Medicare Secondary Payer (MSP) Manual
嚜燐edicare Secondary Payer (MSP) Manual
Chapter 5 每 Contractor MSP Claims Prepayment Processing
Requirements
Table of Contents
(Rev. 12709; Issued: 07-11-24)
Transmittals for Chapter 5
10 - Coordination with the MSP Contractor
10.1 - A/B MACs and DME MACs Contractor MSP Auxiliary File Update Responsibility
10.2 - MSP Contractor Electronic Correspondence Referral System (ECRS)
Attachment 1 - ECRS Web User Guide, Software Version 1.0
Attachment 2 - ECRS Web Quick Reference Card Version 1.0
10.2.1 - ECRS Functional Description
10.3 - Providing Written Documents to the MSP Contractor
10.4 - A/B MACs and DME MACs Record Retention
10.5 - Notification to A/B MACs and DME MACs of MSP Auxiliary File Updates
10.6 - Referring Calls to the MSP Contractor
10.7 - Additional Activities Arranged by Non-GHP MSP Type
10.7.1 - No-Fault Development
10.7.2 - Workers' Compensation (WC) Development
10.7.3 - Liability Development
10.8 - MSP Contractor Numbers
10.8.1 - No-Fault Development
10.8.2 - Workers' Compensation (WC) Development
10.8.3 - Liability Development
20 - Sources That May Identify Other Insurance Coverage
20.1 - Identification of Liability and No-Fault Situations
20.2 - Identify Claims with Possible WC Coverage
20.3 - Medicare Claims Where Veterans' Affairs (VA) Liability May Be Involved
20.3.1 - VA Payment Safeguards
20.4 - Identification of On-Going Responsibility for Medicals (ORM) in Liability, No-Fault,
and Workers' Compensation Situations
20.4.1 - Background Regarding ORM for A/B MACs and DME
MACs
20.4.2 - Policy Regarding ORM
20.4.3 - Operationalizing ORM for Liability, No-Fault, and Workers' Compensation
Situations
20.5 每 Medicare Residual Payments Due When On-going Responsibility for Medicals (ORM)
Benefits Terminate, or Deplete, During a Beneficiary＊s Provider Facility Stay or Upon a
Physician, or Supplier, Visit
30 - Develop Claims for Medicare Secondary Benefits
30.1 - Further Development Is Not Necessary
30.2 - Further Development Is Required
30.3 - GHP May Be Primary to Medicare
30.3.1 - Develop ESRD Claims Where Basis for Medicare Entitlement Changes
30.4 - Workers' Compensation Responses
30.4.1 - Patient Receives Concurrent Services Which Are Not Work-Related
30.5 - No-Fault Responses
30.5.1 - No-Fault Insurer Denies That It Is the Primary Payer
30.5.2 - No-Fault Insurance Does Not Pay All Charges Because of a Deductible or
Coinsurance Provision in Policy
30.5.3 - State Law or Contract Provides That No-Fault Insurance Is Secondary to Other
Insurance
30.6 - Liability Claim Is Filed and There is Also Coverage Under Automobile or NonAutomobile Medical or No-Fault Insurance
40 每 A/B MACs (Part A), A/B MACs (Part B), A/B MACs (Part HHH), and DME MACs Claims
Processing Rules
40.1 - Claim Indicates Medicare is the Primary Payer
40.1.1 - Facts Indicate Reasonable Likelihood of Workers' Compensation Coverage
(Other Than Federal Black Lung Benefits)
40.1.1.1 - The Beneficiary Is on the Black Lung Entitlement Rolls
40.1.2 - Services by Outside Sources Not Covered
40.1.2.1 - Exception
40.1.3 - Notice to Beneficiary
40.2 - Update CWF MSP Auxiliary File
40.2.1 - Action if Payment Has Been Made Under No-Fault Insurance
40.3 每 Processing Part B Claims Involving GHPs
40.3.1 - GHP Denies Payment for Primary Benefits
40.3.2 - GHP Does Not Pay Because of Deductible or Coinsurance Provision
40.3.3 - GHP Gives Medicare Beneficiary Choice of Using Preferred Provider
40.4 - GHP Pays Primary
40.4.1 - GHP Pays Charges in Full
40.4.2 - GHP Pays Portion of Charges
40.4.3 - GHP Pays Primary Benefits When Not Required
40.5 - Primary Payer Is Bankrupt or Insolvent
40.5.1 - Billing Beneficiaries During the Liquidation Process
40.5.2 - When to Make a Medicare Secondary Payment
40.5.3 - Amount of Secondary Payment
40.5.4 - Time Limits for Filing Secondary Claims After Liquidation Process
40.6 - Conditional Primary Medicare Benefits
40.6.1 - Conditional Medicare Payment
40.6.2 - When Primary Benefits and Conditional Primary Medicare Benefits Are Not
Payable
40.7 每 A/B MACs (Part B) and DME MACs Processing Procedures for Medicare Secondary
Claims
40.7.1 - Crediting the Part B Deductible
40.7.2 - Medicare Payment Calculation Methodology
40.7.3 - Medicare Secondary Payment Calculation Methodology for Services
Reimbursed on Reasonable Charge or Other Basis Under Part B
40.7.3.1 - Medicare Secondary Payment Part B Claims Determination for
Services Received on ASC X12 837 Professional Electronic Claims
40.7.3.2 - Medicare Secondary Payment Part A Claims Determination for
Services Received on ASC X12 837 Institutional Electronic or Hardcopy
Claims Format
40.7.3.3 - Balancing for Incoming ASC X12 837 MSP Claims Where MSP
Amounts Appear at the Claim Level and Not at the Service Detail Line
40.7.4 - Effect of Medicare Limiting Charge on Medicare Secondary Payments
40.7.4.1 - GHP Does Not Pay for Certain Services
40.7.4.2 - Third Party Payment Includes Both Medicare Covered and
Noncovered Services
40.7.5 - Effect of Failure to File Proper Claim
40.7.6 - Medicare Secondary Payment for Managed Care Organizations' (MCO)
Copayments
40.7.7- MSP Situations Under CAP
40.8 每 A/B MACs (Part A) Processing Procedures for Medicare Secondary Claims
40.8.1 - Medicare Secondary Payment Calculation Methodology When Proper Claim
Has Been Filed
40.8.2 - Rule to Determine the Amount of Secondary Benefits
40.8.3 - Application of the MSP Formula
40.8.4 - Provider Interim Payment (PIP) Reduction
40.8.5 - MSP Part B Claims (Outpatient and Other Part B Services, Home Health Part
B and Ancillary Services When Part A Benefits are Exhausted)
40.8.6 - MSP Outpatient Claims Involving Lab Charges Paid by Fee Schedule
40.8.6.1 - Prorating Primary Payments
40.8.6.2 - Calculation of Deductible and Coinsurance
40.8.7 - Calculating Medicare Secondary Payments When Proper Claim Has Not Been
Filed With Third Party Payer
40.8.8 - Determining Patient Utilization Days, Deductible, and Coinsurance Amounts
40.8.9 - Benefits Exhausted Situations When Medicare Is Secondary Payer for
Reasonable Cost Providers
40.8.10 - Deductible and/or Coinsurance Rates Spanning Two Calendar Years
40.8.11 - Submit Data to CWF When Full Payment Made by Primary Payer
40.8.12 - Submit Data to CWF When Partial Payment Made by Primary Payer
50 - MSP Pay Modules to Calculate Medicare Secondary Payment Amount
50.1 - Medicare Secondary Payer (MSP) Payment Modules (MSPPAY) for A/B MACs
(Part B) and DME MACs
50.1.1 - Payment Calculation Processes for MSP Claims
50.1.2 - MSPPAY "Driver" Module
50.1.3 - Return Codes
50.1.4 - Executing and Testing MSPPAY Software
50.1.5 每 A/B MACs (Part B) and DME MACs MSPPAY Processing Requirements
50.1.6 - Error Resolution
50.1.7 - Payment Calculation for Physician/Supplier Claims (MSPPAYB Module)
50.1.8 - Payment Calculation for Physician/Supplier Claims (MSPPAYBL)
50.2 - Medicare Secondary Payer (MSP) Payment Modules (MSPPAY) for Part A MACs
50.2.1 - Payment Calculation Processes for MSP Claims
50.2.2 - MSPPAY "Driver" Module
50.2.3 - Return Codes
50.2.4 - Installation
50.2.5 每 Part A Processing Requirements
50.2.6 - Error Resolution
50.2.7 - Payment Calculation for Inpatient Bills (MSPPAYAI Module)
50.2.8 - Payment Calculation for Outpatient Claims (MSPPAYOL)
50.2.8.1 每 MSPPAY Update to Apportion Prospective Payment System (PPS)
Outlier Amounts to All Service Lines with Potential Outlier
Involvement
50.2.9 - Payment Calculation for Outpatient Bills (MSPPAYAO Module)
50.3 每 Multiple Primary Payer Amounts For a Single Service
50.4 - Processing Medicare Secondary Payer (MSP) Fully Paid Claims for Outpatient and
Home Health Claims
60 - MSP Reports
60.1 每 Monthly Part A Report (Form CMS-1563) and Monthly Part B Report (Form CMS1564) on Medicare Secondary Payer Savings
60.1.1 - Overview of Report
60.1.2 - Savings Calculations
60.1.3 - Recording Savings
60.1.3.1 - Source of Savings
60.1.3.2 - Type of Savings
60.1.3.2.1 每 Pre-payment Savings 每 Cost Avoid (Unpaid MSP Claims)
60.1.3.2.2 每 Pre-payment Savings 每 Full Recoveries
60.1.3.2.3 每 Pre-payment Savings 每 Partial Recoveries
60.1.3.2.4 每 Post-payment Savings 每 Full Recoveries
60.1.3.2.5 每 Post-payment Savings 每 Partial Recoveries
60.1.3.2.6 每 Total Post-payment Savings
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