CMS Issues Reminder on MSP Billing Rules, Appeal Options

MSP Billing Rules

CMS is reminding organizations of Medicare Secondary Payer (MSP) billing and appeal processes after the agency inappropriately denied some claims. Organizations are advised that they must continue to provide services to patients who have open or closed secondary payer records on file or if Medicare inappropriately denied a claim, according to MLN Matters SE21002.

Organizations are required to determine whether Medicare is the primary or secondary payer prior to submitting a claim. If another insurer, such as workers’ compensation (WC) is the primary payer—for example, the patient is receiving treatment related to an injury covered under WC—that insurer should be billed first. Then, after receiving the primary payer’s remittance advice, Medicare may be billed as the secondary payer when appropriate. If a beneficiary receives multiple services, each service must be billed to the appropriate payer.

CMS is aware that it recently inappropriately denied MSP claims when services unrelated to the MSP-covered accident or injury were provided. If an organization believes a claim has been inappropriately denied, it should first review the claim to ensure it was submitted to the proper payer. If the claim was submitted to the correct payer, the organization should contact its MAC and, if necessary, file an appeal.

The MAC should be informed that the service is not related to the MSP-covered accident or injury on file and why the service is unrelated. If the service is covered by Medicare, the organization should request that Medicare pay the claim.

The organization should not tell the patient to contact the Benefits Coordination and Recovery Center to delete an open MSP record. Generally, an open MSP record is active and should not be deleted.

The organization must not bill the patient or refer the claim to a collection agency.

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