Medicare Secondary Payer Quick-Reference Billing Guide
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MSP Situation |
Refer to Working Aged, Disability or ESRD |
Bill Other Insurance as Primary |
Bill Medicare as Primary |
Bill Medicare as Secondary |
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Person with disability is under 65 years of age and . . . |
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The beneficiary is not covered under a large-group health plan and does not have a spouse. |
X |
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The beneficiary is covered under a large-group health plan from a past or present employer; the employer has fewer than 100 employees; the beneficiary has no spouse. |
X |
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The beneficiary is covered under a large-group health plan from a past employer, the employer has more than 100 employees; the beneficiary has no spouse. |
X |
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The beneficiary is covered under a large-group health plan from a present employer, the employer has more than 100 employees; the beneficiary has no spouse. |
X |
X |
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The beneficiary is not covered under any large-group health plan from a past or present employer, but the beneficiary has a spouse or family member who is employed and has the beneficiary covered under his or her large-group health plan. The spouse’s or family member’s employer has fewer than 100 employees. |
X |
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The beneficiary is not covered under any large-group health plan from a past or present employer, but the beneficiary has a spouse or family member who is currently employed and has the beneficiary covered under his or her large-group health plan. The spouse’s or family member’s employer has more than 100 employees. |
X |
x |
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The disabled child is covered under a parent’s contract; the employer has fewer than 100 employees. |
X |
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The disabled child is covered under a parent’s contract; the employer has more than 100 employees. |
X |
X |
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Refer to Working Aged, Disability or ESRD |
Bill Other Insurance as Primary |
Bill Medicare as Primary |
Bill Medicare as Secondary |
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End-stage renal disease (ESRD) |
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The beneficiary has coverage under a current or former employer and is entitled to Medicare solely on the basis of ESRD. (See the ESRD guidelines in the Coverage section of this manual.) |
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X |
X |
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The beneficiary does not have any employer-group health coverage through self or family member. |
X |
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Working Aged Beneficiary is 65 years of age or older and . . . |
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The beneficiary is not employed and does not have a spouse. |
X |
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The beneficiary is still employed and covered under an employer-group health plan; the employer has fewer than 20 employees. |
X |
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The beneficiary is still employed and covered under an employer-group health plan; the employer has more than 20 employees. |
X |
X |
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The beneficiary is not employed, but has a spouse or family member who is still employed and has the beneficiary covered under his or her employer-group health plan; the spouse’s employer has fewer than 20 employees. |
X |
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The beneficiary is not employed, but has a spouse or family member who is still employed and has the beneficiary covered under his or her employer-group health plan; the spouse’s employer has more than 20 employees. |
X |
X |
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Medicare does not ususally pay for services related to the following because the diagnosis indicates that coverage may be provided by other insurers: |
Bill Other Insurance |
Bill Medicare |
Bill Medicare as Secondary |
Medicare may make Conditional Payment |
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The beneficiary is involved in an AA or WC accident. The provider is billing a claim with a diagnosis that is related to the injury. |
X |
X |
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The beneficiary is involved in an AA or WC accident. The provider is billing a claim with a diagnosis that is not related to the injury. |
X |
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The beneficiary is involved in a TP accident. The provider is billing a claim with a diagnosis that is related to the injury.** |
X |
X |
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The beneficiary is involved in a TP accident. The provider is billing a claim with a diagnosis that is not related to the injury. |
X |
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The beneficiary is receiving Black Lung benefits. The provider is billing a claim with a diagnosis that is payable under Black Lung. |
X |
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The beneficiary is receiving Black Lung benefits. The provider is billing a claim with a diagnosis that is not payable under Black Lung. |
X |
*When determining who to bill for a AA, BL, TP, or WC claim, refer to this table first and then to the previous table.
**If the provider chooses to bill the TP insurer or file a lien against the potential settlement, they cannot also bill Medicare at the same time. If they cannot collect from the TP promptly, as defined in Definitions, they must bill Medicare for a conditional payment.
Note: Some beneficiaries may choose to be covered by Medicare or Veteran’s Administration (VA) insurance. They cannot be covered by both. For this reason, if a beneficiary is covered under VA insurance, Medicare cannot be billed, even as a secondary payer, except for the copayment amount.