Changes to the Medicare Secondary Payer Record

Medicare receives numerous inquiries on two common scenarios regarding what happens when the Medicare Secondary Payer (MSP) record is changed in our system or when another insurance takes back money stating Medicare should be primary.

Scenario 1: The claim was submitted timely, but WPS Medicare denied the claim for MSP involvement. The patient's file has now been updated and the claim is resubmitted. The claim is denied for timely filing. What options does the provider have at this point?

Scenario 2: Medicare paid the original claim as secondary, now the provider finds out that Medicare is primary. They refund the entire secondary payment and resubmit the claim. The claim denies for late filing. What options does the provider have at this point?

Both scenarios have the same answer. CMS states in the CMS MSP Internet Only Manual (IOM), Publication 100-05, Chapter 3, section 10.5, "The normal Medicare timely filing and reopening rules apply to these situations. The initial claim must be submitted within the timely filing period. An initial determination on a previously adjudicated claim may be reopened for any reason for 1 (one) year from the date of that determination. After 1 (one) year and prior to 4 (four) years from the date of determination, "good cause" is required for Medicare to reopen the claim. In general, Medicare does not consider a situation where (a) Medicare processed a claim in accordance with the information on the claim form and consistent with the information in the Medicare's systems of records and; (b) a third party mistakenly paid primary when it alleges that Medicare should have been primary to constitute "good cause" to reopen".

Medicare can reopen a claim to make additional payments anytime within one year from the date of processing; however, we cannot reprocess the claim if it is outside the one year reopening limit.

For more information, see CMS Internet Only Manual Publication 100-05, Chapter 3Adobe Portable Document Format, Section 10.5.

Page Last Updated: Friday, 16-Dec-2011 12:26:56 CST