Clues for Identifying MSP Calls
Identifying MSP Specifics
Note: This resource is designed for:
• MSP specialists
• CSRs in call centers without MSP specialists
|What Should I Look For? |
| |
|In order to know whether and how you need to resolve an MSP call or whether to refer it to the COB contractor, you need to look for some specific |
|information in the beneficiary’s claim. To do this, you read trailers (which indicate other insurance) and denial messages, ask the caller some probing |
|questions to obtain more information, and check to see if you have the correct information. This resource provides guidelines that will help you with |
|most MSP calls. However, always use your judgment when applying these guidelines. |
| |
|Follow these steps to identify MSP calls: |
| |
|Read trailers and denial messages |
|Ask probing questions, if necessary |
|Check to see if information in a beneficiary’s record is correct |
|Resolve the caller’s issue, or refer to COB contractor |
|Specifics in a Claim |
|Read these trailers which indicate other insurance. |Note: A trailer is a code present within the beneficiary’s claim information on your|
| |system, which indicates the beneficiary has other insurance. |
| |Working Aged |
| |Disability |
| |Workers’ Compensation |
| |No-fault insurance |
| |Liability |
| |Black Lung |
| |ESRD |
| |VA (exclusion) |
| |Federal Public Health (exclusion) |
|Read these denial messages. |Our records show that Medicare is your secondary payer. This claim must be sent to |
| |your primary insurer first. |
| |Claim denied because this care may be covered by another payer per coordination of |
| |benefits. |
| |Our records show that an automobile, medical, liability, or no-fault insurance plan |
| |is primary for these services. Submit this claim to the primary payer. |
|Read these denial messages. (Continued) |Claim denied because this injury is the liability of the no-fault carrier. |
| |This claim is denied because this service may be covered by the Workers’ Compensation|
| |plan. Ask your provider to submit a claim to that plan. |
| |Medicare does not pay for these services because they are payable by another |
| |government agency. Submit this claim to that agency. |
| |Medicare does not pay for this item or service. No payment was made because your |
| |primary insurer’s payment satisfied the provider’s bill. |
|Ask these questions for each type of trailer you find. |Working Aged: |
| |Are you currently employed? If not, are you retired? As of what date? |
| |Is your husband/wife currently employed? If not, is he/she retired? As of what date?|
| |Are you receiving health benefits from your employer? |
| |Are you receiving health benefits from your husband’s/wife’s employer? |
| |Do 20 or more employees, including yourself, work for the employer from whom you get |
| |health benefits? |
| |Disability: |
| |Are you receiving group health plan (GHP) coverage from an employer for whom you |
| |work? |
| |Are you receiving GHP coverage through the current employment of a family member? |
| |Do 100 or more employees, including yourself, work for the employer from whom you get|
| |group health benefits? |
| |Workers’ Compensation: |
| |Are you now getting any medical services, related to an illness or injury that |
| |occurred on the job, for which you have filed or will file a Workers’ Compensation |
| |claim? |
| |Have you received a Workers’ Compensation settlement? |
|Ask these questions for each type of trailer you find. |No-Fault Insurance: |
|(Continued) |Are you getting any treatment for an injury for which another party could be held |
| |responsible and could be covered under no-fault insurance? |
| |Liability: Are you getting any treatment for an illness or injury for which another |
| |party could be held responsible and could be covered under liability insurance? |
| |Black Lung: Are you getting Black Lung (coal miner’s) Medical Benefits? |
| |ESRD: |
| |Do you have End-Stage Renal Disease (ESRD)? |
| |What is the date of your first dialysis? What type of dialysis? |
| |Did you have a kidney transplant? If so, what was the date of the transplant? |
| |Note: Some MSP Customer Service Representatives (CSRs) confirm the first three items|
| |through the Renal Management Information System (REMIS). Individual call center |
| |procedures may be different. For example, if the caller disagrees with the |
| |information in the trailer your procedures may require you to refer the caller to the|
| |COB contractor to verify the information. |
| |Are you receiving GHP coverage through your own or a family member’s current or |
| |former employer? |
| |Are you also entitled to Medicare based on age or disability? |
|Check to see if information in the beneficiary’s record is |Research the records on your system. |
|correct. |Research the records on the CWF. |
| |Look for discrepancies between your system’s information and the CWF information. |
|Check to see if information in the beneficiary’s record is |Note: The information on the CWF is the only information that CMS recognizes as |
|correct. (Continued) |valid. |
|Resolve the caller’s issue using these guidelines. |The claim was denied. Tell the beneficiary whether or not it was denied correctly |
| |and, if not, what action you are taking to correct it. |
| |The CWF record is correct but your of the beneficiary’s information is incorrect. |
| |Correct your information. |
| |An individual is calling to report that his or her Large Group Health Care coverage |
| |has ended. Update your system to show that the coverage is terminated. |
| | |
| |Note: You can do a simple termination for all records, except those terminating more|
| |than 6 months before the date of accretion (or date the trailer is added to CWF. If |
| |the termination date is more than 6 months before the date of accretion, transfer to |
| |the COB contractor. The date of accretion ruling applies only to records with |
| |origination contractor numbers that are maintained by the COB. These numbers are |
| |11100 – 11114, 33333, 55555, 77777, 88888, and 99999. |
| |If any other insurance coverage has ended, update your system and CWF to show that |
| |the coverage is terminated. |
| |If an individual is calling to report that he or she has retired, update your system |
| |and CWF to show the coverage is terminated. If you are unable to update an MSP |
| |record, refer the call to the COB contractor (see page 6). |
| |An individual is calling because he or she received written correspondence that his |
| |or her benefits are exhausted for an automobile case. Instruct the beneficiary to |
| |send the information to the lead contractor. If you have an MSP department, send |
| |them any written documentation. |
| |Note: The lead contractor is a CMS predetermined intermediary by state who has lead |
|Resolve the caller’s issue using these guidelines. |recovery responsibility on third party liability cases (e.g., no-fault, liability, |
|(Continued) |Workers’ Compensation). The COB contractor assigns the lead based on the CMS |
| |contractor list. |
| | |
| |If an individual is calling to report that he or she has received information that a |
| |liability case is no longer being pursued, instruct the beneficiary to send the |
| |information to the lead contractor. If you have an MSP department, send them any |
| |written documentation. |
| |Note: If there is no matching record on the CWF, send an MSP inquiry to the COB |
| |contractor through ECRS to set up the record on the CWF. |
| |If the provider/supplier receives a denial from an insurance company indicating that |
| |Medicare is the primary payer, determine why Medicare is primary, e.g., is the |
| |insured person retired, or did the insurance terminate? If the provider/supplier is |
| |unable to provide this information, tell them to contact the beneficiary. Then, have|
| |the provider submit the claim to Medicare for consideration. |
| |If you encounter an MSP record that does not require additional development by the |
| |COB contractor or when records do not have an existing termination date, follow these|
| |directions: |
| |In the case of a claim for secondary or conditional payment, create an “I” record or |
| |terminate an existing record on CWF according to your call center procedures. |
| |IF you are unable to perform the above task because additional development is |
| |necessary, use ECRS. |
| |If the beneficiary called the COB contractor and the COB contractor told him or her |
| |to call the carrier because they want to know where claim information originated, |
| |probe the beneficiary to try to locate the claim. |
| |If any other claims-specific information needs to be resolved. Research the claim as|
|Resolve the call using these guidelines. (Continued) |needed or instruct the beneficiary to contact the provider. |
| |If an attorney is calling to ascertain Medicare’s interests, check to see if the file|
| |is already present on CWF. If so, direct the attorney to the lead contractor. |
| |If an attorney is calling to report that he or she is representing a beneficiary, |
| |check to see if the file is already present on the CWF. If so, direct the attorney |
| |to the lead contractor. |
|Refer the call to the COB contractor using these guidelines. |If information on the beneficiary’s record in CWF is incorrect. |
| |If you are unable to update an MSP record. |
|Note: You may refer the call to the COB contractor by taking|If an individual is calling to report a beneficiary accident or any type of MSP |
|any of the following actions: |situation. |
|A CWF assistance request may be submitted through ECRS by the|If a beneficiary questions a development letter sent by the COB Contractor. |
|MSP specialist/MSP department. |An attorney is calling to ascertain Medicare’s interests, and there is no file on the|
|You may refer the caller to the COB contractor instead of |CWF. |
|entering the information on ECRS. |An attorney is calling to report that he or she is representing a beneficiary, and |
|For information on whether or not to use ECRS, consult your |there is no file on the CWF. |
|call center trainer or manager. | |
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