Medicare Secondary Payer (MSP) Overview
Medicare Secondary Payer Manual (CMS Pub. 100-05)
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, refer to the CMS Guidelines and Resources for Medicare Secondary Payer (MSP).
IDENTIFYING MSP RECORDS: Check the beneficiary's eligibility file in FISS DDE (Inquiry Option 10), the CGS IVR, or myCGS. If an MSP record exists and the claim date of service falls within the effective and termination dates, Medicare is secondary.
SUBMITTING MSP CLAIMS TO MEDICARE: MSP claims must be submitted electronically (ANSI ASC X12N 837 format or keyed directly into the Fiscal Intermediary Standard System (FISS) via Direct Data Entry (DDE). For more information, refer to the Submitting Medicare Secondary Payer (MSP) Claims and Adjustments web page. Effective January 1, 2016, paper UB-04 claims can only be submitted if your agency meets the small provider exception (CMS Pub. 100-04, Ch. 24 §90) or if the services are related to Black Lung.
MSP BILLING RESOURCES: Specific data elements (e.g., occurrence codes, value codes, payer codes and insurer information) are required to ensure correct processing and payment. CGS offers the following resources for additional information.
- Medicare Secondary Payer (MSP) Billing & Adjustments quick resource tool – A flow chart that lists the required data elements for each MSP record type
- The Medicare Secondary Payer (MSP) Billing & Adjustments Online Tool – An online decision tree that mirrors the quick resource tool
- Billing MSP Claims With Value Code 44
- Federal Black Lung (BL) Program
- Medicare Payment for MSP Claims
- Medicare Secondary Payer FAQs
SUSPENDED MSP CLAIMS: MSP claims/adjustments that require Medicare staff intervention may suspend for more than 60 days. You may call the Provider Contact Center if the claim remains in the same "S MXXXX" status/location for longer than 60 days.
MSP Resources from the Centers for Medicare & Medicaid Services (CMS)
- Medicare Secondary Payer Web page
- Medicare Secondary Payer Fact Sheet
- Model Admission Questions to Ask Medicare Beneficiaries (CMS Pub. 100-05, Ch. 3, Section 20.2.1)
- Contact the Benefits Coordination & Recovery Center (BCRC)
- Processing MSP Claims Related or Unrelated to an Accident or Injury for Non-GHP Claims with ICD-9-CM Diagnosis Codes 500-508 and 800-999 or Related ICD-10-CM Diagnosis Codes – Medicare Secondary Payer (MSP) Manual (Pub 100-05, Ch. 6, Section 40.10
Updated: 06.08.22