100-05 Medicare Secondary Payer Manual: Chapter 3 - MSP Provider, Physician, and Other Supplier Billing Requirements

Medicare Secondary Payer (MSP) Manual
Chapter 3 - MSP Provider, Physician, and Other Supplier Billing
Requirements
Table of Contents
(Rev. 11874, 02-23-23)
Transmittals for Chapter 3
10 - General
10.1- Limitation on Right to Charge a Beneficiary Where Services Are Covered by
a Group Health Plan (GHP)
10.1.1 - Right of Providers to Charge Beneficiary Who Has Received Primary Payment from
a GHP
10.1.2 - Right of Physicians and Other Suppliers to Charge Beneficiary Who Has Received
Primary Payment from a GHP
10.1.3 - Payment When a Proper Claim is Not Filed
10.2 - Situations in Which MSP Billing Applies
10.3 – Provider, Physician, and Other Supplier Responsibility When a Request is Received from an
Insurance Company or Attorney
10.4 – Provider, Physician, and Other Supplier Responsibility When Duplicate Payments Are
Received
10.5 - Incorrect GHP Primary Payments
10.6 - Retroactive Application
20 - Obtain Information from Patient or Representative at Admission or Start of Care
20.1 - General Policy
20.2 - Verification of Medicare Secondary Payer (MSP) Online Data and Use of Admission
Questions
20.2.1 - Model Admission Questions to Ask Medicare Beneficiaries
20.2.2 - Documentation to Support the Admission Process
30 – Provider, Physician, and Other Supplier Billing
30.1 - Health Care Provider Billing Where Services are Covered by a GHP
30.2 - Provider Billing Where Services are Accident Related and No-Fault Insurance May Be
Available
30.2.1 – Provider Bills No-Fault Insurance First
30.2.1.1 - No-Fault Insurance Does Not Pay
30.2.1.2 - Liability Claim Also Involved
30.2.1.3 - No-Fault Payment is Reduced Because Proper Claim Not Filed
30.2.2 - Responsibility of Provider Where Benefits May Be Payable Under 	Workers'
Compensation(WC)

30.2.2.1 - Responsibility of Provider Where Benefits May be
Payable Under a Workers’ Compensation Medicare
Set-Aside Agreement (WCMSA)
30.2.3 - Responsibility of Provider Where Benefits May be Payable Under the Federal Black
Lung (BL) Program
30.3 - Provider Billing Medicare for Secondary Benefits Where Services are Covered by a GHP
30.4 - Instructions to Providers:How to Submit Claims to A/B MACs (Part A)When There Are
Multiple Primary Payers
30.5 - Instructions to Physicians and Other Suppliers: How to Submit Claims to A/B MACs (Part B)
and DME MACs When There Are One or More Primary Payers
30.6 - MSP Situations under the Competitive Acquisition Program (CAP)
40 - Completing the Form CMS-1450 in MSP Situations by Providers of Service
40.1 - Full Payment by the Primary Payer
40.1.1 - Inpatient Services
40.1.2 - Outpatient Bills, Part B Inpatient Services, and Home Health Agency (HHA) Bills
40.2 - Partial Payment by Primary Payer
40.2.1 - Partial Payment by Primary Payer for Inpatient Services, Outpatient Services, Part B
Inpatient Services, and HHA Bills
40.2.2 - Partial Payment by Primary Payer That Applies to Medicare Covered Services
40.3 - Annotation of Claims Denied by GHPs, Liability or No-Fault Insurers
40.3.1 - Annotation of Claims to Request Conditional Payments
50 - Summary of MSP Data Elements for the Form CMS-1450 (UB-04)
60 - Completing the Form CMS-1500 in MSP Situations by Physicians and Other Suppliers

10 - General
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
A/B Medicare Administrative Contractors (MACs) (Part A), A/B MACs (Part B), or A/B MACs
(Part HHH) (collectively referred to as A/B MACs) and Durable Medical Equipment MACs
(DME MACs) are required in professional and public relations activities to inform providers,
physicians, other suppliers, and beneficiaries about the MSP provisions and that claims for
services to beneficiaries for which Medicare is the secondary payer must be directed first to the
primary plan where there is primary coverage for the services involved. The Medicare law
and/or provider agreement require the submitter to identify on the claim all known payers
obligated to pay primary to Medicare.
10.1- Limitation on Right to Charge a Beneficiary Where Services Are
Covered by a Group Health Plan (GHP)
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
A provider, physician, or other supplier that receives direct payment from the Medicare program
may not charge a beneficiary if the provider, physician, or other supplier has been paid or could
have been paid by a GHP an amount which equals or exceeds any applicable deductible or
coinsurance amount.
EXAMPLE
A Medicare beneficiary who had GHP coverage was hospitalized for 20 days. The hospital's
charges for covered services were $5000. The inpatient deductible had not been met. The gross
amount payable by Medicare (as defined in Pub. 100-05, Chapter 2) for the stay if there had been
no GHP coverage is $4,000. The GHP paid $4,500 ($840 of which was credited to the Medicare
deductible). Medicare will make no payment, since the plan's payment was greater than
Medicare's gross amount payable of $4,000. No part of the $500 difference between the
hospital's charges and the GHP's payment can be billed to the beneficiary since the beneficiary's
obligation, the deductible, was met by the GHP payment. The provider submits a bill to Medicare
reflecting the appropriate amount paid by the primary payer.
10.1.1 - Right of Providers to Charge Beneficiary Who Has Received
Primary Payment from a GHP
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
When a primary plan has paid a beneficiary, the amounts the provider (including renal dialysis
facilities or facilities that receive direct payment from the Medicare program) may collect for
Medicare covered services from the beneficiary are limited to the following:
• 	The amount paid or payable by the primary plan to the beneficiary. If this amount
exceeds the amount which would have been payable by Medicare as primary
payer (without regard to deductible or coinsurance), the provider may retain the
primary payment in full without violating the terms of the provider agreement;
• 	The amount, if any, by which the applicable Medicare deductible and coinsurance
amounts exceed any primary payment made or due the beneficiary or due the
provider for medical services; and

• 	The amount of any charges made to the beneficiary for the noncovered
component of a partially covered service, e.g., the charge differential for a private
room that is not medically necessary but that is requested by the beneficiary.
However, such a charge may not be collected from the beneficiary to the extent
that the primary plan pays it directly to the provider.
EXAMPLE
A Medicare beneficiary with GHP coverage was a hospital inpatient for 20 days. The hospital's
charges for Medicare covered services were $16,000. The inpatient deductible had not been met.
The gross amount payable by Medicare for the stay in the absence of GHP coverage is $11,500.
The GHP paid $14,000, a portion of which was credited to the entire inpatient deductible.
Medicare makes no secondary payment, since the GHP’s payment was greater than the gross
amount payable by Medicare of $11,500. No part of the $2,000 difference between the hospital's
charges and the GHP’s payment can be billed to the beneficiary, since the beneficiary's
obligation, the deductible, was met by the GHP’s payment. The provider files a non-payment bill
reflecting the applicable deductible for purposes of crediting the deductible.
10.1.2 - Right of Physicians and Other Suppliers to Charge Beneficiary Who Has
Received Primary Payment from a GHP
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
When a beneficiary has been paid by a primary plan, the amount a physician or other supplier
who accepts assignment may collect for Medicare covered services from the beneficiary is
limited to the following:
• 	The amount paid or payable by the primary plan to the beneficiary. (If this
amount exceeds the amount that is Medicare would pay as primary payer
(without regard to deductible or coinsurance), the physician or other supplier may
retain the primary payment in full without violating the conditions of
assignment.); or
• 	If the primary payment is less than the applicable Medicare deductible and
coinsurance amounts, the difference between the fee schedule amount (or the
amount the physician is obligated to accept as payment in full, if less), and the
sum of the primary plan’s payment is the Medicare secondary payment.
EXAMPLE
A physician charges $362 for a service. The GHP allows $362 but pays a primary payment
of only $212 because of a $150 plan deductible. The Medicare fee schedule amount is $300.
amount is $300. The amount that Medicare pays as secondary payer is $53.60 since the Medicare secondary
payment amount cannot exceed the amount Medicare would pay primary payer ($300 fee schedule
amount minus the $233 Part B deductible equals $67 x 80 percent = $53.60). The combined primary
payment and Medicare secondary payment is $265.60 ($212 + $53.60).
The physician may charge the beneficiary $34.40, the difference between the Medicare fee
schedule amount ($300) and the sum of the primary payment ($212) plus the Medicare
secondary payment ($53.60). The $34.40 charge to the beneficiary represents the portion of the
Part B deductible and coinsurance amounts in excess of the GHP’s payment. The $233 Part B
deductible is credited in full. The remaining GHP’s payment is applied to the beneficiary's Part B

coinsurance obligation, leaving the beneficiary responsible for the remaining coinsurance
obligation of $34.40.
In the case of non-inpatient psychiatric services, the Part B deductible is credited on the basis of the
Medicare fee schedule amount. There is no annual limit on incurred expenses for non-inpatient psychiatric
services. (See Pub. 100-05, Chapter 2.)
10.1.3 - Payment When a Proper Claim is Not Filed
(Rev.11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
If a provider, physician, or other supplier receives from a payer, that is primary to Medicare, a
payment that is reduced because the provider, physician, or other supplier failed to file a proper
claim, the provider, physician, or other supplier must include this information on the claim for
secondary payment that is submitted to Medicare. Medicare’s secondary payment will be based
on the full payment amount (before the reduction for failure to file a proper claim) unless the
provider, physician, or other supplier demonstrates that the failure to file a proper claim is
attributable to a physical or mental incapacity of the beneficiary that precluded the beneficiary
from being able to provide other payer information.
For example, a physician’s charges are $1,000. The primary plan’s allowable charges without
reduction for failure to file a proper claim are $800.00. The Medicare allowable was $700.00.
The primary plan would have paid $640.00 if a proper claim had been filed. The primary plan
reduced its payment to $500.00 because the physician had not filed a proper claim. Medicare’s
secondary payment would be based on a primary plan payment of $640.00 rather than the
reduced amount of $500.00. The beneficiary may not be billed for the reduction in the primary
plan’s payment due to the physician’s failure to file a proper claim.
10.2 - Situations in Which MSP Billing Applies
(Rev.11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
Medicare secondary billing procedures apply in the following situations:
• 	Where the Veterans Affairs (VA) authorized services, Medicare does not make payment
for items or services furnished by the VA or other non-Federal provider. pursuant to such
an authorization. Note, although certain MSP billing procedures apply, VA is not an
MSP provision. Rather, it represents a Medicare payment exclusion.
• 	Where services are payable under Workers’ Compensation (WC), no-fault or liability
insurance, Medicare does not make payment for otherwise covered items or services to
the extent that payment has been made, or can reasonably be expected to be made. Under
certain circumstances, Medicare may make conditional payments, subject to
reimbursement, if the WC, no-fault, or liability insurer has not paid or will not pay
promptly. Medicare is secondary to WC, no-fault, and liability insurance even if State
law or a private contract of insurance stipulates that its benefits are secondary to
Medicare benefits or otherwise limits its payments to Medicare beneficiaries.
• 	Medicare benefits are secondary to benefits payable under a GHP for individuals eligible
for or entitled to Medicare Part A based on ESRD during a Medicare coordination
period as described in Pub. 100-05, Chapter 2, §20.

• 	Medicare benefits are secondary to benefits payable under a GHP for individuals age 65
or over who have GHP coverage as a result of their own current employment status or
the current employment status of a spouse of any age. (See Pub. 100-05, Chapter 2§10,
for an explanation of this provision.)
• 	Medicare benefits are secondary to benefits provided by GHPs for certain disabled
individuals under age 65 (entitled to Medicare on the basis of disability) who have
coverage based on their own current employment status or the current employment
status of a family member, e.g., a spouse or other family member of a disabled
beneficiary. (See Pub. 100-05, Chapter21, §30, for an explanation of this provision.)
• 	Payment made by any of these primary payers can be used to satisfy unmet deductibles
and the individual's coinsurance. Inpatient, psychiatric hospital, Skilled Nursing Facility
(SNF), or Religious Non-medical Institution care that is paid for by a primary payer is not
counted against the number of lifetime psychiatric days available to the beneficiary.
10.3 - Provider, Physician, and Other Supplier Responsibility When a Request is
Received from an Insurance Company or Attorney
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (Mbi) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of their
processes.
The provider, physician, or other supplier notifies the MSP Contractor, the entity responsible
for coordination of benefits (formerly known as the Benefits Coordination & Recovery Center
or the Coordination of Benefits Contractor and hereafter termed the “MSP contractor”),
promptly if a request is received from an attorney or an insurance company for a copy of a
medical record or a bill concerning a Medicare patient. The MSP Contractor is given a copy of
the request or, if it is unavailable, details of the request, including:
• 	The name and Medicare beneficiary identifier of the patient;
• 	Name and address of the insurance company and/or attorney; and,
• 	Date(s) of services for which Medicare has been or will be billed.
A/B MACs and DME MACs receiving MSP information from providers, physicians, and other
suppliers should follow the procedures outlined in Pub. 100-05, Chapter 5.
10.4 – Provider, Physician, and Other Supplier Responsibility When Duplicate
Payments Are Received
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)

In any case in which a provider, physician, or other supplier has received a primary
payment from Medicare and a duplicate primary payment from a primary plan, the A/B
MACs and DME MACs instruct the provider, physician, or other supplier to refund to the
beneficiary any Medicare deductible and coinsurance amounts paid by the beneficiary
that were duplicated by the primary payment. If the primary payment exceeds the
deductible and coinsurance amounts, the excess constitutes a debt to Medicare because it
duplicates all or part of the amount Medicare has paid and, therefore, must be collected
from the provider, physician, or other supplier. Medicare must be reimbursed within 60
days of the receipt of the duplicate payment. A copy of the letter to the provider,
physician, or other supplier is sent to the beneficiary. Interest is applicable if repayment
is not made to Medicare within 60 days.
The MSP regulations at 42 CFR § 489.20 require providers to pay Medicare within 60
days from the date a payment is received from another payer (primary to Medicare) for
the same service for which Medicare paid. A provider refunds the Medicare payment
within 60 days by submitting an adjustment bill or via the Medicare Credit Balance
Report. The MSP regulations at 42 § CFR 411.24(h) and § 411.25 require all entities that
receive a primary payment from both Medicare and a primary plan to repay Medicare. A
physician or other supplier submits a refund check to Medicare. This refund is due
Medicare, regardless of which payment the provider, physician, or other supplier
received first and even if the insurance payment was refunded to the beneficiary or the
insurer.
Providers report credit balances resulting from MSP payments on the Form CMS-838 if
the overpayment has not been repaid by the last day of the reporting quarter. If the
provider identifies and repays an MSP credit balance within a reporting quarter, in accordance
with the 60-day requirement, it is not reported on the Form CMS-838, i.e., once payment is
made, a credit balance would no longer be reflected in the provider records.
If an MSP credit balance occurs late in a reporting quarter, and the Form CMS-838 is due prior to
expiration of the 60-day requirement, the overpayment must be included in the credit balance
report. However, payment of the credit balance does not have to be made at the time the Form
CMS-838 is submitted, but within the 60 days allowed.
10.5 - Incorrect GHP Primary Payments
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
A GHP may advise a provider, physician, or other supplier that the GHP believes that Medicare
may be the proper primary payer for services for which the GHP had previously made a primary
payment. The GHP may request that the provider, physician, or other supplier either submit an
initial claim to Medicare or request that Medicare reopen its determination on previously
submitted claims for the services. The normal Medicare timely filing and reopening rules apply
to these situations. The initial claim must be submitted within the timely filing period. An initial
determination on a previously adjudicated claim may be reopened for any reason for 1 (one) year
from the date of that determination. After 1 (one) year and prior to 4 (four) years from the date
of determination, “good cause” is required for Medicare to reopen the claim. In general,
Medicare does not consider a situation where (a) Medicare processed a claim in accordance with
the information on the claim form and consistent with the information in the Medicare’s systems

of records and (b) a third party mistakenly paid primary when it alleges that Medicare should
have been primary to constitute “good cause” to reopen.
.
10.6 - Retroactive Application
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
If A/B MACs and DME MACs, including the MSP Contractor notify the provider, physician, or
other supplier, or the provider, physician, or other supplier learns from other sources that an
employer plan may be primary payer for services for which Medicare paid primary benefits, the
provider, physician, or other supplier takes the following actions:
• 	Determines whether there is GHP coverage and, if so, the name and address of
the GHP, if that information is not annotated on the claim;
• 	Checks its records to confirm whether Medicare paid primary benefits for other
services rendered during a coordination period for which a GHP may be primary;
and
• 	Notifies the MSP Contractor of the results of the development efforts according
to Pub. 100-05, Chapter 5 Contractor MSP Claims Processing Requirements.
This information is necessary for Medicare to determine its proper payment. If the GHP pays or
has already paid the provider, physician, or other supplier for all or part of the services, the
provider, physician, or other supplier submits a corrected bill to the A/B MACs and DME MACs
along with the GHP’s explanation of benefits (EOB) or remittance advice if the claim is
submitted hardcopy. The A/B MACs and DME MACs recoups from the provider, physician, or
other supplier the amount of Medicare benefits paid in excess of any amount it is obligated to
pay as secondary payer.
20 - Obtain Information from Patient or Representative at Admission or Start of Care
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
20.1 - General Policy
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
Based on the law and regulations, providers, physicians, and other suppliers are required to file
claims with Medicare using billing information obtained from the beneficiary to whom the item
or service is furnished. Section 1862(b)(6) of the Act, (42 USC 1395y(b)(6)), requires all
entities seeking payment for any item or service furnished under Part B to complete, on the
basis of information obtained from the individual to whom the item or service is furnished, the
portion of the claim form relating to the availability of other health insurance. Additionally, 42
CFR § 489.20(g) requires that all providers must agree “to bill other primary payers before
billing Medicare."
Thus, any providers, physicians, and other suppliers that bill Medicare for services rendered to
Medicare beneficiaries must determine whether or not Medicare is the primary payer for those
services. This must be accomplished by asking Medicare beneficiaries, or their representatives,
questions concerning the beneficiary's MSP status. Exceptions to this requirement are discussed

below in 1, 3 and 6. If providers, physicians or other suppliers fail to file correct and accurate
claims with Medicare, and a mistaken payment situation is later found to exist, 42 CFR § 411.24
permits Medicare to recover its conditional or mistaken payments.
Section 20.2.1 of this chapter, "Model Admission Questions to Ask Medicare Beneficiaries," is a
set of questions that may be used to determine the correct primary payers of claims for all
beneficiary services furnished by a hospital.
NOTE: Providers are required to determine whether Medicare is a primary or secondary payer
for each inpatient admission of a Medicare beneficiary and outpatient encounter with a
Medicare beneficiary prior to submitting a bill to Medicare. It must accomplish this by asking
the beneficiary about other insurance coverage. The model admission questions in section
20.2.1 of this chapter represent the types of questions that should be asked of Medicare
beneficiaries for every admission, outpatient encounter, or start of care. Exceptions to this
requirement are discussed below in 1, 3 and 6.
EXCEPTIONS
These questions may be asked in connection with online access to Common Working File
(CWF) or the X12 270 transmission and the X12 271 response. (See Section 20.2.) If the
provider lacks access to CWF, or does not have a copy of the 271 response, it will follow
the procedures found below in section 20.2.1. The X12 270 Transaction Set is used to
transmit Health Care Eligibility Benefit Inquiries from health care providers, insurers,
clearinghouses and other health care adjudication processors. The X12 270 Transaction
Set can be used to make an inquiry about the Medicare eligibility of an individual. The
X12 271 Transaction Set is the appropriate response mechanism for Health Care
Eligibility Benefit Inquiries.
NOTE: There may be situations where more than one payer is primary to Medicare (e.g.,
liability insurer and GHP). The provider, physician, or other supplier must identify all
possible payers.
This greatly increases the likelihood that the primary payer is billed correctly. Verifying
MSP information means confirming that the information previously furnished about the
presence or absence of another payer that may be primary to Medicare is correct, clear,
and complete, and that no changes have occurred

1. Policy for Hospital Reference Lab Services and Independent Reference Lab
Services
Background
Section 943 (TREATMENT OF HOSPITALS FOR CERTAIN SERVICES UNDER
MEDICARE SECONDARY PAYER (MSP) PROVISIONS) of the Medicare
Prescription Drug, Improvement & Modernization Act of 2003 states:
“(a) IN GENERAL. – The Secretary shall not require a hospital (including a critical
access hospital) to ask questions (or obtain information) relating to the application of
section 1862(b) of the Social Security Act (relating to Medicare Secondary Payer
provisions) in the case of reference lab services described in subsection (b), if the
Secretary does not impose such requirement in the case of such services furnished by an
independent laboratory.
“(b) REFERENCE LABORATORY SERVICES DESCRIBED. – Reference laboratory
services described in this subsection are clinical laboratory diagnostic tests (or the
interpretation of such tests, or both) furnished without a face-to-face encounter between
the individual entitled to benefits under part A or enrolled under part B, or both, and the
hospital involved and in which the hospital submits a claim only for such test or
interpretation.”

Policy
The Centers for Medicare & Medicaid Services (CMS) will not require independent reference
laboratories to collect MSP information in order to bill Medicare for reference laboratory
services as described in subsection (b) above. Therefore, pursuant to section 943 of The
Medicare Prescription Drug, Improvement & Modernization Act of 2003, CMS will not require
hospitals to collect MSP information in order to bill Medicare for reference laboratory services
as described in subsection (b) above. This policy, however, will not be a valid defense to
Medicare’s right to recover when a mistaken payment situation is later found to exist.
A/B MACs shall instruct hospital and independent labs, which have already collected and
retained MSP information for beneficiaries, that they may use that information for the
billing of non-face-to-face reference lab services. However, in situations when there is a
face-to-face encounter with the beneficiary, A/B MACs shall instruct hospitals and
independent labs that they are required to collect MSP information from the beneficiary
when billing for lab services.
Instructions to A/B MACs on how to process reference lab claims submitted on Form
CMS-1500 are available by clicking on the following hyperlink:
https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/clm104c26pdf. (After you get to chapter 26,
go to section 10.2 which discusses reference lab services.)
2. Policy for Recurring Outpatient Services
Hospitals must collect MSP information from the beneficiary or his/her representative for
hospital outpatients receiving recurring services. Both the initial collection of MSP
information and any subsequent verification of this information must be obtained from
the beneficiary or his/her representative. Following the initial collection, the MSP
information should be verified once every 90 days. If the MSP information collected by
the hospital, from the beneficiary or his/her representative and used for billing, is no older
than 90 calendar days from the date the service was rendered, then that information may
be used to bill Medicare for recurring outpatient services furnished by hospitals. This
policy, however, will not be a valid defense to Medicare’s right to recover when a
mistaken payment situation is later found to exist.
NOTE: A Medicare beneficiary is considered to be receiving recurring services if he/she
receives identical services and treatments on an outpatient basis more than once within a
billing cycle.
Hospitals must be able to demonstrate that they collected MSP information from the
beneficiary or his/her representative, which is no older than 90 days, when submitting
bills for their Medicare patients. Acceptable documentation may be the last (dated)
update of the MSP information, either electronic or hardcopy.
3. Policy for Medicare Advantage (MA) Members

If the beneficiary is a member of an MA plan, hospitals are not required to ask the MSP
questions or to collect, maintain, or report this information.
4. Policy for MSP Retirement Dates
During the intake process, when a beneficiary cannot recall his/her precise retirement
date as it relates to coverage under a group health plan as a policyholder or cannot recall
the same information as it relates to his/her spouse, as applicable, hospitals must follow
the policy below.
When a beneficiary cannot recall his/her retirement date but knows it occurred prior to
his/her Medicare entitlement dates, as shown on his/her Medicare card, hospitals report
his/her Medicare A entitlement date as the date of retirement. If the beneficiary is a
dependent under his/her spouse's group health insurance and the spouse retired prior to
the beneficiary's Medicare Part A entitlement date, hospitals report the beneficiary's
Medicare entitlement date as his/her retirement date.
If the beneficiary worked beyond his/her Medicare A entitlement date, had coverage
under a group health plan during that time, and cannot recall his/her precise date of
retirement but the hospital determines it has been at least five years since the beneficiary
retired, the hospital enters the retirement date as five years retrospective to the date of
admission. (Example: Hospitals report the retirement date as January 4, 2016, if the date
of admission is January 4, 2021) As applicable, the same procedure holds for a spouse
who had retired at least five years prior to the date of the beneficiary's hospital admission.
If a beneficiary's (or spouse's, as applicable) retirement date occurred less than five years
ago, the hospital must obtain the retirement date from appropriate informational sources;
e.g., former employer or supplemental insurer.
5. Policy for Provider Records Retention of MSP Information
Title 42 CFR § 489.20(f) states that the provider agrees to maintain a system that, during
the admission process, identifies any primary payers other than Medicare, so that
incorrect billing and Medicare overpayments can be prevented. Based on this regulation,
hospitals must document and maintain MSP information for Medicare beneficiaries.
Without this documentation, the A/B MACs and DME MACs would have nothing to audit
submitted claims against. CMS recommends that providers retain MSP information for
10 years.
A. Obtain Liability or No-Fault Insurance Information
Providers are required to obtain information on possible MSP situations.
Medicare patients, or their representatives, at admission or start of care, are asked
if the services are for treatment of an injury or illness which resulted from an
automobile accident or other incident, for which liability or no- fault insurance
may pay, or for which another party is held responsible. This includes an incident

that occurs on the provider's premises. The provider obtains the name, address,
and policy number of any liability or no-fault insurance company or any
other party that may be responsible for payment of medical expenses that resulted
from the accident or illness.
B. Obtain Workers' Compensation (WC) Information
Providers are required to inquire of the beneficiary or representative at the time
hospitalization is ordered, at admission, or when the service is rendered, whether
the condition is work-related. When the patient or the patient's physician
indicates that the condition is work-related or there is other indication that it is
work-related, the provider is required to ask the patient or the patient's physician,
wherever possible, whether WC is expected to pay. (Generally, where hospital
services are covered under a WC program, the WC carrier or the employer will
authorize the services in advance.)
If the patient denies that WC benefits are payable for a condition which the
provider believes may be covered by WC, a supplementary statement is attached
to the billing form containing information about the circumstances of the accident
and the reasons it is claimed that WC benefits are not payable.
C. Obtain GHP Data from Working Aged Beneficiaries
To obtain the information needed to ascertain whether to bill a GHP as primary
payer, providers ask beneficiaries age 65 or over admitted for inpatient care or
receiving outpatient care, or their representatives, selected questions. See section
20.2.1 of this chapter for the model questionnaire. These include the age of the
beneficiary, the employment status of the beneficiary and the spouse, whether the
beneficiary is covered under a GHP because of the beneficiary's or the spouse's
current employment, and the patient's identification number and the name and
address of the GHP.
D. Obtain GHP Data from Disabled Beneficiaries
Providers are required to identify individuals who meet the disability provisions
by asking every Medicare beneficiary under age 65 if the individual has group
health coverage based on their own current employment status or the current
employment status of a family member. If the individual has such coverage, the
provider requests the name and address of the employer plan and the individual's
identification number and bills the plan for primary benefits, except where the
provider has information that clearly shows that the employer plan is not primary
payer. If the individual responds negatively to either question, or the provider has
otherwise determined that the employer plan is not primary payer, the provider
bills Medicare for primary benefits.

E. Obtain GHP Data from ESRD Beneficiaries
Health care providers identify beneficiaries who are entitled to Medicare based on
ESRD through information available to them (e.g., the beneficiary's Medicare
card) and to ascertain whether the services may be payable under a GHP during
the 30-month coordination period. Providers determine whether the services were
rendered in the coordination period by checking their own records, e.g.,
information contained on Form CMS-2728 or, if the potential Medicare payment
is $50 or more, with other providers or facilities, or the beneficiary's physician, if
necessary, to determine the date the individual started a regular course of dialysis
or the date the individual received a kidney transplant (or entered a hospital to
receive a transplant) or the date an individual began a course of home dialysis. If
the individual is in the 30-month coordination period, the provider asks if the
beneficiary is insured under a group health insurance plan of his or her own, or as
a family member. If the response is yes, the provider asks for the name and
address of the plan and the beneficiary's identification number. A coordination of
benefits (COB) period may be applicable even if an ESRD beneficiary or his (her)
spouse is not currently employed throughout the COB period. The beginning date
of a COB period is different when an individual receives a kidney transplant or
receives home dialysis than when an individual receives regular (outpatient)
dialysis (3-month waiting period).
If the information obtained does not indicate GHP coverage, the provider
annotates the bill to that effect (e.g., GHP coverage lapsed, benefits exhausted). If
the information indicates that GHP coverage exists, the provider obtains the
information indicated above from the beneficiary or the beneficiary's
representative.
6. Policy for Provider Based and Non-Provider Based Services, such as Ambulance
Services
Some hospitals offer provider-based services, such as a transfer ambulance service that is
affiliated with the hospital. The affiliated provider-based service does not need to repeat
the MSP questions if the beneficiary has already had their information verified by the
provider. In the above example, the hospital-affiliated ambulance provider does not need
to ask the MSP questions if the beneficiary is seen by the hospital admissions staff. The
admissions staff shall verify the beneficiary’s insurance information and it bills the
appropriate insurer for the ambulance service.
However, if the provider is an independent provider (such as if the ambulance provider
above were not affiliated with the hospital), then the independent provider is responsible
for verifying the correct information prior to billing for services.
For audit purposes, and to ensure that the provider has developed for other primary payer
coverage, the provider retains a record of the development or other information on which
it based its determination that Medicare is primary payer. See Pub. 100-05, Chapter 5 for
action to take where a claim is received for primary benefits and there is reason to

believe that Medicare may be secondary payer.
20.2 - Verification of Medicare Secondary Payer (MSP) Online Data and Use of
Admission Questions
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
Physicians, providers and suppliers shall not deny medical services or entry to a SNF or hospital
after you discover that there is:
• 	an open or closed GHP (whether the beneficiary is entitled due to age, disability, or End Stage
Renal Disease) or NGHP (Liability (L), No-Fault (NF) or Workers’ Compensation (WC), MSP
record found in the HIPAA Eligibility Transaction System (HETS) 270/271, or on CWF; or,
• 	a claim that was previously mistakenly denied by Medicare due to an MSP occurrence.
Information about the 270/271 HETS transaction can be found on the following link:
https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-
Technology/HETSHelp/About-HETS .
MSP Online Data Elements
Providers with online capability may now access the following MSP information via the
HETS 270/271 or from the CWF MSP auxiliary file:
• 	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; and
• 	Employee data: ID number, and information.
At the provider's discretion, these data may be viewed during either the admission or the
billing process. However, the data must be viewed before a bill is submitted to Medicare,
and should ideally be viewed before the patient leaves the hospital.
If the model questions are used during the admissions process, the provider will verify
each data element by using the questions, found in section 20.2.1 of this chapter, to help
identify other payers that may be primary to Medicare. It will comply with any
instructions that follow a particular question. Note: If the provider has the ability to
submit and receive a X12 270/271 transaction, the admission staff shall ask the
beneficiary if any insurance information found on CWF, or the X12 271 response, has
changed in lieu of asking all the MSP questions. When submitting the X12 270
transaction the provider must include the beneficiary entitlement date to be sure all MSP
periods are received on the X12 271 response. If there are no changes or updates to the
beneficiary’s insurance then there is no need to ask the questions. However, having

access to CWF or the X12 270/271 transaction does not absolve the provider of its
responsibility from asking the MSP questions as necessary. If there are changes to the
insurance information, or if there is uncertainty regarding information based on
conversation, then the provider must ask the MSP questions. Providers must make a
notation for auditing purposes that all the questions were not asked upon admission, or
during the telephone interview/screening, based on the beneficiary’s statement that their
insurance information has not changed or does not require updating. The Medicare A/B
MACs shall request this notation and confirmation during its hospital review. If the
provider lacks access to CWF or it does not utilize the X12 270/271 transaction the
provider shall follow the procedures found under section 20.2.1 of this chapter.
This means the provider shall ask the beneficiary the necessary MSP questions to determine the
correct primary payer. The providers are held liable to obtain the correct MSP information so
claims are billed to the correct primary payer accordingly per the CMS regulations 42 CFR §
489.20.
20.2.1 - Model Admission Questions to Ask Medicare Beneficiaries
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
The following outline of questions provides important points of data to gather from Medicare
beneficiaries that are helpful for providers to determine who has primary payment responsibility
for a claim or set of claims by asking the questions upon each inpatient and outpatient admission.
The information assists in the proper coordination of benefits to ensure adherence to MSP
provisions as outlined in section 1862(b) of the Social Security Act.
Part I. INFORMATION ABOUT BLACK LUNG, WORKERS’
COMPENSATION (WC), NO-FAULT AND LIABILITY
1. 	Are you receiving benefits under the Black Lung Benefits Act (BL)?
2. 	If yes, the following BL information is required to submit claims appropriately:
• 	Date Black Lung Benefits began
Note: BL is the primary payer for claims related to BL.
3. 	Was the illness/injury due to a work-related accident/condition?
4. 	If yes, the following WC information is required to submit claims appropriately:
• 	Name and address of employer
• 	Name and address of insurance carrier
• 	Policy or claim number
• 	Date of the workplace illness or the injury
Note: WC is the primary payer only for services related to work-related injuries
or illness.

5. 	Are you receiving treatment for an injury or illness covered under no-fault (and/or
medical-payment coverage) including premises or automobile?
6. 	If yes, the following no-fault/auto insurance information is required to submit claims
appropriately:
• 	Name and address of insurance carrier
• 	Policy or claim number
• 	Date of illness or injury
Note: No-fault insurance is the primary payer only for services related to the
accident.
7. 	Are you receiving treatment for an injury, or illness, which another party may be
liable?
8. 	If yes, the following liability information is required to submit claims appropriately:
• 	Name and address of insurance carrier
• 	Policy or claim number
• 	Date of illness or injury
Note: Liability insurance is the primary payer only for services related to the
liability settlement, judgment, or award.
Part II. INFORMATION ABOUT MEDICARE ENTITLEMENT AND
GROUP HEALTH PLANS
1. 	Are you entitled to Medicare based on Age, Disability or ESRD?
Note: If entitlement is based solely on ESRD, skip Part II and complete Part III.
Stop after completing Part II if you are entitled to Medicare based on Age or
Disability.
2. 	Do you have group health plan (GHP) coverage based on your own current
employment, or the current employment of either your spouse or another family
member?
If yes, the employer GHP may be primary to Medicare. Continue below. If no,
stop here as Medicare is primary.
3. 	How many employees, including yourself or spouse, work for the employer
from whom you have GHP coverage? (1-19, 20 – 99 or 100 or more)
Note: If you are aged and there are 20 or more employees, your GHP is primary.
If you are disabled and your employer, spouse, or family member employer, has
100 or more employees, your GHP is primary.

4. 	The following employer GHP information is required to submit claims appropriately:
• 	Name and address of the employer (your own or your spouse’s/family member’s)
through which you receive GHP coverage
• 	Name and address of GHP
• 	Policy number (sometimes referred to as the health insurance benefit package
number)
• 	Group number
• 	Date the GHP coverage began
• 	Name of policyholder (if coverage is through your spouse/other family member)
• 	Relationship to patient (if other than self)
Part III. INFORMATION ABOUT THE PATIENT IF ESRD
MEDICARE ENTITLEMENT APPLIES (INLUDING DUAL
ENTITLEMENT: AGE AND ESRD OR DISABILITY AND ESRD)
1. 	Do you have employer group health plan (GHP) coverage through yourself, a spouse,
or family member if dually entitled based on Disability and ESRD?
If yes, the employer GHP may be primary to Medicare. Continue below.
2. 	Have you received a kidney transplant?
• 	Date of transplant
3. 	Have you received maintenance dialysis treatments?
• 	Date dialysis began
4. Are you within the 30-month coordination period?
Note: the 30-month coordination period starts the first day of the month an individual
is eligible for Medicare (even if not yet enrolled in Medicare) because of kidney
failure (usually the fourth month of dialysis) regardless of entitlement due to age or
disability. 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.
5. Were you receiving GHP coverage prior to and on the date of Medicare entitlement
due to ESRD (or simultaneous entitlement due to ESRD and Age or ESRD and
Disability)?
Note: If yes, the GHP is primary during the 30-month coordination period.
6. The following information is required to submit claims appropriately:
• 	Name and address of the employer (your own or your spouse’s/family member’s)

through which you receive GHP coverage
• 	Name and address of GHP
• 	Policy number (sometimes referred to as the health insurance benefit package
number)
• 	Group number
• 	Name of policyholder (if coverage is through your spouse/other family member)
• 	Relationship to patient (if other than self)
20.2.2 - Documentation to Support the Admission Process
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
The provider retains a copy of completed admission questions, the CWF print out or copy
of the 271 responses including all notations, in its files (or online) for audit purposes to
demonstrate that development for primary payer coverage takes place. It is not necessary
that the beneficiary sign the completed questions. However, providers may identify the
date when the questions are asked. Medicare permits providers to retain hard copy
questions and responses on paper, optical image, microfilm, or microfiche. Hard copy
and data described in this paragraph must be kept for at least 10 years after the date of
service that appears on the claim. (See Pub. 100-05, Chapter 5 for information about the
documentation to be used in a review.) Medicare requires it to retain negative and
positive responses to admission questions for 10 years with DOJ's record retention requirements,
after the date of service. Online data cannot be purged before then.
30 - Provider, Physician, and Other Supplier Billing
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
If services are covered under an open GHP or related to an NGHP MSP accident or injury incident, bill the
primary insurer first.
There are situations where providers bill for services related to a new accident or injury that are not related
to an existing NGHP MSP record found on HETS or CWF. Physicians, providers and suppliers may need to
use the same diagnosis codes that are found on the NGHP record in HETS and CWF. You may submit these
claims to Medicare after you submit these claims to the appropriate GHP and/or NGHP insurer. The NGHP
insurer may deny these claims if the claim is not related to the original accident or injury or the case has
not been settled. After you submit these claims to Medicare, Medicare may mistakenly deny these services
because the diagnosis codes on the claim are related to the diagnosis codes found on the NGHP MSP
record on HETS and CWF. Physicians, providers and suppliers may appeal the denied claim with your
MAC. Physicians, providers and other suppliers must provide an explanation, or a reason code, to justify
why the services are not related to the accident or injury on record. Nonetheless, physicians, providers and
other suppliers must continue to see or provide services to the beneficiary if claims are mistakenly denied.
30.1 - Provider Billing Where Services are Covered by a GHP
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
Providers may seek reimbursement from a GHP insurer before billing Medicare when there is an
indication the insurer is primary payer. A GHP is billed first as primary payer even where there
may be primary coverage for only part of the stay or services (e.g., split stays where the
beneficiary terminated employment during the stay and the GHP coverage terminated
concurrently.)

When a provider bills a GHP as primary payer, the bill itemizes the services rendered even
though they are services for which Medicare reimburses on a fee schedule or other
reimbursement methodology.
30.2 - Provider Billing Where Services are Accident Related and No-Fault Insurance
May Be Available
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
If a provider learns that no-fault insurance may pay for covered services, it must bill the
insurance company as the primary insurer during the promptly period. If Ongoing Responsibility
for Medicals (ORM) exists and is not closed, then Medicare will not make a payment.
30.2.1 - Provider Bills No-Fault Insurance First
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
If the services are related to an automobile accident, the provider ascertains whether coverage
under no-fault insurance is available. If a provider learns that no-fault insurance may pay for
otherwise covered services, or if the beneficiary has an open ORM record, it must bill the
insurance company as primary insurer during the promptly period. I f t h e r e i s n o t a n
O R M o p e n r e c o r d a n d i f the no-fault insurance will not pay promptly, the provider
shall bill the no-fault insurer first to get the denial. Once the denial is received on the
remittance advice, the provider may bill Medicare for conditional payment.
If no-fault insurance does not pay or does not pay in full and there is indication of primary GHP
coverage under Pub. 100-05, Chapter 2, the provider must bill the GHP for the services not paid
in full. It may bill Medicare for secondary benefits only after all primary payers to Medicare
have been billed.
30.2.1.1 - No-Fault Insurance Does Not Pay
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
If the services are related to an accident and the no-fault insurance has been billed but does not
make payment because the individual's no-fault benefits are exhausted or, the individual's
coverage expired, the beneficiary does not have an ORM record, and no other primary payers to
Medicare have been identified, the provider may bill Medicare. A/B MACs and DME MACs will
need to look at the statements from the no-fault insurer or the CAS segment and paid amount
loop for electronic claims (paid amount loop on the 837 should show zero dollars paid by the
NGHP insurer), or attached RA for hardcopy claims, to determine whether benefits were
exhausted, coverage expired or services were not related to the accident/incident to process the
claim appropriately. A/B MACs and DME MACs may send an ECRS request to the MSP
Contractor to close the MSP record as deem necessary.
When billing Medicare where no-fault insurance has been billed but does not make payment,
annotate the date on which the other payer denied the claim and the reason for denial. If the
provider later receives payment from no-fault insurance, it refunds the Medicare payment by
submitting an adjustment bill for Part A and/or a reopening, or appeal request, for Part B.
Part A providers notify the A/B MACs (Part A) of a No-Fault denial using occurrence code 24

(Date Insurance Denied) and indicate the date on which the other payer denied the claim. The
reason for denial is indicated in remarks. In addition, the following occurrence codes are used to
identify the date of the accident:
01 - Auto Accident and Date
02 - No-Fault Insurance Involved-Including Auto Accident/Other and Date
If the conditions described in Pub. 100-05, Chapter 7 are met, conditional payments may be
made. To request a conditional payment, providers enter value code 14 with zero value in form
locator (FL) 39-41 to indicate the type of other insurer and that conditional payment is requested.
The identity of the other payer is shown on line A of FL 50, and the identifying information
about the insured is shown on line A of FL 58-62. The provider enters the proper occurrence
code in FL 31-36 and the address of the insurer in FL 38 or Remarks (FL 80). In addition, an
explanation of why the conditional payment is justified is shown in Remarks (FL 80). (See Pub.
100-05, Chapter 7 for an explanation of policy and procedures for conditional payment situations
for contested, delayed, or no-fault claims.)
30.2.1.2 - Liability Claim Also Involved
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
If the individual files a claim against a third party for injuries suffered in an accident, the
provider may bill Medicare conditionally for otherwise covered expenses to the extent that
payment has not been made, or cannot be made promptly by a no-fault insurer or liability
insurer. For example, a Medicare beneficiary incurs $20,000 in medical expenses due to an
automobile accident. The individual receives $5,000 in no-fault insurance benefits and also has a
liability claim pending against the driver of the other car. Medicare does not pay benefits for the
$5,000 in expenses paid for by the no-fault insurer but does pay benefits based on the additional
$15,000 in expenses. Medicare recovers from the liability insurer or the beneficiary when the
liability claim is settled.
30.2.1.3 - No-Fault Payment is Reduced Because Proper Claim Not Filed
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
When a provider receives a reduced no-fault payment because of failure to file a proper claim,
(see Pub. 100-05, Chapter 1 for definition), the Medicare secondary payment may not exceed the
amount that would have been payable if the no-fault insurer had paid on the basis of a proper
claim.
The provider must inform the A/B MACs and DME MACs that a reduced payment was made and
notify it of the amount that would have been paid if a proper claim had been filed. Failure to
notify Medicare of the latter amount would constitute the filing of a false claim against the
United States and could result in prosecution.

30.2.2 - Responsibility of Provider Where Benefits May Be Payable Under Workers'
Compensation (WC)
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
Information supplied by the provider is one of the means of alerting the A/B MACs (Part A) to
actual or potential WC coverage. A condition is work-related if it resulted from an accident that
occurred on the job or from an occupational disease. The billing form is completed in accordance
with Pub 100-04, Medicare Claims Processing Manual, Chapter 25, "Completing and Processing
the Form CMS 1450 Data Set" when any of the following apply:
• 	The provider or the patient states that the condition is work-related;
• 	The condition, or serious aggravation thereof, resulted from an accident which
occurred in the course of the individual's employment, e.g., the patient fell from a
scaffold while at work;
• 	The diagnosis is one which is commonly associated with employment, e.g.,
pneumoconiosis (including silicosis, asbestosis, and "black lung" disease in the
case of a coal miner); radiation sickness, anthrax, undulant fever; dermatitis due
to contact with industrial compounds; and lead, arsenic, or mercury poisoning;
• 	The beneficiary previously received workers’ compensation for the same
condition;
• 	There is indication that a workers’ compensation claim is pending; or
• 	There is other indication that the condition arose on the job.
Where there is an indication that workers’ compensation may pay for the services, the provider
bills the WC carrier. If WC pays for all of the services (whether at the provider's customary
charge rate or at a special WC rate) the provider submits a Medicare bill indicating the insurer
paid in full. The beneficiary’s Medicare deductible will be credited, however no payment will be
made.
If the provider's WC claim is denied, the provider determines whether any other MSP provisions
apply and bills accordingly. If no other primary payers are available, the provider submits:
• 	A bill in accordance with the regular billing procedures indicating occurrence
code 24 (insurance denied) and the date of denial in FL 31-36; an
• 	A supplementary statement calling attention to the fact that workers’
compensation has denied payment or annotates FL 80, remarks, with the reason.
Providers, Physicians and other suppliers must follow the appropriate billing requirements to bill
Medicare in Liability insurance (including self-insurance), No Fault insurance or Workers’

Compensation situations, and also as identified in Pub. 100-05, Chapter 5.
30.2.2.1 Responsibility of Provider Where Benefits May be Payable Under a Workers’
Compensation Medicare Set-Aside Agreement (WCMSA)
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
A WCMSA is an agreement between the CMS and the CMS beneficiary about what value
of settlement funds must be spent for care related to all settled WC injuries or illnesses
before Medicare begins primary payment for those settled injuries or illnesses.
Indicators that a WCMSA may exist include:
• 	The condition was claimed as work-related and received full-and-final settlement that
included funds for future care;
• 	The beneficiary previously filed a workers’ compensation claim for the
same condition;
• 	The beneficiary indicates that a WCMSA exists; or
• 	The HETS 270/271 transaction shows that a “W” MSP WC record exists.
An MSP record is not a reason to deny services, but information as to who is the appropriate
primary payer for that situation. Providers must first verify via the HETS 270/271 transaction
whether a “W” record exists. Where there is an indication showing a “W” MSP WCMSA record exists,
the patient should have a WCMSA that may pay for services, and the provider bills the patient,
directly. If the WCMSA does not pay for all of the services due to total exhaustion the provider may
submit a Medicare bill indicating what the WCMSA paid. Medicare may then pay as a primary or
secondary payer, dependent upon the WCMSA status. The provider should determine whether any
other MSP provisions apply and bill accordingly. If no other primary payers are available, the
provider submits:
• 	A bill in accordance with the regular billing procedures indicating
occurrence code 24 (insurance denied) and the date of denial in FL 31-36;
and
• 	A supplementary statement calling attention to the fact that WCMSA denied
payment or annotates FL 80, remarks, with the reason.
30.2.3 - Responsibility of Provider Where Benefits May be Payable Under the Federal
Black Lung (BL) Program
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
Providers are to identify beneficiaries who may be entitled under the Federal Black Lung (BL)
Program. Where it appears that a beneficiary may be entitled to receive medical benefits under
the Federal BL Program administered by DOL, the provider bills DOL in the following
situations:
• 	Diagnosis Is BL Related (which includes a diagnosis that is related to BL within

the family of ICD diagnosis codes) - The provider bills all services to DOL, and
includes its DOL assigned provider number on the billing form.
• 	Diagnosis Is Not BL Related - The bill is for an inpatient stay during which some
BL covered procedures were furnished. The provider bills all services to DOL.
• 	The bill is for outpatient services that include one or more BL related procedures.
The provider bills DOL only for those procedures that are reimbursable under the
BL program.
• 	DOL Does Not Pay for All of the Services - If a provider bills DOL, but DOL
doesn't pay for the services in full, the provider bills Medicare as provided in Pub.
100-04, Chapter 25, "Completing and Processing the Form CMS 1450 Data Set,"
attaching a copy of DOL's denial notice which gives the specific reason for
nonpayment. If a claim is denied because of the provider's failure to obtain
a DOL provider number or to furnish documentation needed by DOL,
payment 	may not be made under Medicare.
30.3 - Provider Billing Medicare for Secondary Benefits Where Services Are Covered
by a GHP
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
If a GHP pays primary benefits, secondary Medicare benefits may be payable to supplement the
amount paid by the GHP. Medicare secondary benefits may be payable if the following situations
apply:
• 	The plan payment is less than the provider's charges for Medicare covered
services;
• 	The plan payment is less than the gross amount payable by Medicare; and,
• 	The provider does not accept and is not obligated to accept the GHP primary
payment as payment in full.
When a provider bills Medicare for secondary benefits, the primary payment amounts are
reported according to sections 40.1.1 - 40.1.2 below. If a GHP denies a claim for primary
benefits, the provider submits a bill for conditional primary benefits with an explanation of any
reason given by the plan for its denial. For an inpatient hospital or SNF stay, if the GHP's
payment equals or exceeds the gross amount payable by Medicare, or equals or exceeds the
provider's charges for Medicare covered services or the provider accepts or is obligated to accept
the GHP payment as payment in full, a no payment bill is submitted in accordance with Pub.
100-05, Chapter 5.
Any excess of the GHP payment over the gross amount payable by Medicare is not deducted
from the provider's Medicare reimbursement at final cost settlement. If the GHP denies a

provider's claim for primary benefits, the provider submits a claim for primary Medicare
benefits or conditional primary benefits as provided for in Pub. 100-05, Chapter 5.
30.4 - Instructions to Providers: How to Submit Claims to A/B MACs
(Part A) When There Are Multiple Primary Payers
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
There are situations where there is more than one primary payer that pays on a Medicare Part A
electronic claim and Medicare may still make a secondary payment on the claim. When there are
multiple primary payers, providers must do the following when sending the claim to Medicare
for secondary payment.
• 	Comply with Section 1.4.2, titled “Coordination of Benefits,” found in the 837
Institutional Implementation Guide regarding the submission of Medicare beneficiary
claims to multiple payers for payment. Follow the model that discusses the “provider to
payer to provider” methodology of submitting electronic claims.
• 	After receiving the electronic remittance advice from the primary payers, the provider
sends the other payers’ claim information to Medicare using the 837 format. For MSP
claims, they place the primary payer paid amounts, in loop 2300, qualifier HIXX-1 =
BE. The place the value codes in HIXX-2 and the (value code) monetary amounts in
HIXX-5. NOTE: In regard to Value Code 44, Obligated to Accept as Payment in Full
(OTAF) amount, indicate a value of “Y” in loop 2320, segment OI03. This will inform
Medicare that an OTAF amount is present on the claim and the amount can be found in
the 2300 loop HI segment.
• 	If, for any reason, providers must send a hardcopy MSP claim, they must place the MSP
Value codes and Value code amounts in FL 39-41 of the Form UB04/CMS-1450.
30.5 - Instructions to Physicians and Other Suppliers: How to Submit Claims
to A/B MACs (Part B) and DME MACs When There Are One or More Primary
Payers
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
A. When Medicare is the Secondary Payer Following One Primary Payer There are
situations where one primary payer pays on a Medicare Part B claim and Medicare may
make a secondary payment on the claim. Physicians and other suppliers must comply with the
Section titled “Coordination of Benefits,” found in the 837 version Professional Implementation
Guide (IG) regarding the submission of Medicare beneficiary 	MSP claims Physicians and
other suppliers must follow the section that discusses the provider-to-payer-to-provider
methodology of submitting electronic claims. Physicians and other suppliers must use the
appropriate loops and segments to identify the other payer paid amount, allowed amount, and the
obligated to accept payment in full amount on the 837 as identified below:
Primary Payer Paid Amount:

For line level services, physicians and other suppliers must indicate the primary payer paid amount
for that service line in loop ID 2430 SVD02 of the 837.
For claim level information, physicians and other suppliers must indicate the other payer paid
amount for that claim in loop ID 2320 AMT02 AMT01=D of the 837.
Primary Payer Allowed Amount:
For line level services, physicians and other suppliers must indicate the primary payer allowed
amount by identifying the adjustment amount in the CAS segment using the CO 45 for that service
line of the 837.
For claim level information, physicians and other suppliers must indicate the primary payer allowed
amount by identifying the adjustment amount in the CAS segment using the CO 45 for the 837
claim.
Obligated to Accept as Payment in Full Amount (OTAF):
The OTAF amount for Part A and Part B claims is identified in the CAS segment as group code
CO (usually associated with Claim Adjustment Reason Code 45) with the associated dollar
adjustment amount. The OTAF amount must be greater than zero if there is an OTAF amount, or
if OTAF applies.
B. When Medicare is the Secondary Payer Following Multiple Primary Payers
There may be situations where more than one primary insurer to Medicare makes payment on a
claim; for example, a group health plan makes a primary payment for a service and, subsequently,
another group health plan also makes a primary payment for the same service. 	Claims with
multiple primary payers cannot be sent electronically to Medicare. A hardcopy claim must be
submitted on Form CMS-1500. Physicians and other suppliers must attach the other payers’ EOB,
or remittance advice, to the claim when sending it to Medicare for processing.

C. Submission of MSP Claims with Multiple Primary Payers Where There is More Than
One Insurance Type Code for Part B Claims
When A/B MACs (Part B) and DME MACs receive claims with more than one insurance type code,
the A/B MACs (Part B) and DME MACs must send the shared system and CWF the insurance type
code associated with the highest other payer total claim payment amount. For example, a Medicare
beneficiary sustains injury in a car accident. Five services were performed on the beneficiary.
Since the services performed were related to the accident, the no-fault insurer (referred to as
insurance type code 14) makes a $500.00 payment on each line of the claim totaling
$2,500.00. The beneficiary also has coverage through the spouse’s group health plan. The spouse’s
plan (referred to as insurance type code 12) makes a $400.00 payment on each line of the claim
totaling $2000.00. The A/B MACs (Part B) and DME MACs must send insurance type code 14 (not
insurance type code 12) to the shared system and CWF.
D. Amounts A/B MACs (Part B) and DME MACs and Part B Shared Systems must send
MSPPAY on electronic and paper claims with one or more Primary Payers
There are situations with MSP Part B claims when the 1) the primary payer allowed amount(s)
are greater than the billed amount; 2) the primary paid amount(s) are greater than the primary
payer contractual amounts (a.k.a. the obligated to accept as payment in full (OTAF) amounts);
and 3) the primary paid amount(s) are in excess of the primary allowed amount. When MSP
claims of these types are received and processed it causes the outbound remittance advice (RA)
to be out of balance. To prevent this from occurring the following actions must be taken:
When the other insurer paid amount, or combined paid amount exceeds the physician or other
supplier billed amount, the shared systems shall send the billed amount in place of the primary
payer’s paid amount to MSPPAY and CWF.
When the primary payer allowed amount exceeds the physician or other supplier’s billed amount,
the shared systems shall send the billed amount in place of the primary payer allowed amount to
MSPPAY.
When the primary paid amount is greater than the primary allowed amount, and less than billed
charges, the shared systems shall send the primary payer paid amount instead of the primary
allowed amount to MSPPAY.
When the primary payer paid amount exceeds the primary payer contractual amount, the shared
system shall send the primary payer contractual amount instead of the primary payer paid
amount to MSPPAY.
The remittance advice must show the billed amount, the Medicare payment amount, and the

“impact amounts” from the primary payer(s) on which the Medicare payment is based, and all
Medicare adjustments. The impact amount, as found in section 2.2.13 of the 835 Implementation
Guide, is defined as the amount on which Medicare’s payment is based. This amount will depend
on the payment methodology followed in the above business requirements.
Shared Systems shall no longer use reason code 35 on the outbound remittance advice unless the
life time benefit has been reached is the reason the claim is being adjusted. Shared systems
instead shall use Group Code “CO” with Reason Code “45” on the outbound remittance advice
when the OTAF amount minus the other payer’s payment is the lowest of the three MSP
calculations and is used to identify Medicare’s Secondary payment.
NOTE: In regards to the outbound 837, when the primary payment is equal to or exceeds the
billed amount, and Medicare’s payment is equal to zero, the outbound 837 shall show Medicare’s
zero payment in the 2320 AMT segment. The shared systems shall identify in the CAS segment
of the outbound 837 the amount that exceeds the billed amount and the reason why Medicare is
making a zero payment by using group code and claims adjustment reason code CO 94
(processed in excess of charges), with an accompanied negative dollar amount, and OA 23
(payment adjusted because charges have been paid by another payer) with an accompanied
negative dollar amount.
E. - When A/B MACs (Part B) and DME MACs receive a hard copy Part B claim with
multiple primary payer amounts
A/B MACs (Part B) and DME MACs must take into consideration instructions found in section
30.5.D above when sending the correct amounts to MSPPAY for payment calculation.
Primary Payer Paid Amounts: For line level service claims, the A/B MACs (Part B) and DME
MACs must add all primary payer paid amounts for that service line and send the total line level
payment amount to MSPPAY. If only claim level information is sent to Medicare, the A/B
MACs (Part B) and DME MACs add all other payer paid amounts for that claim and sends the
total claim payment amount to MSPPAY. Note: If the payment amount is greater than the billed
amount, send the billed amount to MSPPAY instead of the other payer paid amount.

Primary Payer Allowed Amount: For line level services, A/B MACs (Part B) and DME MACs
use one of the two fields as follows:
• 	Either the higher of the allowed amount for that service line, or
• 	The total of the other payer paid amounts, whichever is higher, and send it to
MSPPAY.
If only claim level information is sent to Medicare, A/B MACs (Part B) and DME MACs
use one of the two fields as follows:
• 	Take the total claim level allowed amount, or
• 	The total of the paid amount, if less than the billed amount, whichever is
higher, and send it to MSPPAY.
Obligated to Accept as Payment in Full Amount (OTAF): For line level services, the carrier
takes the lowest OTAF amount for that service line, which must be greater than zero, and sends
that amount to MSPPAY. If only claim level information is sent to Medicare, the A/B MACs
(Part B) and DME MACs take the lowest claim level OTAF amount, which must be greater than
zero, and send it to MSPPAY. (NOTE: If submitted charges are lower than the OTAF amount,
then send the lowest Medicare covered charge for that service line to MSPPAY.
Claim Example:
Below is an example of a hard copy Part B MSP claim, with more than one primary payer, sent
to A/B MACs (Part B) and DME MACs. All services are Medicare covered services.
Payer 1 	Submitted
Covered Charges
Other Payer Allowed
Amount (Medicare Part
B only)
OTAF 	Other Payer
Paid Amount
Line 1 	$60.00 	$60.00 	$50.00 	$40.00
Line 2 	$40.00 	$30.00 	$30.00 	$30.00
Total 	$100.00 	$90.00 	$80.00 	$70.00

The
A/B
MACs
(Part
B) and
DME
MACs must send the following line level other payer amounts to MSPPAY based on the
instructions cited above.
Based
on the
example above, since Payer 2 had no OTAF amount on service line 2 and Payer 1 had an OTAF
amount greater than zero on service line 2, Payer 1's OTAF of $30.00 is used and sent to
MSPPAY. Since the combined payment amount is higher than the primary payer OTAF amount
for Line 1 and line 2, the OTAF amounts are sent to MSPPAY in place of the paid amounts.
30.6 - MSP Situations Under the Competitive Acquisition Program (CAP)
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
Drugs Obtained Through the CAP for Beneficiaries with Insurance Primary to Medicare
Providers that elect into the CAP voluntarily agree to obtain CAP drugs for Medicare
beneficiaries exclusively through an approved CAP vendor. In situations where participating
CAP providers obtain a drug from the CAP vendor for a beneficiary who is incorrectly
determined to have Medicare as their primary insurer, but the provider and the CAP vendor must
first bill the appropriate primary insurer for the drug and the administration service.
Upon receipt of the primary insurer’s payment, MSP claims should then be submitted by the
physician to their local carrier for the administration service and by the approved CAP vendor to
the CAP designated carrier for the drug. Providers are required to submit MSP claims even if
they believe there is no outstanding balance due. Such claims must adhere to CAP guidelines
and include the drug HCPCS code, the prescription number provided by the approved CAP
vendor and an appropriate CAP no-pay modifier.
Approved CAP vendor claims must also adhere to CAP requirements and include the assigned
prescription number.
Payer 2 	Submitted
Covered Charges
Other Payer Allowed
Amount (Medicare Part
B only)
OTAF 	Other Payer
Paid Amount
Line 1 	$60.00 	$50.00 	$50.00 	$40.00
Line 2 	$40.00 	$30.00 	$0 	$30.00
Total 	$100.00 	$80.00 	$50.00 	$70.00
Line 1: 	Other Payer Allowed Amount (Part B): 	$60.00
OTAF: 	$50.00
Other Payer Paid Amount: 	$50.00 (the OTAF amount is
substituted for line1)
Line 2 	Other Payer Allowed Amount (Part B) 	$40.00
OTAF: 	$30.00
Other Payer Paid Amount 	$30.00 (the billed amount is
substituted for line1)

All participating CAP providers to submit MSP claims for drug administration services where
the drug was obtained from the approved CAP vendor. Failure to submit an MSP claim for the
drug administration prevents the processing of the vendor’s MSP claim by the CAP designated
carrier.
Drugs Obtained Outside of the CAP for Beneficiaries with Medicare
In certain rare situations, participating CAP providers may mistakenly obtain drugs for Medicare
beneficiaries outside of the CAP vendor because they had determined that the beneficiary had
another insurer that was primary to Medicare. In order to make an appropriate payment for
drugs administered under these unusual circumstances, we are allowing temporary use of the J3
modifier to bypass CAP edits and pay the participating CAP provider at the current ASP rate.
We have requested a modifier for use in this rare situation. Local carriers will be notified
through the usual quarterly update process when a new modifier is available. At that time, the J3
modifier will no longer be accepted for this purpose.
As we expect the situations that require this modifier to be infrequent, local carriers have the
ability to review claims with this modifier to monitor for proper use and educational
opportunities.
MSP Claims for Drugs Present on the Provider’s CAP Drug List
In order to prevent processing errors for MSP claims where the drug billed on the provider’s
claim is present on the selected CAP drug list, local carriers are to implement a SCF rule allowing
an override of the CAP claims processing edits. This SCF rule will allow claims to be identified
as MSP and not require the CAP modifiers or prescription number.
40 - Completing the Form CMS-1450 in MSP Situations by Providers
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
Where Medicare is determined to be the primary payer, Medicare is shown on line A of FL 50.
Where Medicare is the secondary payer, Medicare is shown on line B. All bills where Medicare
is secondary because of primary payer coverage are prepared in accordance with the following
instructions.
40.1- Full Payment by the Primary Payer
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
See below inpatient and outpatient processes.
40.1.1- Inpatient Services
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)

If payment by the primary payer for Medicare covered services (as determined by the formula in
section 40.2.2 below) equals or exceeds the provider's charge for those services or the current
Medicare interim payment amount (without regard to deductible or coinsurance), or the provider
accepts or is obligated to accept the primary payer payment as payment in full and receives at
least this amount, no payment is due from Medicare, and no utilization is charged to the
beneficiary. However, the provider submits a no-payment bill for determining the benefit
period. In addition, primary payer payments are used to satisfy unmet deductibles. The A/B
MACs (Part A) shall process the bill in accordance with Pub. 100-5, Chapter 5 and as follows:
• 	The provider completes the total and noncovered charges columns as if there had
been no other payment;
• 	Where blood is involved, the provider completes the blood items. (This data is
for the beneficiary's utilization records only and is not to be used for the Provider
Statistical & Reimbursement [PS&R] Report);
• 	The provider does not complete the coinsurance amount (no days are charged).
However, inpatient deductible and total deductions are completed when
applicable. (This data is for the beneficiary's utilization records only and is not to
be used for the PS&R Report.);
• 	The provider shows total covered and noncovered days in the usual manner. The
A/B MACs (Part A) count days paid by the primary payer as covered days;
• 	The provider enters the appropriate value code to identify the primary payer;
• 	The provider enters the amount paid by the primary payer in the Value Amount
field;
• 	The provider enters condition code 77 in the condition code field when it receives
an amount it is obligated to accept from the primary payer as payment in full;
• 	The A/B MACs (Part A) do not complete the nonpayment code;
• 	The A/B MACs (Part A) enter the additional MSP data elements that may apply
to the bill based on the applicable MSP provision according to section 50 below.
40.1.2 - Outpatient Bills, Part B Inpatient Services, and Home Health Agency

(HHA) Bills
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
No bill is submitted if:
• 	Payment by the primary payer for Medicare covered services equals or exceeds:
o 	The provider's charges for those services, or
o 	The current Medicare interim payment amount (without regard to the
deductible or coinsurance), or the provider accepts (or is obligated to
accept) the primary payer's payment as payment in full (and it receives at
least this amount) and the provider knows the individual has already met
the deductible.
• 	A GHP payment for an ESRD beneficiary equals or exceeds the Medicare rate
(without regard to the deductible or coinsurance) and the hospital-based renal
dialysis facility knows the individual has met the deductible; and
• 	Where an HHA is billing for DME or orthotic/prosthetic devices and the patient
is not under a plan of treatment and the provider knows the individual has met
the deductible.
A bill is submitted to:
• 	Inform Medicare of charges where the deductible may not yet be met. Although
Medicare can make no payment, it can apply the expenses to the beneficiary's
deductible. A bill is required for crediting the deductible.
The provider completes the bill in the usual manner and determines the charges including those
covered by the primary payer's payment. The amount paid by the primary payer for Medicare
covered services is reported in the appropriate value code and amount. See section 50 below for
additional MSP data elements that may apply to the bill based on the applicable MSP provision.
The provider enters condition code 77 when it receives the amount it is obligated to accept from
the primary payer as payment in full.
40.2 - Partial Payment by Primary Payer
(Rev.11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
See partial payment processes and procedures below.

40.2.1 - Partial Payment by Primary Payer for Inpatient Services, Outpatient Services,
Part B Inpatient Services, and HHA Bills
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
A modified bill will be submitted if payment by the primary payer for Medicare covered services
is less than the provider's charges for those services and the current Medicare interim payment
amount (without regard to the deductible or coinsurance) and the provider does not accept (and
is not obligated to accept) the primary payer's payment as payment in full, or the primary
payment is less than the Medicare rate (without regard to the deductible and coinsurance),
The bill will be submitted in accordance with Chapter 25, "Completing and Processing the
Form CMS 1450 Data Set," of the Medicare Claims Processing Manual, with the following
modifications:
• 	The provider completes the total and noncovered charges as if there had been no other
payment;
• 	For inpatient hospital or SNF services, the provider completes total covered and non-
covered days in the usual manner. It counts days paid by the primary payer as covered
days;
• 	The primary payer is identified on the first payer line in FL 50. Medicare is
identified as the secondary or tertiary payer by completing the second or third payer
line;
• 	The appropriate primary payer value code and amount paid is shown in value code
and amount fields;
• 	The amount the provider is obligated to accept as payment in full from the primary
payer when the primary payer pays a lesser amount is shown as value code 44;
• 	The address of the primary payer is shown in Remarks (FL 84); and
• 	If the primary payer is a GHP for an ESRD beneficiary, the provider enters
occurrence code 33 and the first day of the first month of the Medicare
coordination period. In addition, the provider enters the appropriate
occurrence/condition codes in section 50 below.
40.2.2 - Partial Payment by Primary Payer That Applies to Medicare Covered Services
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)

The provider indicates the primary payer's allocation of its payment between covered and non-
covered Medicare services, by entering the amount the primary payer paid toward Medicare
covered services in value codes (FLs 39 - 41) and value amount fields on the Form CMS-1450.
Where the provider cannot determine those services covered by the primary payment, it applies a
ratio of Medicare covered charges to total charges for the services to the primary payment
amount to determine the portion attributable to Medicare covered services and enters this amount
in value codes/amounts (FLs 39-41). It treats all services (other than those for which the
beneficiary may be charged, such as a private room that is not medically necessary) furnished on
any day for which benefits are payable as covered. It must be able to validate its ratio of covered
and non-covered charges if requested.
If a benefit exhausted case is also a day outlier, Medicare covered charges cannot be determined
until the impact of the primary payment on utilization is determined.
EXAMPLE 1
Total charges were $110. Medicare covered charges were $90. The primary payer's
payment was $88. Since the provider cannot determine the actual allocation of the
primary payer's payment, it uses the following calculation to determine the allocation
shown below:
($90 divided by $110) x $88 = $72
The provider enters $72 in value code/amounts (FLs 39-41).
EXAMPLE 2
Total charges were $5,000. Medicare covered charges were $4,000. The primary payer's
payment was $3,000. Since the non-PPS provider cannot determine the allocation of the
primary payer's payment, it determines the allocation as follows:
($4,000 divided by $5,000) x $3,000 = $2,400
The non-PPS provider enters $2,400 in the value code amount.
EXAMPLE 3
Total charges were $550. Medicare covered charges were $500. The primary payer's payment
was $330. Since the HHA cannot determine the allocation of the primary payer's payment, it
determines the allocation as follows:
($500 divided by $550) x $330 = $300

The HHA enters $300 in the value code amount.
40.3 - Annotation of Claims Denied by GHP's, Liability or No-Fault Insurers
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
Primary Medicare benefits that are paid (if the beneficiary is not appealing the GHP denial)
when a single or a multiple employer plan for which CMS has approved the plan’s multi-
employer exemption request denies a claim for primary benefits because:
• 	The beneficiary is age 65 or over and is enrolled in a single employer plan of an
employer who does not employ 20 or more employees;
• 	The beneficiary is age 65 or over and is enrolled in a multi-employer plan by
virtue of employment with an employer that does not employ 20 or more
employees and the plan has elected the small employer exception;
• 	The beneficiary is not entitled to primary benefits under the plan;
• 	The beneficiary is under age 65 and disabled and the employer does not employ
100 or more employees and the employer is not a member of a multiple employer
GHP which has at least one employer that employs 100 or more employees;
• 	The beneficiary is not entitled to benefits under the plan on the basis of rules that
apply equally to all participants without regard to age or Medicare entitlement;
• 	Benefits under the GHP are exhausted for the services involved;
• 	The services are not covered by the GHP under any circumstances for any
covered individual;
• 	The beneficiary has Medicare based on ESRD (under age 65 and eligible based on
ESRD) and not in a Medicare coordination period.
Medicare does not pay primary Medicare benefits if it is believed that the GHP covers the
particular service and the plan asserts that the services are not covered for “primary
payment” when provided to Medicare beneficiaries.
Where a GHP denies payment for any of these reasons, the provider shows occurrence
code 24 or 25 (insurance denied) and the date of denial in FLs 32-35 (occurrence codes).
In addition, it provides the reason for the denial in Remarks (FL 84).

Medicare primary benefits cannot be paid when a GHP offers only secondary coverage of
services covered by Medicare and it does not allege that the employer has fewer than 20
employees (or 100 employees in the case of disabled beneficiaries). The provider enters
occurrence code 24 (insurance denied) and the date of denial in FLs 32-35 (occurrence codes).
In addition, it enters the annotation "Plan offers secondary coverage of services covered by
Medicare."
40.3.1 - Annotation of Claims to Request Conditional Payments
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
When a liability or no-fault insurer does not make payment e.g., the services are not covered
under no-fault insurance or the individual's insurance coverage expired, the provider bills
Medicare as usual. In addition, the proper occurrence code is shown in FLs 32-35. Occurrence
code 24 is completed to show the date the other payer denied the claim, and the reason for denial
is shown in Remarks (FL 84).
A conditional primary payment may be requested if conditional payment criteria are met.
The provider enters value code 14 with a zero-value amount in FLs 39-41 to indicate the type of
other insurer and that conditional payment is requested. The identity of the other payer is shown
on line A of FL 50, and the identifying information about the insured is shown on line A of FLs
58-60. The provider enters the proper occurrence code in FLs 32-35 and the address of the
insurer in FL 38 or Remarks (FL 84). In addition, an explanation of why the conditional
payment is justified is shown in Remarks (FL 84). (See Pub. 100-05, Chapter 7 for an
explanation of policy and procedures for conditional payment situations for contested, delayed,
or no-fault claims.)
When a GHP does not make payment for the reasons described below, a conditional Medicare
payment can be requested. Conditional payments may be requested where:
• 	The provider has filed a proper claim under the plan and the plan denies the claim
in whole or in part; or
• 	The provider fails to file a proper claim because of the physical or mental
incapacity of the beneficiary.
The provider requests conditional primary payment by entering the appropriate value
code to indicate the type of other insurer. Applicable GHP value codes are 12, 13 or 43.
The value amount is completed with zero value in FLs 39-41. In addition, it includes
occurrence code 24 (insurance denied) and the date of denial by the GHP. The identity of
the GHP is entered on line A of FL 50, the identifying information about the insured is
entered on line A of FLs 58-62, and the address of the GHP is entered on FL 38 or
Remarks (FL 84). In addition, the provider enters the annotation "Beneficiary has

appealed or is protesting GHP denial" in Remarks, FL 84.
Neither primary benefits nor conditional primary Medicare payments may be made where
a GHP denies payment for particular services on the grounds they are not covered by the
plan, and the A/B MACs (Part A) believe the plan does cover them. Conditional benefits
are not paid if a plan offers only secondary coverage for services covered by Medicare,
and the
GHP does not allege that the employer has fewer than 20 employees. Conditional primary
benefits are not paid even if the GHP has only collected premiums for secondary rather than
primary coverage. Where a GHP has denied the claim because the plan provides only secondary
coverage, the A/B MACs (Part A) denies the claim for Medicare primary benefits unless the
single employer GHP or multi-employer plan with an approved multiple employer plan
exemption alleges that the employer has fewer than 20 employees.
50 - Summary of MSP Data Elements for the Form CMS-1450 (UB-04)
(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)
The following table identifies the data elements that are submitted on bills to
communicate the status of the primary payer and payment where Medicare is the
secondary payer. See Medicare Claims Processing Manual 100-04, Chapter 25,
"Completing and Processing the Form CMS -1450 Data Set," for a crosswalk to the
electronic data elements or segment names.
Data Element 	Value for MSP 	MSP Situation
Condition Code
02-Employment Related 	Workers' Compensation and Black
Lung
05-Lien has been filed 	WC, No-fault, Liability,
06-ESRD Patient within coordination
period and covered by GHP
End Stage Renal Disease and covered
by a GHP
08-Beneficiary would not furnish
information concerning other insurance
coverage
All MSP situations
09-Neither patient nor spouse is employed Working Aged, Disability, or ESRD
11-Disabled Beneficiary but no GHP
exists
Disability

Data Element 	Value for MSP 	MSP Situation
28-Patient and/or Spouse's GHP is
Secondary to Medicare
Working Aged
29-Disabled Beneficiary and/or Family
Member's GHP is Secondary to Medicare
Disability
77-Provider Accepts Payment by a
Primary Payer as Payment in Full
All MSP Situations
D7-Claim Change Reason Code for
Adjustment Requests to Make Medicare
the Secondary Payer
All MSP Situations
D8-Claim Change Reason Code for
Adjustment Requests to Make Medicare
the Primary Payer
All MSP Situations
Occurrence Code and Date
01-Auto Accident 	No-Fault or Liability
02-No-fault Insurance including Auto
accident/Other
No- Fault
03-Accident/Tort Liability 	Liability
04-Accident/Employment Related 	WC or BL
05-Other Accident 	Liability
18-Date of Retirement 	Working Aged, Disability, or ESRD
19-Date of Retirement Spouse 	Working Aged, Disability, or ESRD
24-Date Insurance Denied 	All MSP Situations
25-Date Benefits Terminated by Primary
Payer
All MSP Situations
33-First day of the Medicare coordination
period for ESRD beneficiaries covered by
GHP
ESRD
A1-Birth date -Insured A 	Working Aged, Disability, or ESRD
A2-Effective Date-Insured A Policy 	Working Aged, Disability, or ESRD

Data Element 	Value for MSP 	MSP Situation
A3- Benefits Exhausted for Payer A 	Working Aged, Disability, or ESRD
B1-Birth date -Insured B 	Working Aged, Disability, or ESRD
B2-Effective Date-Insured B Policy 	Working Aged, Disability, or ESRD
B3- Benefits Exhausted for Payer B 	Working Aged, Disability, or ESRD
C1-Birth date -Insured C 	Working Aged, Disability, or ESRD
C2-Effective Date-Insured C Policy 	Working Aged, Disability, or ESRD
C3- Benefits Exhausted for Payer C 	Working Aged, Disability, or ESRD
Value Codes and Amounts
12- Working Aged Beneficiary/Spouse
Group Health Plan
Working Aged
13-ESRD Beneficiary in a Medicare
Coordination Period with an Employer
Health Plan
ESRD
14-No-fault, including auto/other. 	No- Fault
15-Workers' Compensation Six zeros in
the amount field indicates a request for a
conditional Medicare payment.
WC
16-PHS, Other Federal Agency 	Other Federal Agency, VA
41-Black Lung Six zeros in the amount
field indicates a request for a conditional
Medicare payment.
Black Lung
42-Veterans Affairs 	VA
43-Disabled Beneficiary Under Age 65
with GHP
Disability
44-Amount Provider Agreed to Accept
from Primary Payer as Payment in Full
All MSP Provisions
47- Any Liability Insurance 	Liability Provisions
Insured's Name

Data Element 	Value for MSP 	MSP Situation
For Primary Payer Information 	All MSP Provisions
Patient's Relationship to Insured
01-Patient is Insured 	All MSP Provisions
02-Spouse 	All MSP Provisions
03- Natural Child/Insured has Financial
Responsibility
Disability, ESRD
08- Employee 	Working Aged, ESRD, Disability
15-Injured Plaintiff 	Liability
Certificate/Social Security Number/Medicare beneficiary identifier
The involved claim number for the
primary coverage is shown
All MSP Provisions
Insurance Group Number
Identification number 	All MSP Provisions
Employment Status Code
1-Employed Full Time 	Working Aged, ESRD, Disability
2-Employed Part-Time 	Working Aged, ESRD, Disability
3-Not Employed 	Working Aged, ESRD, Disability
4-Self-employed 	Working Aged, ESRD, Disability
5-Retired 	Working Aged, ESRD, Disability
Employer Name
WC, Working Aged, ESRD, Disability
Employer Location
WC, Working Aged, ESRD, Disability
Payer ID

Data Element 	Value for MSP 	MSP Situation
All MSP Provisions
60 - Completing the Form CMS-1500 in MSP Situations by Physicians and Other
Suppliers of Services
(Rev. 11874, Issued: 02-23-23; Effective: 03-24-23; Implementation: 03-24-23)
Instructions for completing the Form CMS-1500 can be found in Pub 100-4, Chapter 26,
"Completing and Processing Form CMS-1500 Data Set," of the Medicare Claims Processing
Manual. Specific data elements used to report MSP information are listed below. In addition,
each claim must have an EOB or remittance advice from the primary payer attached that
identifies the amount allowed, paid, or denied by the primary payer.
Item 	Data Element Name 	Instruction to Physician or Other Supplier
Item 4 	Insured's Name 	If the patient has insurance primary to Medicare, either
through the patient's or the spouse's employment or any
other source, the biller lists the name of the insured here.
When the insured and the patient are the same, the biller
enters the word SAME. If Medicare is primary this item is
left blank.
Item 7 	Insured Address 	The insured's address and telephone number. When the
address is the same as the patients, the biller uses the word
SAME. It completes this item only when items 4 and 11
are completed.
Item 8 	Patient Status 	The patient's marital status and whether employed or a
student.
Item 9 	Other Insured Name; 	The last name, first name, and middle initial of the enrollee
in a Medigap policy if it is different from that shown in
item 2. Otherwise, the biller uses the word SAME. If no
Medigap benefits are assigned, the biller leaves this item

Item 	Data Element Name 	Instruction to Physician or Other Supplier
blank. This field may be used in the future for
supplemental insurance plans.
Participating physicians and other suppliers taking
assignment under a MEDIGAP policy complete this item.
Other supplemental claims are not listed here because they
are forwarded automatically to the private insurer if the
private insurer contracts with the carrier to send Medicare
claim information electronically. If there is no such
contract, the beneficiary must file his/her own
supplemental claim.
9a 	Other Insured's Policy or
Group Number
Item 9a. The policy and/or group number of the Medigap
insured preceded by: MEDIGAP, MG, or MGAP.
9b 	Other Insured's Date of
Birth
Item 9b. The Medigap insured's 8-digit birth date
(MMDDCCYY) and sex.
9c 	Employer's Name or
School Name;
Item 9c. Blank if a Medigap PayerID is in item 9d.
Otherwise, the claims processing address of the Medigap
insurer.
9d 	Insurance Plan Name or
Program Name
Item 9d. The 9-digit PAYERID number of the Medigap
insurer. If no PAYERID number exists, then the Medigap
insurance program or plan name is shown.
Item 10a Is Patient's Condition
Related to Employment?
Items 10a thru 10c. "YES" or "NO" must be checked to
indicate whether employment, auto liability, or other
accident involvement applies to one or more of the services
described in item 24. The State postal code must be
shown. Any item checked "YES" indicates there may be
other insurance primary to Medicare. Primary insurance
information must then be shown in item 11.Item 10b Is Patient's Condition
Related to Auto Accident?
Item 10c Is Patient's Condition
Related to Other Accident?
Item 11 	Insured's Policy Group or
FECA Number
If there is insurance primary to Medicare, the biller enters
the insured's policy or group number.
Item 11a Insured's Date of Birth 	Insured's 8-digit birth and sex if different from item 3
Item 	Data Element Name 	Instruction to Physician or Other Supplier

Item 11b Employer's Name or
School Name
The name of the insured's employer is shown here. If there
is a change in the insured's insurance status, e.g., retired,
this contains a retirement date preceded by the word
“RETIRED”.
Item 11c Insurance Plan or Program
Name
The 9-digit PAYERID number of the primary insurer. If
no PAYERID number exists, the complete primary payer's
program or plan name. If the primary payer's EOB does
not contain the claim processing address, this contains the
primary payer's claims processing address as shown on the
EOB.

Transmittals Issued for this Chapter

Rev # 	Issue Date 	Subject 	Impl Date CR#
R11874MSP 02/23/2023 Significant Updates to Internet Only
Manual (IOM) Publication (Pub.) 100-05
Medicare Secondary Payer (MSP) Manual,
Chapter 3
03/24/2023 13085
R10359MSP 09/15/2020 	Update to the Model Admission Questions
for Providers to Ask Medicare Beneficiaries
12/07/2020 11945
R10342MSP 09/04/2020 	Update to the Model Admission Questions
for Providers to Ask Medicare Beneficiaries
- Rescinded and replaced by Transmittal
10359
12/07/2020 11945
R125MSP 	03/22/2019 	Update to Publication (Pub.) 100-05 to
Provide Language-Only Changes for the
New Medicare Card Project
04/22/2019 11193
R123MSP 	08/17/18 	Updating Language to Clarify for Providers
Chapter 3, Section 20 and Chapter 5,
Section 70 of the Medicare Secondary
Payer Manual
11/20/18 	10863
R87MSP 	08/03/2012 	Clarification of Medicare Conditional
Payment Policy and Billing Procedures for
Liability, No-Fault and Workers’
Compensation Medicare Secondary Payer
(MSP) Claims
10/01/2012 7355
R86MSP 	05/25/2012 	Clarification of Medicare Conditional
Payment Policy and Billing Procedures for
Liability, No-Fault and Workers’
Compensation Medicare Secondary Payer
(MSP) Claims Rescinded and replaced by
Transmittal 87
01/07/2013 7355

R85MSP 	05/03/2012 	Clarification of Medicare Conditional
Payment Policy and Billing Procedures for
Liability, No-Fault and Workers’
Compensation Medicare Secondary Payer
(MSP) Claims – Rescinded and replaced by
Transmittal 86
10/01/2012 7355
R57MSP 	10/27/2006 	Instructions for the Coordination of
Medicare Secondary Payer (MSP) Claims
for the Competitive Acquisition Program
(CAP)
01/02/2007 5332
R53MSP 	06/09/2006 	Modifications to Online Medicare
Secondary Payer Questionnaire. This CR
Rescinds and Replaces CR 4098
09/11/2006 5087
R41MSP 	10/21/2005 	Full Replacement of and Rescinding
Change Request (CR) 3504-Modification to
Online Medicare Secondary Payer
Questionnaire
01/21/2006 4098
R37MSP 	10/14/2005 	Manualization of Long-Standing MSP
Policy
N/A 	4028
R26MSP 	03/04/2005 	Clarification of MSP Information
Collection Requirements for Hospital and
Independent Labs
06/06/2005 3729
R25MSP 	02/25/2005 	Changes Included in the Medicare
Modernization Act (MMA)
04/25/2005 3219
R23MSP 	01/21/2005 	Modification to Online Medicare Secondary
Payer Questionnaire
02/22/2005 3504

R21MSP 	10/29/2004 	Instructions on Processing Certain Types of
Medicare Secondary Payer (MSP) Claims
and to Balance the Outbound Remittance
Advice
04/04/2005 3407
R17MSP 	07/16/2004 	Completing CMS-1500 for Labs Where
There Is No Face to Face Encounter
08/16/2004 3267
R11MSP 	02/27/2004 	Hospital Reference Lab Services 	03/29/2004 3064
R01MSP 	10/01/2003 	Initial Issuance of Manual 	N/A 	N/A
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