Course updated: November 30, 2015 Copyright 2013 Cahaba Government Benefit Administrators, LLC

Transcription

1 This course is designed to provide Medicare Part A providers with an understanding of: The various types of Medicare Secondary Payer (MSP) provisions; How to determine when Medicare is primary or secondary; and A general overview of requirements for submitting MSP claims. Course updated: November 30, 2015 Copyright 2013 Cahaba Government Benefit Administrators, LLC

2 Medicare Secondary Payer The Medicare Secondary Payer (MSP) Provisions of section 1862(b) of the Social Security Act protect Medicare funds by ensuring that federal funds are not used to pay for services that are reimbursable under any private insurance plan. These entities include group health plans, workers compensation plans, liability insurance, or no-fault insurance. The MSP provisions apply to situations where Medicare is not the beneficiary s primary insurance. Medicare Secondary Payer: Exceptions to the MSP Requirement In most cases, Federal law takes precedence over state laws and private contracts. Even if a state law or insurance policy states that they are a secondary payer to Medicare, the MSP provisions should be followed when billing for services.

3 MSP Provisions Working Aged - Beneficiary is 65 or older Disability - Beneficiary is under 65 Veterans Administration Federal Black Lung End Stage Renal Disease No-Fault Insurance Liability Insurance Workers' Compensation

4 MSP Provisions: Working Aged Has group health plan (GHP) coverage through own/spouse's employer with 20 or more employees When the working beneficiary or spouse retires, Medicare becomes primary. When billing this provision, use value code 43 and appropriate payer code(s) and/or occurrence code(s).

5 MSP Provisions: Disability Under age 65 and on Medicare due to disability. Has group health plan (GHP) coverage through own/ family member s employer Employer has 100 or more employees to qualify as a Large Group Health Plan (LGHP). When billing this provision, use value code 43 and appropriate payer code(s) and/or occurrence code(s).

6 MSP Provisions: Veteran s Administration (VA) Beneficiaries who have VA can choose to have their claims filed to VA or Medicare. Medicare will pay in the following situations: VA benefits were not claimed; VA did not cover the service. When billing this provision, use value code 42 and appropriate payer code(s) and/or occurrence code(s).

7 MSP Provisions: Federal Black Lung (BL) Program provides benefits to coal miners for lung conditions attributable to coal mining. Medicare will reject a claim if BL diagnosis appears anywhere on the claim. Submit to Department of Labor (DOL) first to determine what they will cover. Medicare will pay if service is not covered by DOL. When billing this provision, use value code 41 and appropriate payer code(s) and/or occurrence code(s).

8 MSP Provisions: End Stage Renal Disease (ESRD) Has group health plan (GHP) coverage through own/ family member s current or former employer during 30-month coordination period. 30-month coordination period is the period of time when the GHP will pay first and Medicare will pay second and begins the first month a patient is eligible for Medicare due to kidney failure (usually the fourth month of dialysis). Provision applies to all Medicare covered items and services (not just treatment of ESRD) furnished during coordination period. When billing this provision, use value code 13 and appropriate payer code(s) and/or occurrence code(s).

9 MSP Provisions: No-Fault or Liability Under 1862(b)(2) of the Act, (42 U.S.C. 1395y(b)(1)), Medicare does not make payment for covered items or services to the extent that payment has been made, or can reasonably be expected to be made under no-fault insurance or a liability insurance policy or plan (including a self-insured plan). When billing for the No-Fault provision, use value code 14 and appropriate payer code(s) and/or occurrence code(s). When billing for the Liability provision, use value code 47 and appropriate payer code(s) and/or occurrence code(s).

10 MSP Provisions: Workers Compensation (WC) Medicare will pay for services in the following situations: WC benefits are exhausted; Conditionally if the WC case is in litigation; If the service is not related to the WC injury, provided no other group coverage exists that falls under the MSP provisions. When billing this provision, use value code 15 and appropriate payer code(s) and/or occurrence code(s). If payment for services cannot be made by WC because they were furnished by a source not authorized by WC, such services can be paid for by Medicare. Medicare remains primary for all medical services not related to the work related injury, provided no other group coverage exists that falls under the MSP provisions.

11 MSP Payments: When Will Medicare Make A Secondary Payment? Medicare may make secondary payment on claims that are denied by the Primary Payer if the services are covered by Medicare and a proper claim has been filed to the Primary Payer and to Medicare. In these situations, providers must provide information from the Primary Payer stating the claim has been denied. For paper submitters, this would be an Explanation of Benefits (EOB) from the Primary Payer stating that the claim has been denied. For electronic submitters, the following information is required: Medicare indicated as the secondary payer, insurance type, Coordination of Benefits (COB) payer paid amount, COB allowed amount, claim adjudication date, service line data, line adjudication data, line adjudication information, and any line adjustments(s) with the accompanying line adjudication date(s).

12 MSP Payments: Contractual Obligations A contractual obligation (CO) arises as a result of an enforceable promise, agreement, or contract. If a provider is obligated to accept, or voluntarily accepts, an amount as payment in full from the primary payer, this is a contractual obligation. For contractual obligations, use value code 44 and amount. The Obligated To Accept as Payment in Full Amount (OTAF) is the amount the provider agreed to accept as payment in full for a service rendered under the provisions of the primary payer's contract. When a primary payer allows less than the billed amount and the provider is contractually obligated to accept that amount as payment in full, then the allowed amount is the OTAF amount. The difference between billed amount and contractual obligation amount that the primary insurance allowed cannot be billed to the beneficiary.

13 MSP Payments: When Will Medicare Make A Conditional Payment? Conditional payment is a Medicare payment, conditioned upon reimbursement to Medicare, for services which another insurer is the primary payer and has not paid and cannot reasonably be expected to make payment promptly. With regard to no-fault and WC insurance, promptly means payment within 120 days after receipt of the claim. For liability insurance, promptly means payment within 120 days after the earlier of the following: The date a claim is filed with an insurer or a lien is filed against a potential liability settlement; or The date the service was furnished or, in the case of inpatient hospital services, the date of discharge. Use the Remarks Field to explain reasons for nonpayment and to justify conditional payments. For Working Aged and Disability, enter employer s name and address that provides the primary insurance.

14 MSP Situations: Three Ways to Determine if MSP Situations Exist MSP situations are determined by: 1. MSP questionnaire conducted by provider at time of admission 2. Benefits Coordination and Recovery Center (BCRC) 3. Accessing patient information through ELGA

15 MSP Situations: MSP Questionnaire Providers, physicians and other suppliers may use a model questionnaire published by the Centers for Medicare and Medicaid Services to collect patient information. This tool is available online in the MSP Manual in chapter 3, section at:

16 MSP Situations: BCRC The Benefits Coordination and Recovery Contractor (BCRC) was created to centralize and consolidate activities that support the collection, management and reporting of other insurance coverage for Medicare beneficiaries. The main purpose/role of the BCRC program is to: Administer the MSP program more effectively and efficiently by utilizing a single contractor entity to operate, coordinate and maintain the MSP processes and generate cost savings through a reduction in mistaken primary Medicare payments. Identify which health benefits are available to a Medicare beneficiary. Assist in the continuous campaign against Medicare fraud, waste and abuse under the Medicare Integrity Program (MIP).

17 MSP Situations: Contacting the BCRC Contact the BCRC to: Report other insurance coverage information. Report or provide updated information on a liability, or workers compensation case. Ask general Medicare Secondary Payer (MSP) questions/concerns. Ask questions regarding Medicare Secondary Development letters and questionnaire. auto/no-fault, BCRC Customer Call Center TDD/TYY Monday through Friday 8:00 a.m. to 8:00 p.m. Eastern Time (except holidays) Specific claim-based issues (including claim processing) should still be addressed to the Provider Contact Center at the Medicare Administrative Contractor.

18 MSP Situations: ELGA Access ELGA - Page 9 and beyond (if MSP situation exists). ELGA will have one additional page for each MSP record. Page 9 would be MSP record 1, page 10 would be MSP record 2, etc. ELGA provides detailed information including the insurer s name and address, and the policy number for the insured. Page 9 only appears if an MSP record exists.

19 MSP Situations: ELGA Screen Information

20 MSP Claim Submission Effective 10/05/2009, initial and/or adjustment MSP claims are no longer accepted into the Fiscal Intermediary Shared System (FISS) via Direct Data Entry (DDE). MSP Claims can be submitted via: An Electronic Media Claim (EMC) using a HIPAA compliant version of ANSI ASC X12N 837 format; PC-ACE Pro32; Hardcopy UB-04/CMS-1450 (if qualified for a paper exception). For more information, review Change Request 6426: For more information on the Administrative Simplification Compliance Act (ASCA) Enforcement of Mandatory Electronic Submission of Medicare Claims, review Change Request 3440:

21 Resources: CMS and Other Resources Medicare Secondary Payer Manual (CMS Pub ), Guidance/Guidance/Manuals/index.html?redirect=/Manuals/IOM/list.asp Chapter 1 Background and Overview Chapter 2 MSP Provisions Chapter 3 MSP Provider Billing Requirements MSP Fact Sheet MLN/MLNProducts/downloads/MSP_Fact_Sheet.pdf Cahaba Educational Material:

22 Click the link below and complete the Medicare Secondary Payer Post-test: When the test is successfully completed, you will be prompted to enter information to record your results.