Identify the Proper Order of Payers for a Beneficiary's Services

Table of Contents

• Background
• Step 1: Check for Open Medicare Secondary Payer Records for the Beneficiary in the Common Working File
• Step 2: Collect MSP Information from the Beneficiary 
• Step 3: Compare the MSP Information you Collected from the Beneficiary to the MSP Information for the Beneficiary in the CWF
• Step 4: Determine Which Payer is Primary, Secondary or Tertiary for the Beneficiary’s Services
• Step 5: Document Your Determination Regarding the Proper Order of Payers and Submit Claims Accordingly
• Related Content

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Background

A Medicare beneficiary may have insurance/coverage in addition to Medicare. Medicare providers must determine, based on the MSP provisions, if Medicare is the primary (or secondary) payer for a beneficiary’s services. It is possible for a beneficiary to have more than one type of insurance or coverage primary to Medicare in which case we may be the tertiary payer. If a beneficiary has insurance or coverage you determined is primary to Medicare, you must bill those payer(s) before billing us. To determine if a beneficiary has other insurance or coverage in addition to Medicare, you:

• must check for open MSP records for the beneficiary in the CWF and
• may need to collect MSP information from the beneficiary or their representative

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Step 1: Check for Open Medicare Secondary Payer Records for the Beneficiary in the CWF

A beneficiary may have one or more open MSP record(s) in the CWF. An open MSP record is one that provides insurance or coverage information about a payer that may be primary to Medicare per the MSP provisions and is not deleted or does not have a termination date prior to the claim’s DOS. To check for open MSP records in the CWF for each beneficiary, use the following provider self-service tools:

• NGSConnex online Web application
• CMS HETS (X12 270/271 transactions)
  • MSP records contain the MSP VC , also known as the MSP Insurance Type code or the Primary Payer code (code ID) which represents the MSP provision. MSP records also contain additional information such as the primary payer’s effective and termination date (if applicable), insurance name, insured’s name, policy number, patient’s relationship to the insured, etc. Review the MSP VCs below:  

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Step 2: Collect MSP Information from the Beneficiary 

In addition to checking for open MSP records in the CWF, you may need to collect MSP information during your MSP screening process. To do so, ask the beneficiary (or their representative) questions regarding their current MSP status. You may use the CMS model MSP questionnaire (CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Section 20.2.1) or your own compliant form with the same content and intent as the model.

CMS requires hospitals to collect MSP information for every inpatient admission and outpatient encounter of a beneficiary. We suggest all Part A providers follow the same frequency. 

There are a few exceptions related to collecting MSP information during the MSP screening process:

• You are required to collect MSP information from beneficiaries who:
  • Receive recurring hospital outpatient services, however, only once every 90 days.
    • These services are identical hospital outpatient services and treatments rendered more than once within a billing cycle (may or may not be repetitive services).
• You are not required to collect MSP information from beneficiaries who:
  • Receive hospital reference laboratory services.
    • These services are clinical laboratory diagnostic tests and interpretation furnished without a face-to-face encounter between the hospital and beneficiary.
  • Are members of MAO plans.
    • We suggest you still collect MSP information if the MAO plan member elected Medicare’s hospice benefit and/or if the MAO plan requires you to do so.
  • Receive services from an affiliated provider and the provider with whom you are affiliated conducted an MSP screening process.
    • Example: A beneficiary receives services from a transfer ambulance service affiliated with a hospital. If the hospital conducted the MSP screening process for the services, the affiliated transfer ambulance does not need to do so.
  • Have an MSP record in the CWF but advised you the information has not changed and there is no other reason to collect additional MSP information.
    • If you can access MSP information in the CWF (or to send/receive X12 270/271 transactions) and you determine a beneficiary has an open MSP record, ask them if the record information has changed.
      1. If it has changed, administer a new MSP questionnaire/form
      2. If it has not changed, you do not need to administer a new MSP questionnaire/form. You may still need to collect information from the beneficiary regarding insurance or coverage not in the MSP record(s). For example, if there is an open GHP MSP record that has not changed (per the beneficiary) but the services are accident related and there is no accident MSP record, then ask the beneficiary the accident questions.

Follow these tips to accurately collect MSP information:

• Ensure your MSP questionnaire/form is dated, and the date matches the claim’s DOS.
• Help the beneficiary understand the questions without responding to the questions for them.
• Document all responses you receive including the primary insurance information. 
• Do not leave response fields to applicable questions blank. If you do, document the reason.
• Collect and record the beneficiary’s and/or spouse’s accurate retirement dates, as applicable. If the beneficiary and/or spouse cannot recall exact retirement dates, follow the policy in the CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Section 20.1, #4 for recording (in your records) and reporting (on your claims) retirement dates. The CMS’ model MSP questionnaire does not contain retirement date questions so you may collect and record this information within your records.
• If the beneficiary is unable to respond, speak to their representative.
• Save the completed MSP questionnaire/form for ten years. 
• The beneficiary is not required to sign the completed MSP questionnaire/form.

For 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.

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Step 3: Compare the MSP Information you Collected from the Beneficiary to the MSP Information for the Beneficiary in the CWF 

Review the MSP information you collected and compare it to any MSP record(s) to look for similarities and discrepancies and discuss them with the beneficiary. It is beneficial to do this before you render services (pre-registration) or while the beneficiary is at your facility (registration). If the beneficiary is no longer at your facility, contact them to resolve any conflicts. Note: If there is a conflict between the information you collected from the beneficiary and the MSP record in the CWF, do not contact the BCRC. Rather, you can report any new MSP information on your MSP, Medicare tertiary or conditional claim or report any corrections on your Medicare primary claim. When processing your claim, we will use the information on it to contact the BCRC to ask them to set up a new MSP record or to correct an existing MSP record to make Medicare primary. 

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

To make the appropriate determination as to whether Medicare is the primary, secondary, or tertiary payer, base your decision on the MSP provisions. After you compare the MSP information you collected to any MSP record(s) in the CWF and resolve any conflicts, determine if the criteria/conditions of one or more of the MSP provisions are met. Follow these general guidelines to determine the proper order of payers for a beneficiary’s services:

• Medicare is primary if the beneficiary
  1. Has no other insurance or coverage
  2. Has other insurance or coverage but it does not meet the criteria/conditions of an MSP provision.
  3. Had other insurance or coverage that met the criteria/conditions of an MSP provision, but it is no longer available, and no additional insurance or coverage is available. For example, Medicare is primary for a beneficiary’s automobile accident-related services if they were rendered after any no-fault or medical-payment insurance/coverage exhausted, any no-fault set aside exhausted, the beneficiary is not also filing a claim with a liability insurer, and no other insurance or coverage is involved.
• Medicare is secondary or tertiary if the beneficiary
  1. Has other insurance or coverage that meets the criteria/conditions of one or more of the MSP provisions and it is still available. 

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Step 5: Document Your Determination Regarding the Proper Order of Payers and Submit Claims Accordingly

Once you determine the proper order of payers for any insurance or coverage the beneficiary may have, document that determination in your records and submit claims accordingly.

If you determine Medicare is primary, submit a Medicare primary claim to us. On that claim, report the reason(s) Medicare is primary using the appropriate CCs, OCs and/or Remarks. We may need to use this claim information to contact the BCRC and ask them to correct an MSP record in the CWF. For additional information review: 

• Prevent an MSP Rejection on a Medicare Primary Claim
• Collect and Report Retirement Dates on Medicare Claims.  
• Correct a Beneficiary’s MSP Record

If you determine one payer is primary to Medicare, submit a claim to that payer before you submit a claim to us. If you determine more than one payer is primary to Medicare, submit a claim to each of those payers, in the appropriate order, before you submit a claim to us. When preparing the MSP, Medicare tertiary or conditional claim, report the primary insurance or coverage information per our instructions below. We may need to contact the BCRC with this information and ask them to set up a matching MSP record in the CWF. For additional information review:

• Prepare and Submit an Medicare Secondary Payer Claim
• Prepare and Submit an MSP Conditional Claim
• Set Up a Beneficiary’s Medicare Secondary Payer Record

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Related Content

• CMS IOM Publication 100-05, Medicare Secondary Payer Manual,
  • Chapter 1, General MSP Overview
  • Chapter 2, MSP Provisions
  • Chapter 3, Chapter 3 - MSP Provider, Physician, and Other Supplier Billing Requirements
• CMS Medicare Secondary Payer webpage
• CMS HIPAA Eligibility Transaction System (HETS) webpage
• MLN® Booklet: Medicare Secondary Payer
• Collect and Report Retirement Dates on Medicare Claims  
• Correct a Beneficiary’s MSP Record
• Prepare and Submit an Medicare Secondary Payer Claim
• Prepare and Submit an MSP Conditional Claim
• Prevent an MSP Rejection on a Medicare Primary Claim
• Set Up a Beneficiary’s Medicare Secondary Payer Record

Revised 11/7/2024