Medicare Secondary Payor (MSP)
Medicare is usually a patient's primary insurance. However, under certain circumstances it is the patient's secondary insurance and not primary. PracticeMaker allows you to submit to Medicare a request for them to pay that portion of the claim that the PRIMARY insurance did not pay. These claims are sent alog with your regular Medicare claims.
The process of submitting an MSP claim is not straight forward. The biller has to have a good understanding of MSP requirements and the fields that must be filled in. Though there is error checking in PracticeMaker, the biller must make sure that all data is pristine and correct before submitting an MSP claim.
You can read some good references to assist you with your understanding. These documents can be found in the "Documents" folder inside the "PracticeMaker5 Manual" folder.
- Medicare Secondary Payor Manual - goes over paper claims, too
- From CMS, understanding OTAF (Obligated To Accept as Full)
- Medicare Secondary Payer (MSP) Billing Guide March 2007 from NHIC, Inc.
Let's go through the requirements needed for an MSP claim.
Correct Coverage Record
A patient with Medicare as the secondary payor, has a primary insurance (Billing Priority = 1) and Medicare (Billing Priority = 2). Below is an example of a correctly completed Coverage record for a Medicare patient. Note that the Group and Group Name fields are blank.
The "Relationship" MUST be Self (code "01"). Here is information directly from the ANSI X12 837 Claim Submission Manual about this field.
SITUATIONAL SBR02 (This means second record in Subscriber
loop)
Individual Relationship Code
Code indicating the relationship between two individuals or entities
Required when the subscriber is the same person as the patient. If the subscriber is not the same person as the patient, do not use this element. (With Medicare this MUST be Self)
Code Definition
18 Self (PracticeMaker sends the correct "18" code when the Description is "Self", as it is above)
Code indicating the relationship between two individuals or entities
Required when the subscriber is the same person as the patient. If the subscriber is not the same person as the patient, do not use this element. (With Medicare this MUST be Self)
Code Definition
18 Self (PracticeMaker sends the correct "18" code when the Description is "Self", as it is above)
The Insurance Type Code is 12 - The selections for this field are limited to the ones below. This information is taken directly from the ANSI X12 837 Claim Submission Manual.
SITUATIONAL
SBR05 Insurance Type Code
Code identifying the type of insurance policy within a specific insurance
Required when the destination payer (Loop 2010BB) is Medicare and Medicare is not the primary payer
Code Definition
12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group (This is the most common choice)
13 Medicare Secondary End Stage Renal Disease Beneficiary in the 12 month
14 Medicare Secondary, No-fault Insurance including Auto is Primary
15 Medicare Secondary Worker's Compensation
16 Medicare Secondary Public Health Service (PHS) or Other Federal Agency
41 Medicare Secondary Black Lung
42 Medicare Secondary Veteran's Administration
43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health
47 Medicare Secondary, Other Liability Insurance is Primary
Code identifying the type of insurance policy within a specific insurance
Required when the destination payer (Loop 2010BB) is Medicare and Medicare is not the primary payer
Code Definition
12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group (This is the most common choice)
13 Medicare Secondary End Stage Renal Disease Beneficiary in the 12 month
14 Medicare Secondary, No-fault Insurance including Auto is Primary
15 Medicare Secondary Worker's Compensation
16 Medicare Secondary Public Health Service (PHS) or Other Federal Agency
41 Medicare Secondary Black Lung
42 Medicare Secondary Veteran's Administration
43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health
47 Medicare Secondary, Other Liability Insurance is Primary
If this field contains values other than these with Medicare selected and Billing Priority = 2, the warning dialog below appears.
Once the Coverage record is properly completed, you will need to work on the claim itself!
Sample Claim 1 Information
Once the primary insurance has paid its share (or in some cases not at all, as with Example 2), the top section of the payment screen could look like the one below. There are many fields that must be completed exactly in order to get paid. Basically, the biller has to complete the required fields to duplicate the information received on the primary carrier's EOB. Once this information is entered into PracticeMaker, it is stored alomh with all other data about the claim.
The Charge portal above, which is located at the top of the Payments and Admin screen, has the following important fields...
- Appr$ field is what the primary insurance approves for that item. You can click directly into the field and enter the approved amount. This field will be automatically filled in if there is a reimbursement record for it based on the Allowance Schedule assigned to the primary insurance and the amount associated with the Code.
- Actual$ is what the insurance pays based an a % decrease, such as with some insurances only paying 80% of what they approve.
- Copay is the remainder between the Appr$ and the Actual$.
- Linepost the the REAL amount received for that charge
- The columns below each of the fields above are the totals.
Click the
button on the top button bar to take you to the screen where additional
information is entered and selected. The graphic below is from the Extras screen for this claim.
The fields above show each charge along with additional field. There are...
- Patient Got Paid-If the insurance company paid the patient any amount on this claim enter the amount here.
- TotPaid is the same field as the LinePost field on the previous screen. You can enter the field here, too, to update the amount
- COB Date is when you received the COB information on this charge.
- COB1 & COB1 $, COB 2 & COB 2 $ and COB 3 & COB 3 $-The first field of each matched pair has the associated drop-down list as shown above. Here you select why the Primary insurance did not pay and the second field is for the amount. For the 99215 charge above the unpaid $15 was for the coinsurance. You can use all three COB matches if you need. Most times, you will select PR1 or PR2.
- Line Check-If the MATH for that
line is correct, meaning all payments and adjustments balance, this
field says "OK". If not, and you submit the claim, it will be rejected!
You MUST pay attention to all information, just as if you were
balancing a checkbook!
Sample Claim 2 Information
Here is an example where the insurance paid nothing on the claim because the entire amount was applied to the patient's deductible. This is why "PR*1" was selected in the COB 1 field for each charge item. Once again, each Line Check field says "OK".
As along as you are extra careful with data entry, and have the correct Insurance Type Code on the Medicare secondary insurance record, your claims should get paid.