Medicare Secondary Payer

In accordance with guidelines established by the Centers for Medicare & Medicaid Services (CMS), all providers are required to complete the MSP questionnaire upon admission. The 90-day requirement is directed at hospitals in the Internet Only Manual (IOM), Publication 100-05, Chapter 3, Section 20.1.2. However, we also encourage home health and hospice providers to review the questionnaire at least every 90 days. Payer sources can change at any time; therefore, it is important that providers stay informed of the beneficiary’s status in the Medicare program.

Reference

• CMS Manual System, Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Section 201.1.2. (PDF)

Last Reviewed: 09/23/2024

HIPAA Electronic Data Interchange (EDI) Front End Updates made it possible to submit Medicare Secondary Payer (MSP) and Tertiary Payer claims as of January 1, 2017. You may refer to Change Request 9666 (PDF) for details. You may also utilize Direct Data Entry (DDE) to submit MSP and Tertiary Payer claims.

Providers are required to complete a Medicare Secondary Payer Questionnaire (MSPQ) upon admission of each Medicare patient. A sample of the MSPQ can be found in the Centers for Medicare & Medicaid Services’ (CMS) Internet-Only Manual (IOM), Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Section 20.2.1 (PDF). Hospitals are required to verify the information at least every 90 days. However, Palmetto GBA encourages all institutional providers to verify the information on a regular basis because payer sources can change at any time.

Upon completing the MSPQ, providers may then access MSP Lookup to get an idea as to whether or not Medicare is the primary or secondary payer. Providers should also access the Health Insurance Query for Home Health Agencies (HIQH) or Health Insurance Query Access (HIQA) to view any valid MSP segments that may exist on the Common Working File (CWF). Providers may also wish to access the eServices on Palmetto GBA's website to view any valid MSP segments that may exist in a beneficiary’s Medicare records.

In order for a claim to be processed as Medicare primary or secondary, the claim must coincide with the information on the common working file (CWF). When a claim is rejected due to conflicting information on CWF, providers should wait until the CWF is updated before submitting any additional claims for that beneficiary. Palmetto GBA is holding claims for up to 75 days for the CWF to be updated.

Claims will be returned to the provider requesting CWF review prior to resubmission. Once the record on CWF is updated, the provider should submit the claim at that time.

If the provider is certain that the services being rendered are not related to the open liability segment on CWF, the provider may submit the claim to Medicare as primary and annotate in the 'remarks' section of the claim that the services are not related to the open liability segment.

When insurance policies are terminated or are not valid, the Medicare patient or the Medicare provider must contact the MSP Contractor to have the files updated. They may be reached at 855-798-2627. Please refer to MLN Matters^® Number SE1416 (PDF) for specific instructions on contacting the MSP Contractor.