Master Core Curriculum

Master Core Curriculum Part A BasicModule 5Medicare Secondary Payer

BL Black Lung CMN Certificate of Medical Necessity COB Coordination of Benefits COBC Coordination of Benefits Contractor CWF Common Working File DDE Direct Data Entry DME Durable Medical Equipment DOL Department of Labor EGHP Employer Group Health Plan Acronyms

EOB Explanation of Benefits ESRD End Stage Renal Disease GHP Group Health Plan IRS/SSA/DATA MATCH Internal Revenue Service/Social Security Administration/Data Match LGHP Large Group Health Plan MSP Medicare Secondary Payer RAP Request of Anticipated Payment TPP Third Party Payer VA Veterans Affairs WC Workers’ Compensation Acronyms

Learning Outcomes At the end of this module, participants will be able to: • Describe the role of the Medicare contractor • Describe the role of the Coordination of Benefits contractor • Identify MSP categories • Describe claim filing requirements for secondary claim situations • Submit a secondary payer claim correctly

What is MSP? • It is the acronym for Medicare Secondary Payer • It means that under certain conditions Medicare pays secondary to insurance plans and programs • Section 1862(b)(2)(A) of the Social Security Act prohibits Medicare from making payment if payment has been made or can reasonably be expected to be made promptly by a third party payer

Provider’s MSP Responsibilities • A provider that bills Medicare for services rendered to Medicare beneficiaries must determine the primary payer for those services • Ask Medicare beneficiaries or their representatives questions concerning the beneficiary’s MSP status

MSP Effective date MSP termination date Patient relationship Subscriber name Subscriber policy number Insurer type Insurer information: Name, group number, address, city, State and ZIP code MSP type Remarks code Employer information Name, address, city, State, and ZIP code (for all contractors, with the exception of 77777); and Employee data ID number, and information Providers with DDE may access certain MSP information via the Common Working File (CWF):

Sample MSP Questions • Questions to ask in order to determine a patient’s MSP status: • Are you receiving Black Lung (BL) Benefits? • Was the illness/injury due to a work related accident? • Was another party responsible for the accident? • Are you currently employed? • Is your spouse currently employed?

COBC • What is the Coordination of Benefits Contractor (COBC)? • The COBC is the source for establishing new MSP records in the Common Working File (CWF) • The COBC is primarily an information gathering entity • The COBC completes MSP updates on a daily basis

Review • Medicare is the secondary payer to insurance plans and programs under certain circumstances • The Coordination of Benefits Contractor establishes new MSP records in the Common Working File • For more information • www.cms.hhs.gov/manuals/105_msp105index.asp

MSP/CWF Terms • Terms for MSP/CWF processing: • MSP Auxiliary File • MSP Auxiliary Record • Occurrence • MSP Effective Date • MSP Termination Date

MSP Situations • Working Aged • ESRD • Disability • Workers’ Compensation/Black Lung • No-Fault • Liability

Working Aged • Medicare benefits are secondary to benefits payable under Group Health Plans (GHP) for individuals age 65 or over who have GHP coverage as a result of : • Their own current employment status with an employer that has 20 or more employees • The current employment status of a spouse of any age with such an employer • Website • www.cms.hhs.gov/manuals/105_msp105index.asp

End Stage Renal Disease (ESRD) • Medicare benefits are secondary to benefits payable under a GHP for individuals eligible because of ESRD • 30-month coordination period

Disabled Beneficiaries Covered Under a Large Group Health Plan (LGHP) • Medicare benefits are secondary to benefits payable under a LGHP for individuals under age 65 entitled to Medicare on the basis of disability who are covered under a LGHP as a result of the: • Individual’s current employment status with an employer that has 100 employees or more; or • Current employment status of a family member with such employer. • Website • www.cms.hhs.gov/manuals/105_msp105index.asp

Workers’ Compensation/Black Lung • Medicare is secondary to WC plans • This includes the black lung benefit • WC acts require that an employer furnish an injured employee with the following: • Medical and hospital services • Medicines • Transportation • Apparatus • Nursing care other necessary restorative items and services

No-Fault/Liability Insurance • No-Fault Insurance • Insurance that makes payment for medical and other expenses incurred as a result of an accident without regard to the contributory fault of any party to the accident • Liability Insurance • Insurance (including a self-insurance plan) that provides payment based on legal liability for injury or illness or damage to property, homeowners' liability insurance, malpractice insurance, product liability insurance and general casualty insurance

Review • Different MSP Situations • Working Aged • ESRD • Disability • Workers’ Compensation/Black Lung • No-Fault • Liability

MSP Billing Procedures • Determine primary payer before submitting claim • Medicare is secondary to certain insurance companies • Medicare is primary to certain insurance coverage

Submitting secondary claims to Medicare • Use value codes • 12 – Working Aged • 13 – End Stage Renal Disease (ESRD) • 14 – Auto No-Fault/Med-Pay • 15 – Workers’ Compensation (WC) • 16 – Other Federal Agency • 41 – Black Lung (BL) • 42 – Veterans Affairs (VA) • 43 – Disability • 47 – Liability

Working Aged • Use value code 12 • If the GHP pays the claim, submit a claim with value code 12 and the amount paid by the primary insurance • If claim is denied by the insurance company, submit claim to Medicare with the following: • Occurrence code 24 and date of denial • Value code 12 with zero amount paid by primary insurance • GHP insurance name as primary (line A) insurance with C payer code, and Medicare as secondary (line B) insurance • Annotate denial reason • Field 84 on hardcopy UB-92 • Page 4 in Direct Data Entry (DDE)

ESRD • If the GHP insurance pays the claim, submit claim indicating the following information: • Value code 13 and the amount paid by the primary insurance • Condition Code 06 • Occurrence Code 33 with the first month of the Medicare coordination period for ESRD • ESRD GHP insurer name as primary (line A) insurance with a B payer code, and Medicare as secondary (line B) insurance

ESRD • If the claim is denied by the GHP, submit claim to Medicare with the following: • Occurrence code 24 and date of denial • Condition Code 06 • Occurrence Code 33 with the first month of the Medicare coordination period for ESRD • Value code 13 with zero amount paid by primary insurance • ESRD GHP insurer name as primary (line A) insurance with a C payer code, and Medicare as secondary (line B) insurance • Annotate denial reason • Field 84 on hardcopy UB-92 • Page 4 in Direct Data Entry (DDE)

Disability • If GHP insurance pays the claim, submit claim with the following information: • Show value code 43 and the amount paid by the primary insurance • Show GHP insurance name as primary (line A) insurance with an G payer code, and Medicare as secondary (line B) insurance • If GHP denied claim, submit claim to Medicare with the following: • Occurrence code 24 and date of denial • Show value code 43 with zero amount paid by primary insurance • Show LGHP insurance name as primary (line A) insurance with C payer code, and Medicare as secondary (line B) insurance • Annotate denial reason • Field 84 on hardcopy UB-92 • Page 4 in Direct Data Entry (DDE)

No - Fault • If the no-fault insurance pays the claim, submit a claim with the following: • Value code 14 and amount paid by primary insurance • Occurrence code 01 or 02 with the date of the accident • No Fault or Med Pay name as primary (line A) insurance with an D payer code, and Medicare as secondary (line B) insurance

No - Fault • If denied by No-Fault insurance, submit a claim to Medicare with the following: • Occurrence code 24 and date of denial or 25 and date benefits exhausted • Occurrence code 01 or 02 with the date of the accident • Value code 14 with zero amount paid by primary insurance • No Fault or Med Pay insurance name as primary (line A) insurance with C payer code, and Medicare as secondary (line B) insurance • Annotate denial reason • Field 84 on hardcopy UB-92 • Page 4 in Direct Data Entry (DDE)

Workers' Compensation • If the WC insurer pays the claim, submit a claim indicating the following information: • Value code 15 and amount paid by primary insurance • Occurrence code 04 with the date of the accident • WC insurer name as primary (line A) insurance with an E payer code, and Medicare as secondary (line B) insurance

Workers' Compensation • If the claim is denied by WC insurer, submit a claim with the following: • Occurrence code 24 and date of denial • Occurrence code 04 with the date of the accident • Show value code 15 with zero amount paid by primary insurance • Show Workers Compensation insurance name as primary (line A) insurance with C payer code, and Medicare as secondary (line B) insurance • Annotate denial reason • Field 84 on hardcopy UB-92 • Page 4 in Direct Data Entry (DDE)

Workers' Compensation • If the primary diagnosis is unrelated to a patient’s WC condition, submit a claim to Medicare with the following: • Occurrence code 05 and date of incident • Remarks stating the reason for the patient’s treatment and explaining how the injury occurred • Field 84 on hardcopy UB-92 • Page 4 in Direct Data Entry (DDE)

Black Lung • If the Black Lung Program pays the claim, submit a claim with the following: • Value code 41 and amount paid by primary insurance • Black Lung as primary (line A) insurance with an H payer code, and Medicare as secondary (line B) insurance • If the claim is denied by the Black Lung Program, send a claim to Medicare with the following : • Occurrence code 24 and date of denial • Value code 41 with zero amount paid by primary insurance • Black Lung Program as primary (line A) insurance with C payer code, and Medicare as secondary (line B) insurance. • Annotate denial reason • Field 84 on hardcopy UB-92 • Page 4 in Direct Data Entry (DDE)

Liability Insurance • If billing Medicare for a claim associated with a liability situation, submit a claim with the following: • Appropriate occurrence code indicating the date of the liability accident • Value code 47 indicating liability showing zero amount paid by primary insurance • If the patient has retained an attorney, include the attorney’s name and address in the remarks section of the claim • Field 84 on hardcopy UB-92 • Page 4 in Direct Data Entry (DDE) • Liability insurance company's name and/or attorney as primary (line A) insurance with C payer code, and Medicare as secondary (line B) insurance

Review • Who is considered “Working Aged”? • What Value Code would you use for a Medicare beneficiary under age 65 who is disabled and covered under a Large Group Health Plan? • What date would you enter with Occurrence code 24?

Review • Fill in the blank UB92 to show the following: • Payment of $125.00 received for a beneficiary entitled to Medicare based on End Stage Renal Disease • Primary insurer is ABC through the spouse’s Employer Group Health Plan

Review • Fill in the blank UB92 to show the following: • Denial received for a beneficiary age 67 covered under her spouse’s insurance • The services are not covered under the plan Date of denial is February 3, 2005 • The name of the insurer is RST

References CMS Website • www.cms.hhs.gov/manuals/105_msp105index.asp

Master Core Curriculum