Medicare Secondary Payer (MSP) Manual

1 Medicare Secondary Payer (MSP) Manual chapter 5 - contractor Prepayment Processing Requirements Table of Contents (Rev. 10401, 10-23-20) Transmittals for chapter 5 10 - Coordination with the Benefits Coordination & Recovery Center (BCRC) - contractor MSP Auxiliary File Update Responsibility - COBC Electronic Correspondence Referral System (ECRS) Attachment 1 - ECRS Web User Guide, Software Version Attachment 2 - ECRS Web Quick Reference Card Version - ECRS Functional Description - Technical Overview - Impact on contractor Data Centers - Providing Written Documents to the COBC - contractor Record Retention - Notification to Contractors of MSP Auxiliary File Updates - Referring Calls to the COBC - Changes in Contractors Initial MSP Development Activities - Additional Activities Arranged by Non-GHP MSP Type - No-Fault Development - Workers' Compensation (WC)

2 Development - Liability Development - COBC Numbers 20 - Sources That May Identify Other Insurance Coverage - Identification of Liability and No-Fault Situations - Identify Claims with Possible WC Coverage - Medicare Claims Where Veterans' Affairs (VA) Liability May Be Involved - VA Payment Safeguards - Identification of On-Going Responsibility for Medicals (ORM) in Liability, No-Fault, and Workers' Compensation Situations - Background Regarding ORM for Contractors - Policy Regarding ORM - Operationalizing ORM for Liability, No-Fault, and Workers' Compensation Situations Medicare Residual Payments Due When On-going Responsibility for Medicals (ORM)

3 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 - Further Development Is Not Necessary - Further Development Is Required - GHP May Be Primary to Medicare - Limits on Development - Develop ESRD Claims Where Basis for Medicare Entitlement Changes - Workers' Compensation Responses - Patient Receives Concurrent Services Which Are Not Work-Related - No-Fault Responses - No-Fault Insurer Denies That It Is the Primary Payer - No-Fault Insurance Does Not Pay All Charges Because of a Deductible or Coinsurance Provision in Policy.

4 State Law or Contract Provides That No-Fault Insurance Is Secondary to Other Insurance - Liability Claim Is Filed and There is Also Coverage Under Automobile or Non-Automobile Medical or No-Fault Insurance - Beneficiary Refuses to Provide Requested Information - Audit Trail of Primary Coverage 40 - FI and Carrier Claim Processing Rules - Claim Indicates Medicare is the Primary Payer - Facts Indicate Reasonable Likelihood of Workers' Compensation Coverage (Other Than Federal Black Lung Benefits) - The Beneficiary Is on the Black Lung Entitlement Rolls - Services by Outside Sources Not Covered - Exception - Notice to Beneficiary - Update CWF MSP Auxiliary File - Action if Payment Has Been Made Under No-Fault Insurance Processing Part B Claims Involving GHPs - GHP Denies Payment for Primary Benefits - GHP Does Not Pay Because of Deductible or Coinsurance Provision - GHP Gives Medicare Beneficiary Choice of Using Preferred Provider - GHP Pays Primary - GHP Pays Charges in Full - GHP Pays Portion of Charges - GHP Pays

5 Primary Benefits When Not Required - Primary Payer Is Bankrupt or Insolvent - Billing Beneficiaries During the Liquidation Process - When to Make a Medicare Secondary Payment - Amount of Secondary Payment - Time Limits for Filing Secondary Claims After Liquidation Process - Conditional Primary Medicare Benefits - Conditional Medicare Payment - When Primary Benefits and Conditional Primary Medicare Benefits Are Not Payable - Carrier Processing Procedures for Medicare Secondary Claims - Crediting the Part B Deductible - Medicare Payment Calculation Methodology - Medicare Secondary Payment Calculation Methodology for Services Reimbursed on Reasonable Charge or Other Basis Under Part B - Medicare Secondary Payment Part B Claims Determination for Services Received on ASC X12 837 Professional Electronic Claims - Medicare Secondary Payment Part A Claims Determination for Services Received on 837 Institutional Electronic or Hardcopy Claims Format - Version 5010 Balancing for Incoming MSP Claims Where MSP Amounts Appear at the Claim Level and Not at the Service Detail Line - Effect of

6 Medicare Limiting Charge on Medicare Secondary Payments - GHP Does Not Pay for Certain Services - Third Party Payment Includes Both Medicare Covered and Noncovered Services - Effect of Failure to File Proper Claim - Medicare Secondary Payment for Managed Care Organizations' (MCO) Copayments - Charging Expenses Against Annual Limit on Incurred Expenses for Services of Independently Practicing Physical Therapists - MSP Situations Under CAP - Intermediary Processing Procedures for Medicare Secondary Claims - Medicare Secondary Payment Calculation Methodology When Proper Claim Has Been Filed - Rule to Determine the Amount of Secondary Benefits - Application of the MSP Formula - PIP Reduction - MSP Part B Claims (Outpatient and Other Part B Services.)

7 Home Health Part B and Ancillary Services When Part A Benefits are Exhausted) - MSP Outpatient Claims Involving Lab Charges Paid by Fee Schedule - Prorating Primary Payments - Calculation of Deductible and Coinsurance - Calculating Medicare Secondary Payments When Proper Claim Has Not Been Filed With Third Party Payer - Determining Patient Utilization Days, Deductible, and Coinsurance Amounts - Benefits Exhausted Situations When Medicare Is Secondary Payer for Reasonable Cost Providers - Deductible and/or Coinsurance Rates Spanning Two Calendar Years - Submit Data to CWF When Full Payment Made by Primary Payer - Submit Data to CWF When Partial Payment Made by Primary Payer 50 - MSP Pay Modules to Calculate Medicare Secondary Payment Amount - Medicare Secondary Payer (MSP) Payment Modules (MSPPAY)

8 For Carriers - Payment Calculation Processes for MSP Claims - MSPPAY "Driver" Module - Return Codes - Executing and Testing MSPPAY Software - Carrier MSPPAY Processing Requirements - Error Resolution - Payment Calculation for Physician/Supplier Claims (MSPPAYB Module) - Payment Calculation for Physician/Supplier Claims (MSPPAYBL) - Medicare Secondary Payer (MSP) Payment Modules (MSPPAY) for Part A Contractors - Payment Calculation Processes for MSP Claims - MSPPAY "Driver" Module - Return Codes - Installation Part A Processing Requirements - Error Resolution - Payment Calculation for Inpatient Bills (MSPPAYAI Module) - Payment Calculation for Outpatient Claims (MSPPAYOL) MSPPAY Update to Apportion Prospective Payment System (PPS) Outlier Amounts to All Service Lines with Potential Outlier Involvement - Payment Calculation for Outpatient Bills (MSPPAYAO Module)

9 Multiple Primary Payer Amounts For a Single Service - Processing Medicare Secondary Payer (MSP) Fully Paid Claims for Outpatient and Home Health Claims 60 - MSP Reports Monthly Part A Report (Form CMS-1563) and Monthly Part B Report (Form CMS-1564) on Medicare Secondary Payer Savings - Overview of Report - Savings Calculations - Recording Savings - Source of Savings - Type of Savings Pre-payment Savings Cost Avoid (Unpaid MSP Claims) Pre-payment Savings Full Recoveries Pre-payment Savings Partial Recoveries Post-payment Savings Full Recoveries Post-payment Savings Partial Recoveries Total Post-payment Savings - Electronic Submission - Data Entry of the Forms CMS-1563 and CMS 1564 System Calculations for Forms CMS-1563 and CMS-1564 Exhibit 1 Medicare Secondary Payer (MSP)

10 Savings Report Exhibit 2 CWF Source Codes and Corresponding CROWD Special Project Numbers - Liability Settlement Tracking Report 70 - Hospital Review Protocol for Medicare Secondary Payer - Reviewing Hospital Files - Frequency of Reviews and Hospital Selection Criteria - Methodology for Review of Admission and Bill Processing Procedures - Selection of Bill Sample - Methodology for Review of Hospital Billing Data - Review of Form CMS-1450 - General Review Requirements - Working Aged Bills - Accident Bills - Workers' Compensation Bills - ESRD Bills - Bills for Federal Government Programs - Disability Bills - Use of