Medicare Secondary Payer (MSP)
Medicare is a secondary payer when the beneficiary is covered by group insurance, Workers' Compensation, or if other third-party liability (no-fault, liability) applies. For detailed information on CMS's Medicare Secondary Payer guidelines, refer to the CGS web page, 'CMS Guidelines and Resources for Medicare Secondary Payer (MSP)', for links to the various CMS MSP regulations.
IDENTIFYING MSP RECORDS: Check the beneficiary's eligibility using ELGH and/or ELGA, the CGS IVR, or myCGS, to determine if a beneficiary has an open MSP record. An MSP record without a termination date is considered an open record. Refer to the Checking Beneficiary Eligibility (Chapter 2) of the FISS Guide for information on using ELGA page 15 and ELGH page 4 to identify MSP records that may impact your Medicare billing.
If the MSP record is for no-fault, liability, workers' compensation, or black lung, and your services are unrelated to the record, and does not include related diagnoses you can submit the claim showing Medicare as the primary payer.
If the MSP record is for no-fault, liability, workers' compensation, or black lung, and your services are related to the record, or includes related diagnoses, you must submit your claim showing Medicare as the secondary payer.
If the MSP record is for any other MSP type (working aged, ESRD or disability), and your dates of service fall within the Effective and Termination dates of the MSP record, you must submit your claim showing Medicare as the secondary payer.
SUBMITTING MSP CLAIMS TO MEDICARE: Medicare requires claims that report payment by a primary insurer to be submitted electronically (ANSI ASC X12N 837 format). If the primary insurer denied payment, your claim must be submitted to Medicare direct data entry (DDE). For more information, refer to the Submitting Medicare Secondary Payer (MSP) Claims and Adjustments web page.
BILLING MSP CLAIMS TO MEDICARE: Specific data elements are required on an MSP claim to ensure correct processing and payment. Some of these data elements include occurrence codes, value codes, payer codes, and insurer information. To determine what data elements are required on your claim based on the type of MSP record, refer to the Medicare Secondary Payer (MSP) Billing & Adjustments quick resource tool. For information about Value Code 44 on MSP claims, refer to the Billing MSP Claims With Value Code 44 webpage.
SUSPENDED MSP CLAIMS - Claims/adjustments with MSP information may require Medicare staff intervention and suspend for more than 60 days. Providers may call the appropriate Provider Contact Center if their MSP claim has been in the same "S MXXXX" status/location for longer than 60 days.
MEDICARE PAYMENT FOR MSP CLAIMS: When a primary insurer's payment for Medicare covered services is less than the provider's charges, the provider may be entitled to additional reimbursement from Medicare. For more detailed information, refer to the Medicare Payment for MSP Claims webpage.
MSP FREQUENTLY ASKED QUESTIONS (FAQs): MSP is one of the most common reasons why providers call the CGS Provider Contact Center. Therefore, CGS has developed a Medicare Secondary Payer FAQs web page to answer the most common MSP questions. We encourage providers to review these FAQs, as well as the Medicare Secondary Payer (MSP) Billing & Adjustments quick resource tool prior to calling CGS.
BLACK LUNG (BL) PROGRAM — The CGS Federal Black Lung (BL) Program web page provides information about billing Medicare for beneficiaries who are covered by the Federal BL Program.
MSP Resources from the Centers for Medicare & Medicaid Services (CMS)
- Medicare Secondary Payer Fact Sheet
- Other Insurer Intake Tool
- CMS Guidelines and Resources for Medicare Secondary Payer
- Updating Beneficiary Information with the Coordination of Benefits Contractor (SE1205)
- Contact the Coordination of Benefits (COB) Contractor
- Guidance for Correct Claims Submission When Secondary Payers Are Involved (SE1217)
- Categorized Diagnosis Code 500-508 and 800-999 on MSP Claims (Change Request 7149)
- Clarification of Conditional Payment Policy for Liability, No-Fault and Workers' Compensation (MLN Matters article 7355)