document your Decision Regarding the Proper Order of Payers and Submit Claims Accordingly
• Related Content

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Determine if Medicare is Primary or Secondary for a Beneficiary's Services

MSP Provisions require certain coverage to be billed primary to Medicare for beneficiary services. You can determine Medicare as primary, secondary, or greater payer when you determine whether or not the beneficiary has other coverage.

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Step 1: Collect MSP Information from the Beneficiary During an MSP Screening Process

The MSP screening process includes asking questions concerning the beneficiary’s most current MSP status. CMS requires providers to collect MSP information for every outpatient encounter or start of care for a beneficiary. All providers should follow this screening process frequency. In addition, providers are encouraged to verify MSP information with patients on a routine basis. Obtain documentation that supports your completion of the MSP screening process with each beneficiary. CMS does not require that the MSP screening process occur prior to seeing the patient but must be completed and documented prior to submitting a bill to Medicare.

Medicare does not require you to collect MSP information from beneficiaries who are members of MAO plans though the MAO plan may require you to do so.

For more details about the MSP screening process, refer to the CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Sections 20.1 and 20.2.

You can use the CMS’ model MSP questionnaire or an in-house, CMS-compliant form (which has the same content and intent as the CMS model MSP questionnaire). To view the CMS model MSP questionnaire, refer to the CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Section 20.2.1.

Follow these tips to accurately collect MSP information when using the CMS model MSP questionnaire:

• Help the beneficiary understand the questions without responding for them.
• Document all responses you receive.
• Do not leave response fields to any applicable questions blank (if you must, document the reason).
• Document the beneficiary’s and/or their spouse’s accurate retirement dates, as applicable. If the beneficiary and/or their spouse cannot recall their exact dates of retirement, follow CMS’ policy for recording (in your records) and reporting (on your claims) their retirement dates. Refer to the CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Section 20.1, #4.
• If the beneficiary is unable to respond, speak to their representative.
• Save the completed form for ten years (the beneficiary is not required to sign the form).

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Step 2: Check for Open MSP Records for a Beneficiary in Medicare’s Records

Fact: Medicare may have open MSP records for a beneficiary with MSP information. This information may not be as current as the MSP information you collect from the beneficiary but you must still check Medicare’s records for MSP information for the beneficiary.

Use the following provider self-service tools:

• NGSConnex online web application
  • The MSP record, if any, contains the MSP type code which represents the MSP Provision that may apply to the beneficiary (refer to the chart below). Within each record, you can find the primary insurer’s effective date, termination date and MSP type code.

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Step 3: Compare the MSP Information you Collected to the MSP Information in Medicare’s Records

Review the collected MSP information the MSP information in Medicare’s records to look for similarities and discrepancies. If the information does not match, you may need to contact the beneficiary or their representative to resolve any conflicts.

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Step 4: Determine Which Payer is the Primary Payer, Secondary Payer, etc. for the Beneficiary’s Services

Follow these general guidelines to determine payment order:

1. Medicare is primary for the beneficiary’s services if a beneficiary has only Medicare and no other coverage is available.
2. If a beneficiary has other coverage, you need to know if the criteria/conditions for any one or more of the MSP Provisions (also called MSP categories) been fully met which would make one or more other payer primary to Medicare for the beneficiary’s services. The other coverage is primary to Medicare for the beneficiary’s services if it meets the criteria/conditions required under any of the applicable MSP Provisions. It is possible for a beneficiary to have more than one type of coverage which may make Medicare the tertiary payer (or greater).
3. To make the right decision, you must have a working knowledge of the criteria/conditions of the MSP Provisions that make certain other payers primary to Medicare. MSP Provisions include Working Aged, Disabled, ESRD, Liability, Workers’ Compensation, and No-Fault. You can find a wide variety of MSP-related resources listed under Related Content that can help you become familiar with the MSP Provisions.

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Step 5: Document your Decision Regarding the Proper Order of Payers and Submit Claims Accordingly

• If Medicare is primary for the beneficiary, submit a Medicare primary claim. Refer to Prevent an MSP Rejection on a Medicare Primary Claim to avoid any issues that can lead to claim rejection.
• If one payer is primary to Medicare for the beneficiary, you must submit a claim to that payer before submitting a claim to Medicare.
• If more than one payer is primary to Medicare for the beneficiary, you must submit a claim to each of those payers, in the appropriate order, before submitting a claim to Medicare.

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Related Content

• CMS IOM Publication 100-05, Medicare Secondary Payer Manual,
  • Chapter 1, Background and Overview
  • Chapter 2, MSP Provisions
  • Chapter 3, MSP Provider, Physician, and Other Supplier Billing Requirements, Sections 20.1 and 20.2
• CMS Medicare Secondary Payer web page
• Medicare Secondary Payer for Provider, Physician, and Other Supplier Billing Staff

Revised 11/08/2024