MSP Decision Tree

Respond to the questions below to determine whether Medicare is primary or secondary payer of a claim.

Q0

Was the illness/injury due to an accident?

   
Q1 Q0Y

Was the accident related to a car accident?

   
Q2 Q0N

Is the patient receiving black lung benefits?

   
DE Q1Y

This claim needs to be filed to the Auto Insurance as primary. Medicare is secondary. (Type 14 for electronic filing)

Q3 Q1N

Was the accident due to an injury at work?

   
DE Q2Y

This claim needs to be filed with the Black Lung Carrier as primary. Medicare is secondary. (Type 41 for electronic filing)

Q32 Q2N

Is the service related to a Government Research Program?

   
Q4 Q3Y

Is there a worker's compensation fund set aside?

   
Q5 Q3N

Should this claim be paid by a Liability Insurance or is there a lawyer involved?

   
DE Q32Y

This claim needs to be filed to the Government Research Program. Medicare is secondary. (Type 16 for electronic filing)

Q33 Q32N

Was this performed at a Veterans Hospital or covered under the Veterans Administration?

   
DE Q4Y

Needs to be paid by WCSA funds

DE Q4N

This claim needs to be filed to the Worker's Compensation Carrier. Medicare is secondary. (Type 15 for electronic filing)

DE Q5Y

This claim needs to be filed with the Liability Carrier. Medicare is secondary. (Type 47 for electronic filing)

Q6 Q5N

Is the patient receiving black lung benefits?

   
DE Q33Y

This claim needs to be filed to the Veterans Administration.

Q34 Q33N

Is the patient enrolled in a Medicare advantage plan?

   
DE Q6Y

This claim needs to be filed with the Black Lung Carrier as primary. Medicare is secondary. (Type 41 for electronic filing)

Q7 Q6N

Is the service related to a Government Research Program?

   
Q35 Q34Y

Is the Medicare Advantage plan a Medicare replacement policy?

   
Q36 Q34N

Is the patient eligible for Medicare due to...

      
DE Q7Y

This claim needs to be filed to the Government Research Program. Medicare is secondary. (Type 16 for electronic filing)

Q8 Q7N

Was this performed at a Veterans Hospital or covered under the Veterans Administration?

   
DE Q35Y

Medicare does not coordinate with a Medicare replacement plan. This should be filed with the patient's HMO.

Q37 Q35N

Should the Medicare cost plan pay on the claim?

   
Q48 Q36A

Age…Is the patient employed?

   
Q49 Q36B

Disability... Is the patient employed?

   
Q50 Q36C

ESRD... Is the claim within the 30-month coordination period?

   
DE Q8Y

This claim needs to be filed to the Veterans Administration.

Q9 Q8N

Is the patient enrolled in a Medicare advantage plan?

   
DE Q37Y

With a Medicare cost HMO, claims should be billed to either Medicare or the HMO.

Q38 Q37N

Is the patient eligible for Medicare due to...

      
Q51 Q48Y

Does the employer have more than 20 employees?

   
Q52 Q48N

Is the patient's spouse/parent currently employed?

   
Q54 Q49Y

Does the employer have more than 100 employees?

   
Q55 Q49N

Is the patient's spouse/parent currently employed?

   
DE Q50Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary due to ESRD. (Type 13 for electronic filing)

DE Q50N

This claim needs to be filed to Medicare as primary.

Q10 Q9Y

Is the Medicare Advantage plan a Medicare replacement policy?

   
Q22 Q9N

Is the patient eligible for Medicare due to...

      
Q39 Q38A

Age... Is the patient employed?

   
Q40 Q38B

Disability... Is the patient employed?

   
Q41 Q38C

ESRD... Is the claim within the 30-month coordination period?

   
DE Q51Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary. (Type 12 for electronic filing)

DE Q51N

This claim needs to be filed to Medicare as primary.

Q53 Q52Y

Does the employer have more than 20 employees?

   
DE Q52N

This claim needs to be filed to Medicare as primary.

DE Q54Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary due to disability. (Type 43 for electronic filing)

DE Q54N

This claim needs to be filed to Medicare as primary.

Q56 Q55Y

Does the employer have more than 100 employees?

   
DE Q55N

This claim needs to be filed to Medicare as primary.

DE Q10Y

Medicare does not coordinate with a Medicare replacement plan. This should be filed with the patient's HMO.

Q11 Q10N

Should the Medicare cost plan pay on the claim?

   
Q23 Q22A

Age... Is the patient employed?

   
Q24 Q22B

Disability... Is the patient employed?

   
Q25 Q22C

ESRD... Is the claim within the 30-month coordination period?

   
Q42 Q39Y

Does the employer have more than 20 employees?

   
Q43 Q39N

Is the patient's spouse/parent currently employed?

   
Q45 Q40Y

Does the employer have more than 100 employees?

   
Q46 Q40N

Is the patient's spouse/parent currently employed?

   
DE Q41Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary due to ESRD. (Type 13 for electronic filing)

DE Q41N

This claim needs to be filed to Medicare as primary.

DE Q53Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary. (Type 12 for electronic filing)

DE Q53N

This claim needs to be filed to Medicare as primary.

DE Q56Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary due to disability. (Type 43 for electronic filing)

DE Q56N

This claim needs to be filed to Medicare as primary.

DE Q11Y

With a Medicare cost HMO, claims should be billed to either Medicare or the HMO.

Q12 Q11N

Is the patient eligible for Medicare due to

      
Q26 Q23Y

Does the employer have more than 20 employees?

   
Q27 Q23N

Is the patient's spouse/parent currently employed?

   
Q29 Q24Y

Does the employer have more than 100 employees?

   
Q30 Q24N

Is the patient's spouse/parent currently employed?

   
DE Q25Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary due to ESRD. (Type 13 for electronic filing)

DE Q25N

This claim needs to be filed to Medicare as primary.

DE Q42Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary. (Type 12 for electronic filing)

DE Q42N

This claim needs to be filed to Medicare as primary.

Q44 Q43Y

Does the employer have more than 20 employees?

   
DE Q43N

This claim needs to be filed to Medicare as primary.

DE Q45Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary due to disability. (Type 43 for electronic filing)

DE Q45N

This claim needs to be filed to Medicare as primary.

Q47 Q46Y

Does the employer have more than 100 employees?

   
DE Q46N

This claim needs to be filed to Medicare as primary.

Q13 Q12A

Age... Is the patient employed?

   
Q14 Q12B

Disability... Is the patient employed?

   
Q15 Q12C

ESRD... Is the claim within the 30-month coordination period?

   
DE Q26Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary. (Type 12 for electronic filing)

DE Q26N

This claim needs to be filed to Medicare as primary.

Q28 Q27Y

Does the employer have more than 20 employees?

   
DE Q27N

This claim needs to be filed to Medicare as primary.

DE Q29Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary due to disability. (Type 43 for electronic filing)

DE Q29N

This claim needs to be filed to Medicare as primary.

Q31 Q30Y

Does the employer have more than 100 employees?

   
DE Q30N

This claim needs to be filed to Medicare as primary.

DE Q44Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary. (Type 12 for electronic filing)

DE Q44N

This claim needs to be filed to Medicare as primary.

DE Q47Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary due to disability. (Type 43 for electronic filing)

DE Q47N

This claim needs to be filed to Medicare as primary.

Q16 Q13Y

Does the employer have more than 20 employees?

   
Q17 Q13N

Is the patient's spouse/parent currently employed?

   
Q18 Q14Y

Does the employer have more than 100 employees?

   
Q19 Q14N

is the patient's spouse/parent currently employed?

   
DE Q15Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary due to ESRD. (Type 13 for electronic filing)

DE Q15N

This claim needs to be filed to Medicare as primary.

DE Q28Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary. (Type 12 for electronic filing)

DE Q28N

This claim needs to be filed to Medicare as primary.

DE Q31Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary due to disability. (Type 43 for electronic filing)

DE Q31N

This claim needs to be filed to Medicare as primary.

DE Q16Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary. (Type 12 for electronic filing)

DE Q16N

This claim needs to be filed to Medicare as primary.

Q20 Q17Y

Does the employer have more than 20 employees?

   
DE Q17N

This claim needs to be filed to Medicare as primary.

DE Q18Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary due to disability. (Type 43 for electronic filing)

DE Q18N

This claim needs to be filed to Medicare as primary.

Q21 Q19Y

Does the employer have more than 100 employees?

   
DE Q19N

This claim needs to be filed to Medicare as primary.

DE Q20Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary. (Type 12 for electronic filing)

DE Q20N

This claim needs to be filed to Medicare as primary.

DE Q21Y

This claim needs to be filed to the Employer's Heath plan as primary. Medicare is secondary due to disability. (Type 43 for electronic filing)

DE Q21N

This claim needs to be filed to Medicare as primary.

 
Last Updated Dec 10 , 2023