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

[Return to Top]

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.

[Return to Top]

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.

[Return to Top]

Step 2: Ensure the Primary Payer’s Payment Satisfied the Medicare Deductible and Coinsurance Amounts

1. 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.
2. 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.
3. 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.

[Return to Top]

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.

[Return to Top]

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 40.8.2 and 40.8.3

Reviewed 10/25/2023