JK: Medicare Secondary
Payer Part B Billing Basics
October 15, 2014
1440_1014
Today’s Presenters
• Alicia Forbes, CPC
– Provider Outreach and Education
• Carleen Parker
– Provider Outreach and Education
• Lori Langevin
– Provider Outreach and Education
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National Government Services, Inc.
Disclaimer
National Government Services, Inc. has produced this material as
an informational reference for providers furnishing services in our
contract jurisdiction. National Government Services employees,
agents, and staff make no representation, warranty, or guarantee
that this compilation of Medicare information is error-free and will
bear no responsibility or liability for the results or consequences of
the use of this material. Although every reasonable effort has been
made to assure the accuracy of the information within these pages
at the time of publication, the Medicare Program is constantly
changing, and it is the responsibility of each provider to remain
abreast of the Medicare Program requirements. Any regulations,
policies and/or guidelines cited in this publication are subject to
change without further notice. Current Medicare regulations can be
found on the Centers for Medicare & Medicaid Services (CMS)
website at http://www.cms.gov.
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No Recording
• Attendees/providers are never permitted to
record (tape record or any other method) our
educational events
– This applies to our webinars, teleconferences, live
events, and any other type of National Government
Services educational event
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Acronyms
• Please access the Acronyms page on the
NGSMedicare.com website to view any
acronym used within this presentation.
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Objectives
• After this session you will be able to:
– Identify key MSP fields on the CMS-1500 claim form
– Understand differences between billing MSP on paper
versus electronically
– Properly bill MSP conditional claims
– Utilize resources and contact information for
assistance and additional information
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Agenda
• MSP provision/category overview
• Identifying the primary payer
• CMS-1500 claim form (02/12) claim
submissions
• Electronic claim submissions
• Conditional Medicare Payment Procedures
• Contact information and references
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MSP Provision/Category
Overview
How do the Provisions Work
Each provision
has own set of
criteria
All provision
criteria met
All provision
criteria not met
Medicare
secondary
Medicare primary
(unless another
provision applies)
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MSP Provisions/Category Review
•
•
•
•
•
•
•
•
Working aged
Disabled
ESRD
Workers’ compensation
Automobile or other no-fault insurance
Liability
Federal Black Lung Program
Veterans Administration
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MSP Reference Sheet
• Medicare Learning
Network
• http://www.NGSMedicare.
com
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MSP Provisions/Category Review
• CMS IOM Publication 100-05, Medicare
Secondary Payer Manual, Chapters 1 through 8
• Chapter 2
•
•
•
•
•
•
Section 10: Working Aged Individuals
Section 20: End-stage Renal Disease Beneficiaries
Section 30: Disabled Beneficiaries
Section 40: Liability Insurance
Section 50: Workers’ Compensation
Section 60: No-Fault Insurance
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National Government Services, Inc.
Identifying the Primary Payer
Provider’s MSP Responsibilities
• Per Provider Agreement
– Determine whether or not Medicare is primary payer
for services rendered
• Maintain system to identify any primary payer other
than Medicare at each visit
– Bill other payers before billing Medicare
– Submit MSP claims when required
• Even if primary payer made payment in full
• CMS IOM Publication 100-05, Medicare Secondary
Payer Manual, Chapter 3, Sections 20.1 and 20.2
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Beneficiary Responsibilities
• Not responsible to determine if other
coverage is or is not primary to Medicare
• Should provide information and current
insurance cards
• Should call BCRC when something changes
– Retirement
– Accident
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Benefits Coordination
& Recovery Center
• Formerly Coordination of Benefits Contractor
• Now called Benefits Coordination & Recovery
Center (BCRC)
• Describes initiatives that both CMS and
BCRC are undertaking to maintain the most
up-to-date and accurate beneficiary MSP
information on Medicare’s CWF
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BCRC Activities
MLN SE1416
• MLN Matters SE1416
• Provider update with beneficiary in office
– Initial
• Records will be updated
– Subsequent attempts
• Proof of information can be faxed or mailed on insurer
or employer’s company letterhead
• You can contact the insurer or employer organization
that last updated record
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BCRC Activities
MLN SE1416
• Provider update when beneficiary not in office
– Three options
• Have beneficiary contact BCRC
• Contact beneficiary’s insurer to resolve
• Fax or mail proof of information on insurer or
employer’s company letterhead
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BCRC Activities
MLN SE1416
• Provider update with new information
– Two options to changing existing record
• Beneficiary will need to call to close out record
• Fax or mail proof of information on insurer or
employer’s company letterhead
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BCRC Activities
MLN SE1416
• Provider update when deceased beneficiary
– Initial
• A SINGLE update can be made by ONE provider for a
deceased beneficiary, once date of death has been
confirmed
– Subsequent attempts
• Any subsequent updates would need to be handled by
a family member with appropriate documentation,
including a death certificate
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Contacting the BCRC
• Medicare Benefits Coordination and Recovery Center
Official Home Page
• BCRC Contact Page
– Customer Service Representatives
• Monday through Friday, 8:00 a.m.-8:00 p.m. ET, except holidays:
855-798-2627
• TTY/TDD: 1-855-797-2627 (hearing and speech impaired)
• Important Special Edition to contact BCRC
– MLN Matters SE1416
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Primary Payer
Identification Methods
• Check Medicare’s records
– NGSMedicare.com website
• IVR
• NGSConnex
• Collect information
– Ask patient, representative or family member
– MSP questionnaire
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Interactive Voice Response System
• Connecticut, Maine, Massachusetts, New
Hampshire, New York, Rhode Island,
Vermont
– 877-869-6504
• Monday–Friday
– 6:00 a.m.–7:00 p.m. ET
• Saturday
– 7:00 a.m.–3:00 p.m. ET
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MSP Questionnaire
• CMS model MSP questionnaire
– CMS IOM Publication 100-05, Chapter 3, Section
20.2.1
• CMS MSP Model Questionnaire
– Can use hardcopy or online questionnaire
– Six parts: Ask all questions in Parts I, II and III
• IV, V and VI completed if indicated
– Not required to use CMS version
• Must have same content and intent
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Claim Submission
Claim Filing Time Limits
• Limit is one calendar year from date of service
– Claims not submitted timely are provider-liable
• Beneficiary cannot be charged
• Exceptions (MLN Matters article MM7270)
– Administrative error
– Retroactive Medicare entitlement, including when State
Medicaid agencies involved
– Retroactive disenrollment from Medicare Advantage
Plan or Program of All-Inclusive Care of the Elderly
(PACE) Provider Organization
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MSP Claim Submission
• Most providers required to submit MSP
claims electronically due to ASCA regulations
– If submit all other claims electronically, must also
submit MSP claims electronically
• Ten ASCA exceptions include:
– Medicare tertiary (third) payer claims
– Providers submitting < ten claims per month
– Physician/practitioner/supplier with < ten FTE
employees
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ASCA
• ASCA enforcement
– Electronic submissions required since October 10,
2003
– CMS began enforcing regulations on July 5, 2005
• For more information:
– CMS IOM Publication 100-04, Chapter 24, Sections
90–90.6
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MSP Paper Claim Completion
• Paper claims must be submitted on red and
white CMS-1500 claim form (02/12)
• For MSP claims, specific items must be
completed
– Remainder of claim completed according to CMS
IOM,, Publication 100-04, Medicare Claims
Processing Manual, Chapter 26
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MSP Paper Claim Completion
• Item 4
– If insurance primary to Medicare, list name of insured
– When insured and patient are same, enter “SAME”
• Item 6
– Check appropriate box for patient’s relationship
to insured
• Item 7
– Enter insured’s address and telephone number
– When address is same as patient’s, enter “SAME”
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MSP Paper Claim Completion
• Item 10a
– Is patient’s condition related to employment? Yes/No
• Item 10b
– Is patient’s condition related to auto accident? Yes/No
– If answer = yes, include two digit state code under
Place
• Item 10c
– Is patient’s condition related to other accident?
Yes/No
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MSP Paper Claim Completion
• Item 11
– Enter insured’s policy or group number
• Item 11a
– Enter insured’s eight-digit birth date and sex if
different from Item 3
• Item 11b
– Enter employer’s name, if applicable
• Item 11c
– Enter nine digit payer ID for primary insurer or
complete primary payer’s program/plan name
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MSP Electronic Claim Completion
• Electronic claim submission methods:
– Directly to Medicare (PC-ACE)
– Through clearinghouse or vendor via HIPAAcompliant software
• Must use 837P
• Information needed similar to paper claims
– Required items on paper claim have electronic
equivalents
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National Government Services, Inc.
MSP Electronic Claim Submission
• Required MSP data for electronic claim:
–
–
–
–
Indication of Medicare as the secondary payer
Insurance Type Code
COB Payer Paid Amount Claim Level
Claim Contract Information (OTAF) – Claim Level
• OTAF = Obligated to Accept as Payment in Full
– Claim Adjudication Date - Claim Level
– Service Line Information
– Line Adjudication Information
– Line Adjustments
– Line Adjudication Date
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Indication of Medicare as
Secondary Payer
• Payer Responsibility Sequence Number
Code (SBR01 element)
– P = Primary
– S = Secondary
– T = Tertiary
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Indication of Medicare as
Secondary Payer
• Claim Filing Indicator Code (SBR09 element),
such as:
–
–
–
–
–
–
MB = Medicare
AM = Automobile Medical
CI = Commercial Insurance Company
LI = Liability
LM = Liability Medical
WC = Workers’ Compensation Health Claim
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Common MSP Type Codes
(SBR05 Element)
Code
Description
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Working aged beneficiary age 65 or over with employer GHP through
self or spouse
13
End-stage renal disease beneficiary in 30 month coordination period
with an employer GHP
14
No fault insurance including automobile and other types
15
Worker’s Compensation
16
Public Health Service (PHS) or other federal agency
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Federal Black Lung Program
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Veteran’s Administration
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Disabled beneficiary under age 65 with large group health plan (LGHP)
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Liability insurance
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COB Payer Paid Amounts
- Claim Level
• Required when claim has service line
approved/allowed amount and service line
paid amount
– AMT segment - loop 2320 (Other Subscriber
Information)
• COB Payer Paid Amount – Claim Level
– With D qualifier
– Total amount primary payer paid on claim (zero allowed)
• COB Allowed Amount – Claim Level
– No longer needed with 5010
– B6 qualifier was 4010 requirement
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Claim Contract Information
– Claim Level
• Obligated to Accept as Payment in Full
– Only required when OTAF amount greater than zero
– Medicare claims processing system determines
OTAF amount
• Subtracts contractual obligation group code amount
from submitted charges
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Claim Adjudication Date
– Claim Level
• Required on all electronic MSP claims
• Used to report date claim paid/processed by
primary payer
• DTP segment in loop 2330B
– DTP01 element = 573 (indicates date listed is date
claim paid)
– DTP02 element = D8 (indicates format of date)
– DTP03 element = enter date claim paid/adjudicated
by primary payer
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Service Line Information
• Approved amount (allowed amount)
– Please note for electronic claim submissions that this
section was exclusive to the 4010 format which is no
longer accepted
– Information no longer required in AMT segment in
2400 loop
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Service Line Information
• Line Adjudication Information
– Services billed to primary payer
• Procedure code, units billed, amount paid, etc.
– Required if claim adjudicated by primary payer and
service line adjustments applied
– SVD segment in 2430 loop
• Information in SVD01 must match payer ID for
primary payer
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Service Line Information
• Line Adjustments
– Required if primary payer made line level adjustments
– CAS segment of 2430 loop, include:
• Monetary adjustment amounts
• CARC from primary remittance advice
• Claim adjustment group code, such as:
–
–
–
–
CO = Contractual Obligations
OA = Other Adjustments
PI = Payer Initiated Reductions
PR = Patient Responsibility
• Code descriptions on http://www.wpc-edi.com under
Code Lists
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Service Line Information
• Line Adjudication Date
– Required on all electronic MSP claims
– DTP segment of 2430 loop
• Date/time qualifier of 573
• Date/time period format qualifier of D8
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Remember!
Paid amount entered in Service Line
Adjudication field
+ Adjustments listed in Line Level adjustment
fields
must = total amount billed for that service line
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MSP Electronic Claim Submission
• MSP electronic billing guidance on
http://www.NGSMedicare.com
• Medicare Secondary Payer Manual for Electronic
Submitters/ANSI Specifications for 837P
• CMS-1500 Crosswalk for Electronic Claim Format:
Professional Claim (837)
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Billing MSP Claims Using
PC-ACE Pro32
• Parallels items on paper CMS-1500 claim
form
• Creates compliant ANSI X12 file to submit to
National Government Services electronically
• PC-ACE Pro32 Medicare Secondary Payer
(MSP) Reference Guide available on
http://www.NGSMedicare.com
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Conditional Medicare
Payment Procedures
Conditional Payments
• Medicare pays the provider because payment
has not been made or is not expected to be
made by primary insurer
• Payments are made “on condition” that
Medicare will be reimbursed if it is
demonstrated that the insurance is or was
responsible for making primary payment for
services rendered
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Four Circumstances When a
Conditional Payment Can be Made
1. Beneficiary appeal/protest GHP denial of claim
– Except when GHP only offers coverage secondary to Medicare
2. GHP denied claim because timely filing limit expired
3. Provider failed to file proper claim due to mental/ physical incapacity of
beneficiary
4. Claim sent to specific primary insurers and payment not made within
promptly period
– Only applies to specific primary insurances:
• WC
• No-fault insurance
• Liability insurance (including self insurance)
– If primary GHP exists, claim must be billed to that insurer first before
Medicare conditional payment may be considered
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Conditional Payments
• Conditional payments are not required to be
requested by providers
• When request approved by Medicare:
– No payment to provider from primary payer
– Medicare makes payment made to provider
– Medicare recoups from beneficiary or insurer any
monies paid out if determined that primary was
responsible for making payment
• Judgment
• Determination
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Conditional Payments –
Clarification MLN Matters MM7355
MM7355 clarifies the following:
1) The procedures to follow when submitting liability insurance, no-fault
insurance and WC claims when the liability insurer, no-fault insurer
and WC carrier does not make prompt payment or cannot reasonably
be expected to make prompt payment
•
This includes self-insurance
2) Defines the promptly payment rules
3) Instructs you how to submit liability insurance, no-fault insurance and
WC claims to your Medicare contractors when requesting Medicare
conditional payments
– This includes self-insurance
• Reference: http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM7355.pdf
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Conditional Payments –
Clarification MLN Matters MM7355
• The conditional payment policy has not changed, but the
processes and billing procedures have changed for Part B
providers
• Previously, the only way to request a conditional payment
was to submit a claim to Medicare, have it reject due to a
primary liability, WC or auto insurance policy being on file and
then request a conditional payment upon appeals
• Effective 1/1/2013, part B providers can request a conditional
payment when first submitting the claim to Medicare
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“Promptly” Definition – Clarification
MLN Matters MM7355
• No-fault insurance and WC
– Payment within 120 days after receipt of claim by
primary insurance
• Date of service for specific items and service treated as
claim date when determining promptly period
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“Promptly” Definition – Clarification
MLN Matters MM7355
• Liability Insurance
– Payment within 120 days after earlier of the following:
• Date general liability claim filed with insurer or lien filed
against potential liability settlement, or
• Date service furnished
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Requesting Medicare Part B
Conditional Payment
• Requirements for Medicare beneficiaries
– Not required to file claim with liability insurer or
cooperate with provider in filing claim
– Are required to cooperate in filing of no-fault claims
• If refuses to cooperate in filing of no-fault claims,
Medicare will not pay
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Data Requirements for
Conditional Payment for 837 5010
Professional Claims
Type of
Insurance
CAS
No2320 or 2430 –
Fault/Liability valid information
why NGHP or
GHP did not
make payment
WC
Insurance Type
Code 2320
SBR05 from
previous payer(s)
14 / 47
2320 or 2430 – 15
valid information
why NGHP or
GHP did not
make payment
Claim Filing Paid Amount Condition
Code
Indicator
(2320 AMT
(2300 HI)
(2320 SBR09) or 2430
SVD02)
AM or LM
$0.00
WC
59
$0.00
Date of
Accident
2300 DTP 01
through 03 and
2300 CLM 11-1
through 11-3
with value AA or
OA
02-Condition 2300 DTP 01
through 03 and
is
Employment 2300 CLM 11-1
through or 11-3
Related
with value EM
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Contact Information and
References
Who Do I Contact?
• Coordination of Benefits and Recovery
Center
– http://www.cms.gov/Medicare/Coordination-ofBenefits-and-Recovery/Coordination-of-Benefits-andRecovery-Overview/Coordination-ofBenefits/Coordination-of-Benefits.html
• Report potential MSP situations
• Report incorrect insurance information
• Address general MSP questions or concerns
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National Government Services, Inc.
Who Do I Contact?
• Telephone:
– 855-798-2627
– TTY/TDD: 855-797-2627
– Monday - Friday, 8:00 a.m.-8:00 p.m. ET
• BCRC addresses:
– http://www.cms.gov/Medicare/Coordination-ofBenefits-and-Recovery/Coordination-of-Benefits-andRecovery-Overview/Contacts/Contacts-page.html
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National Government Services, Inc.
Who Do I Contact?
• Contact National Government Services to
obtain answers to questions about:
– Medicare claim/service denials and adjustments
– How to submit claims
• Provider Contact Center phone numbers and
addresses
– http://www.NGSMedicare.com
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National Government Services
Website
• http://www.NGSMedicare.com
–
–
–
–
–
MSP
Email Updates
Medicare Monthly Review
News articles
Education
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References and Resources
• Medicare Secondary Payer for Provider,
Physician, and Other Supplier Billing Staff
Fact Sheet
– http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads/MSP_Fact_Sheet.pdf
• Remittance advice RARC and CARC codes
– http://www.wpc-edi.com/reference/
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Email Updates
• Subscribe to receive the latest, up-to-date
Medicare information.
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Website Survey
• This is your chance to have your voice
heard—Say “yes” when you see this pop-up
so National Government Services can make
your job easier!
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Medicare University
• http://www.MedicareUniversity.com
• Interactive online system available 24/7
• Educational opportunities available
– Computer-based training courses
– Teleconferences, webinars, live seminars/face-to-face
training
• Self-report attendance
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Medicare University
Self-Reporting Instructions
• Log on to the National Government Services
Medicare University site at
http://www.MedicareUniversity.com
– Topic = JK: Medicare Secondary Payer Part B Billing
Basics
– Medicare University Credits (MUCs) = 1
– Catalog Number = To be provided
– Course Code = To be provided
– For step-by-step instructions on self-reporting please
visit the Accessing the Self-Reporting Tool page on
the NGSMedicare.com website
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Thank You!
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