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When Is Medicare The Secondary Payer?

Medicare Pays Secondary: Which Is: When: Bill as Primary:
Group Health Plan Plan provided through patient or spouse's current employment by an employer with more than 20 employees or through a multi-employer group with employer with more than 20 employees Patient is 65 or older Group Health Plan
Large Group Health Plan Plan provided through patient or spouse's current employment by an employer with more than 100 employees or through a multi-employer group with employer with more than 100 employees Patient is disabled Large Group Health Plan
Group Health Plan for End Stage Renal Disease (ESRD) patient Plan provided through patient or spouse's current employment by an employer Patient has ESRD Services provided within first 30 months of Medicare eligibility or entitlement Group Health Plan
Consolidated Omnibus Budget Reconciliation Act (COBRA) Plan provided under COBRA provision Patient has ESRD Services provided within first 30 months of Medicare eligibility or entitlement COBRA plan
Workers' Compensation Coverage provided under Workers' Compensation because of a job-related illness or injury Services are related to job-related illness or injury Worker's Compensation insurance
Auto, No-Fault, Medical, or Liability Coverage provided due to an auto accident or other accident where no-fault or liability insurance is involved Services are related to auto accident or other accident No-fault or liability insurance
Black Lung Federal plan for health conditions related to Black Lung Services are related to Black Lung disease Department of Labor
Veterans Administration Federal plan that covers service for veterans provided in a Veterans Administration facility Services are provided in a Veterans Administration facility N/A
Federal Government programs Various federal grant programs for research, etc. Services are paid under the federal government program The federal agency administering the program that is paying for the services
Federal, State, or Local Penal system Government entity responsible for care of incarcerated patient Patient is incarcerated
Patient is not responsible for own cost of care under that penal system
Penal system in which patient is incarcerated

Is There a Primary Payer Other Than Medicare?

The provider is responsible for determining whether there is a primary payer other than Medicare. To do so:

  1. Properly and thoroughly administer the MSP Questionnaire. The MSP Questionnaire can be found in the CMS Internet Only Manual (IOM), Publication 100-05, Chapter 3, Section 20.2.1.
  2. Check CWF, if your facility has access to the Fiscal Intermediary Shard System (FISS)/Direct Data Entry (DDE) system
  3. Check the Interactive Voice Response system. The phone number is (866)590-6702.
  4. Check C-SNAP.

If the services are related to an accident and information is not available from the sources listed above, check with family, legal representation, guardian, etc.

If the information provided by the beneficiary differs from the information gathered from the other sources listed above, contact the Benefits Coordination and Recovery Center (BCRC) to update CWF before submitting a claim to Medicare. The phone number is (855) 798-2627.

When Is A Secondary Payer Claim Sent To Medicare?

  1. For all inpatient claims, even if the primary payer paid the claim in full
  2. For outpatient claims, even if the primary payer paid the claim in full, when the deductible has not been met
  3. For claims in which the primary payer made partial payment
  4. For claims in which the primary payer denied the claim in full
  5. For claims where the no-fault or liability insurer has not responded and 120 days have elapsed since the date of the accident or the date the claim was sent to the no-fault or liability insurer

Page Last Updated: Tuesday, 15-Jul-2014 09:19:57 CDT