Cahaba GBA has provided a document with detailed information required on the MSP claim for:

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Hannah Butler
6 years ago
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1 Secondary Payer Overview A Beneficiary may have additional health insurance coverage through another plan or program. When the beneficiary receives services, a decision must be made about which coverage has primary responsibility for payment and which one is the secondary payer. The Secondary Payer (MSP) questionnaire should be filled out by all patients at their initial visit and it is recommended the information be updated every three months. The Centers for & Medicaid Services (CMS) emphasizes that providers must investigate all options to find out whether is the secondary payer in each individual case. MSP Types - Reason for other coverage entitlement. A = Working Aged B = End stage renal disease (ESRD) D = Automobile/Liability No-Fault E = Workers' Compensation (WC) F = Federal, Public Health G = Disabled H = Black Lung (BL) I = Veterans Affairs (VA) L=Liability W=Workers Compensation Set-Aside Arrangement (WCMSA) NOTE: VA and other Federal payments are exclusions rather than MSP non-payments. DETERMINING IF MEDICARE IS PRIMARY OR SECONDARY The beneficiary should fill out the MSP questionnaire prior to the initial visit and it is recommended to be updated every ninety days. There may be certain instance that your staff may want to update prior to ninety days; for example a patient schedules an appointment for back pain, then you might want to create a MSP short form so the patient can indicate if this is an injury, possibly work related, other liability or MVA. After the patient completes the MSP questionnaire, Table 1 (See attached) will assist in determining if is the primary or secondary payer. MSP QUESTIONNAIRE The Secondary Payer questionnaire attached at the end of this document is a model of the type of questions that may be asked to help identify MSP situations. If you choose to use this questionnaire, please note that it was developed to be used in sequence. Instructions are listed after the questions to facilitate transition between questions. The instructions will direct the patient to the next appropriate question to determine MSP situations. Billing Secondary Payer Cahaba GBA has provided a document with detailed information required on the MSP claim for: 1. BILLING MEDICARE PRIMARY, SECONDARY & CONDITIONALLY A. Working Aged or Disability insurance when primary insurance is billed and payment is received. B. Services related to No-fault, Liability or Workers Compensation when primary insurer is billed and payment is received

2 C. Services related to No-fault, Liability, or Workers Compensation when primary insurance denied payment or benefits exhausted. BILLING MEDICARE CONDITIONALLY D. Services related to No-fault, Liability or Workers Compensation when primary insurer is billed and no response is received from insurer after 120 days. BILLING MEDICARE CONDITIONALLY E. Services unrelated to No-fault, Liability or Workers Compensation. BILLING MEDICARE PRIMARY F. Services that were denied by the Department of Labor. BILLING MEDICARE CONDITIONALLY G. Veterans Administration benefits were not used. BILLING MEDICARE CONDITIONALLY or a copy is due to VA BILLING MEDICARE SECONDARY H. Disability or Working Aged insurance is primary and payment denied, applied to deductible or not paid promptly. BILLING MEDICARE CONDITIONALLY. I. Services unrelated or not authorized by Public Health Services or other Federal Agency. BILLING MEDICARE CONDITIONALLY. J. is primary for 30-month ESRD coordination period. Primary insurer billed and payment/denial received, applied to deductible, or not paid promptly. BILLING MEDICARE CONDITIONALLY Secondary Payer Billing Codes consist of: Condition Codes Occurrence Codes Value Codes Relationship Codes For detailed billing instructions regarding the items listed above click on: Resource material obtained through CMS manuals: Other material obtained through the following A/B MAC s Cahaba GBA Trailblazers Wisconsin Physicians Service (WPS) National Government Services (NGS) Other questions regarding Secondary Payer Billing may be directed to: Linda Robertson, Director of Billing Midwest Healthcare, Inc

3 Table 1 List of Common Situations When May Pay First or Second If the patient... And this condition exists Then this program pays first And this program pays second Is age 65 or older, and is covered The employer has less than 20 by a through current employment or spouse s employees current employment Is age 65 or older, and is covered The employer has 20 or more by a through current employment or spouse s employees, or at least one employer is a multi-employer current employment group that employs 20 or more individuals Has an employer retirement plan and is age 65 or older Retiree coverage Is disabled and covered by a The employer has less than 100 through his or her own current employment or employees... through a family member s current employment Is disabled and covered by a through his or The employer has 100 or more employees, or at least one her own current employment or through a family member s current employer is a multi-employer group that employs 100 or more employment individuals and Coverage Is in the first 30 months of eligibility or entitlement to and Coverage After 30 months and COBRA coverage Is in the first 30 months of eligibility or entitlement to COBRA... and COBRA coverage After 30 months COBRA Is covered under Workers Workers Compensation (for health Compensation because of a jobrelated illness or injury care items or services related to job-related illness or injury) claims Has been in an accident or other situation where no-fault or liability No-fault or liability insurance for accident or other situation related insurance is involved health care services claimed or released Is age 65 or older OR is disabled COBRA and covered by and COBRA

4 MEDICARE SECONDARY PAYER QUESTIONNAIRE Name: Date of Birth: Date: PART I 1. Are you receiving Black Lung (BL) Benefits? No Yes; Date benefits began: BL IS PRIMARY PAYER ONLY FOR CLAIMS RELATED TO BL. 2. Are the services to be paid by a government research program? No Yes GOVERNMENT RESEARCH PROGRAM WILL PAY PRIMARY BENEFITS FOR THESE SERVICES. 3. Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for your care at this facility? No Yes; then DVA IS PRIMARY FOR THESE SERVICES. 4. Was the illness/injury due to a work-related accident/condition? No. GO TO PART II. Yes; Date of injury/illness: Name and address of workers compensation plan (WC) plan: Policy number: Name and address of your employer: WC IS PRIMARY PAYER ONLY FOR CLAIMS FOR WORK-RELATED INJURIES OR ILLNESS, GO TO PART III. PART II 1. Was illness/injury due to a non-work-related accident? No. GO TO PART III Yes; Date of accident: 2. Is no-fault insurance available? (No-fault insurance pays for health care services resulting from injury to you or damage to your property regardless of who is at fault for causing the accident.) No Yes; Name and address of nofault insurer(s) and no-fault insurance policy owner: Insurance claim number: 3. Is liability insurance available? (Liability insurance protects against claims based on negligence, inappropriate action or inaction, which results in injury to someone or damage to property.) No Yes; Name and address of liability insurer(s) and responsible party: Insurance claim number: NO-FAULT INSURER IS PRIMARY PAYER ONLY FOR THOSE SERVICES RELATED TO THE ACCIDENT. LIABILITY INSURANCE IS PRIMARY PAYER ONLY FOR THOSE SERVICES RELATED TO THE LIABILITY SETTLEMENT, JUDGMENT, OR AWARD. GO TO PART III PART III 1. Are you entitled to based on: Age. Go to PART IV. Disability. Go to PART V. End-Stage Renal Disease (ESRD). Go to PART VI. Please note that both Age and ESRD OR Disability and ESRD may be selected simultaneously. An individual cannot be entitled to based on Age and Disability simultaneously. Please complete ALL PARTS associated with the patient s selections. PART IV AGE 1. Are you currently employed? Yes; Name and address of your employer: No. If applicable, date of retirement: No. Never Employed. 2. Do you have a spouse who is currently employed? Yes; Name and address of your spouse's employer: No. If applicable, date of retirement: No. Never Employed. IF THE PATIENT ANSWERED NO TO BOTH QUESTIONS 1 AND 2, MEDICARE IS PRIMARY UNLESS THE PATIENT ANSWERED YES TO QUESTIONS IN PART I OR II. DO NOT PROCEED FURTHER. 3. Do you have group health plan (GHP) coverage based on your own or a spouse's current employment? Yes, both. Yes, self Yes, spouse. No. STOP. MEDICARE IS PRIMARY PAYER UNLESS THE PATIENT ANSWERED YES TO THE QUESTIONS IN PART I OR II.

5 4. If you have GHP coverage based on your own current employment, does your employer that sponsors or contributes to the GHP employ 20 or more employees? No Yes. GHP IS PRIMARY. OBTAIN THE FOLLOWING INFORMATION: Name and address of GHP Policy number (sometimes referred to as the health insurance benefit package number): Group identification number: Name of insured: Relationship to patient: 5. If you have GHP coverage based on your spouse s current employment, does your spouse s employer that sponsors or contributes to the GHP, employ 20 or more employees? No Yes. GHP IS PRIMARY. Name and address of GHP: Policy identification number: Group identification number: Name of policyholder/named insured: Relationship to patient: IF THE PATIENT ANSWERED NO TO BOTH QUESTIONS 4 AND 5, MEDICARE IS PRIMARY UNLESS THE PATIENT ANSWERED YES TO QUESTIONS IN PART I OR II. PART V DISABILITY 1. Are you currently employed? No. Never Employed No. If applicable, date of retirement: Yes Name and address of your employer: 2. Do you have a spouse who is currently employed? No. Never Employed No. If applicable, date of retirement: Yes Name and address of your employer: 3. Do you have group health plan (GHP) coverage based on your own or a spouse s current employment? No Yes, both Yes, self. Yes, spouse. 4. Are you covered under the GHP of a family member other than your spouse? No. Yes. Name and address of your family member s employer: IF THE PATIENT ANSWERED NO TO QUESTIONS 1, 2, 3, AND 4, STOP. MEDICARE IS PRIMARY UNLESS THE PATIENT ANSWERED YES TO QUESTIONS IN PART I OR If you have GHP coverage based on your own current employment, does your employer that sponsors or contributes to the GHP employ 100 or more employees? No. Yes. GHP IS PRIMARY. OBTAIN THE FOLLOWING INFORMATION. Name and address of GHP: Policy number: Group identification number: Name of policyholder/named insured: Relationship to patient: 6. If you have GHP coverage based on your spouse s current employment, does your spouse s employer that sponsors or contributes to the GHP, employ 100 or more employees? No Yes. GHP IS PRIMARY. OBTAIN THE FOLLOWING INFORMATION. Name and address of GHP: Policy number: Group identification number: Name of policyholder/named insured: Relationship to patient: 7. If you have GHP coverage based on a family member s current employment, does your family member s employer, that sponsors or contributes to the GHP, employ 100 or more employees? No Yes. GHP IS PRIMARY. OBTAIN THE FOLLOWING INFORMATION. Name and address of GHP: Policy number: Group identification number: Name of policyholder/named insured: Relationship to patient: IF THE PATIENT ANSWERED NO TO QUESTIONS 5, 6, and 7, MEDICARE IS PRIMARY UNLESS THE PATIENT ANSWERED YES TO QUESTIONS IN PART I OR II.

6 PART VI End-Stage Renal Disease (ESRD) 1. Do you have group health plan (GHP) coverage? No STOP. MEDICARE IS PRIMARY. Yes. If applicable, Name and address of GHP: Policy number: Group identification number: Name of policyholder/named insured: Relationship to patient: Name and address of employer, if any, from which you receive GHP coverage: IF APPLICABLE, YOUR SPOUSE S GHP INFORMATION: Name and address of GHP: Policy number: Group identification number: Name of policyholder/named insured: Relationship to patient: Name and address of employer, if any, from which you receive GHP coverage: IF APPLICABLE, YOUR FAMILY MEMBER S GHP INFORMATION: Name and address of GHP: Policy number: Group identification number: Name of policyholder/named insured: Relationship to patient: Name and address of employer, if any, from which you receive GHP coverage: 2. Have you received a kidney transplant? No Yes. Date of transplant: 3. Have you received maintenance dialysis treatments? No Yes Date dialysis began: If you participated in a self-dialysis training program, provide date training started: 4. Are you within the 30-month coordination period that starts? (The 30-month coordination period starts the first day of the month an individual is eligible for (even if not yet enrolled in ) because of kidney failure (usually the fourth month of dialysis). If the individual is participating in a self-dialysis training program or has a kidney transplant during the 3-month waiting period, the 30-month coordination period starts with the first day of the month of dialysis or kidney transplant.) Yes. No. STOP. MEDICARE IS PRIMARY. 5. Are you entitled to on the basis of either ESRD and age or ESRD and disability? Yes. No. 6. Was your initial entitlement to (including simultaneous or dual entitlement) based on ESRD? Yes. STOP. GHP CONTINUES TO PAY PRIMARY DURING THE 30-MONTH COORDINATION PERIOD. No. INITIAL ENTITLEMENT BASED ON AGE OR DISABILITY. 7. Does the working aged or disability MSP provision apply (i.e., is the GHP already primary based on age or disability entitlement)? Yes. GHP CONTINUES TO PAY PRIMARY DURING THE 30-MONTH COORDINATION PERIOD. No. MEDICARE CONTINUES TO PAY PRIMARY. Signature Signature of Patient s Representative Relationship to Patient Reason Patient is unable to sign

Medicare Secondary Payer (MSP) Questionnaire

Medicare Secondary Payer (MSP) Questionnaire Patient Name Please print Date of Birth PART I 1. Are you receiving Black Lung (BL) Benefits? Yes Date benefits began: / / BL is Primary payer only for claims