MSP Payer Types

It is the Medicare provider's responsibility to determine whether the patient has other insurance that is primary to Medicare and to include this information when submitting claims to Medicare for secondary payment. Often, Medicare Secondary Payer (MSP) cases are identified after processing and the Medicare payment must be recovered from the provider. This is a costly and time-consuming process for both the supplier and Medicare.

It is also very important that the correct MSP type (insurance type code) is reported on electronic claims. Reporting the incorrect MSP type will result in claim denials.

The two-digit numeric value assigned to each MSP type, as well as a description of the MSP type is provided below in an effort to help providers identify the correct value to report on electronic claims.

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MSP Type Brief Description
12 - Working Aged Beneficiary or Spouse with Employer Group Health Plan
  • An Employer Group Health Plan (EGHP) is one that is contributed to by an employer of 20 or more employees
  • The Working Aged is a patient 65 and older who have EGHP coverage through his or her own or their spouse's employment
13 - End-Stage Renal Disease Beneficiary in the 30-Month Coordination Period with an Employer's Group Health Plan
  • Medical group coverage of End Stage Renal Disease (ESRD) is through current or previous employment of patient, patient's spouse or parent, without regard to number of employees or whether employer contributed to EGHP. Many beneficiaries entitled to Medicare because of ESRD will have a Medicare number with suffix "T"
  • Medicare benefits are secondary to benefits payable under an Employer Group Health Plan for individuals who are entitled to Medicare benefits solely on basis of ESRD and patient is younger than 65. Secondary benefits are payable for a period of up to 30 months. This is known as the "coordination period." To determine "coordination period," one of the following must apply:
    • Medicare entitlement usually begins with third month after month in which beneficiary starts a regular course of dialysis. Medicare is the secondary payer for the first 30 months of the individual's entitlement.
    • For those beneficiaries who have undertaken a course in self-dialysis training or have received a kidney transplant during the three-month waiting period, Medicare is the secondary payer for the first 30 months of the individual's Medicare entitlement.
14 - No-fault insurance, including auto, is primary (any no-fault insurance)
  • No-fault insurance pays for health care services resulting from injury to an individual in an accident, regardless of who is at fault for causing the accident.
  • No-fault insurance may be found as part of the following:
    • Automobile insurance policies
    • Homeowners' insurance policies
    • Commercial insurance plans
    • Medical Payments Coverage/Personal Injury
    • Protection/Medical Expense Coverage

Basis for conditional Medicare payment in no-fault cases:

  • The beneficiary has filed a proper claim for no-fault insurance benefits but the intermediary or carrier determines that the no-fault insurer will not pay promptly for any reason other than the circumstances described in 42 CFR 411.32(a)(1). This includes cases in which the no-fault insurance carrier has denied the claim.
  • The beneficiary, because of physical or mental incapacity, failed to meet a claim-filing requirement stipulated in the policy." (42 CFR 411.53)

No-Fault Medicare Set-Aside Arrangement

  • NFMSA is an allocation of funds from a no-fault related settlement, judgment or award that is used to pay for an individual's future medical and/or future prescription drug treatment expenses that would otherwise be reimbursable by Medicare.

For more information, contact the Benefits Coordination & Recovery Center (BCRC).

15 - Workers Compensation
  • Workers' compensation is a law or plan that compensates employees who get sick or injured on the job. Most employees are covered under workers' compensation plans.

Basis for conditional Medicare payment in workers' compensation cases:

  • "The beneficiary has filed a proper claim for workers' compensation benefits, but the intermediary or carrier determines that the workers' compensation carrier will not pay promptly. This includes cases in which a workers' compensation carrier has denied a claim.
  • The beneficiary, because of physical or mental capacity, failed to file a proper claim." (42 CFR 411.45)
  • A claim should be submitted to the other insurer first in the case of an auto accident or other accident when liability insurance applies. According to federal regulations, third party payers have 120 days after receipt of the claim to make payment. When payment or denial is received, submit a claim to Medicare.

Workers' Comp Medicare Set-Aside Arrangement

  • WCMSA is an allocation of funds from a worker's compensation (WC) related settlement, judgment or award that is used to pay for an individual's future medical and/or future prescription drug treatment expenses that would otherwise be reimbursable by Medicare.

Visit the CMS Workers' Compensation Medicare Set Aside Arrangements webpage for more information.

19 - Workers Compensation Medicare Set-aside Arrangements (WCMSA)
  • WCMSA is an allocation of funds from a worker's compensation (WC) related settlement, judgment or award that is used to pay for an individual's future medical and/or future prescription drug treatment expenses that would otherwise be reimbursable by Medicare.
41-Black Lung If the Medicare beneficiary is entitled to Black Lung medical benefits, submit claims to the Department of Labor at the following address:

Federal Black Lung Program
PO Box 470
Lanham, MD 20706
  • For any services not covered, submit a claim to Medicare along with the denial details from the Department of Labor.
  • If a claim for Black Lung or related services is erroneously sent to Medicare, it will be denied. The claim must be submitted to the Federal Black Lung Program.
42-Veteran's Administration (VA)
  • Veterans who are entitled to Medicare may choose which program will be responsible for payment of services that are covered by both programs; however, claims for the same date and service may not be submitted to both programs. When services are authorized by the Veteran's Administration (VA), the authorization binds the VA to pay in full for the items and services provided. If no payment is made by VA, then a claim may be submitted to Medicare.
43 - Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
  • An LGHP is any health plan (contributed to by an employer or by an employee organization, including a self-insured plan) that provides health care directly or through other methods, including insurance or reimbursement to employees, former employees, employer, others associated, or formerly associated with employer in a business relationship or their families. This insurance or reimbursement covers employees of at least one employer that has 100 or more employees on 50% or more of its business days during the preceding calendar year
  • Medicare is secondary payer for disabled Medicare beneficiaries under age 65 who have health insurance coverage under a Large Group Health Plan (LGHP) due to their employment or the employment of a family member
47 - Other Liability Insurance is primary

Notes:
  • MSP type 14 is for all no fault and all auto related accidents while 47 is for other types of accidents (other liability).
  • 42CFR 411.32 (a)(1) "Medicare benefits are secondary to benefits payable by a third party payer even if State Law or the third party payer states that its benefits are secondary to Medicare benefits or otherwise limits its payments to Medicare beneficiaries.
If a beneficiary is involved with an injury as the result of work-related accident, an automobile accident or any other accidental injury, Medicare may be secondary.

In these accidental injuries the claim filing requirements are:
  1. A claim should be submitted to the Workers' Compensation (WC) carrier first for work-related illnesses or injuries. If the claim is contested, the Workers' Compensation Board will notify you. Pending the Workers' Compensation Board decision, you may submit a claim to Medicare.

Basis for conditional Medicare payment in workers' compensation cases:

  • "The beneficiary has filed a proper claim for workers' compensation benefits, but the intermediary or carrier determines that the workers' compensation carrier will not pay promptly. This includes cases in which a workers' compensation carrier has denied a claim.
  • The beneficiary, because of physical or mental capacity, failed to file a proper claim." (42 CFR 411.45)
  • A claim should be submitted to the other insurer first in the case of an auto accident or other accident when liability insurance applies. According to federal regulations, third party payers have 120 days after receipt of the claim to make payment. When payment or denial is received, submit a claim to Medicare.

Basis for conditional Medicare payment in liability cases:

  • "The beneficiary has filed a proper claim for liability insurance benefits but the intermediary or carrier determines that the liability insurer will not pay promptly for any reason other than circumstances described in 42CFR 411.32(a)(1). This includes cases in which the liability insurance carrier has denied the claim."
  • "The Beneficiary has not filed a claim for liability insurance benefits." (42 CFR 411.52)

Basis for conditional Medicare payment in no-fault cases:

  • "The beneficiary has filed a proper claim for no-fault insurance benefits but the intermediary or carrier determines that the no-fault insurer will not pay promptly for any reason other than the circumstances described in 42 CFR 411.32(a)(1). This includes cases in which the no-fault insurance carrier has denied the claim.
  • The beneficiary, because of physical or mental incapacity, failed to meet a claim-filing requirement stipulated in the policy." (42 CFR 411.53)

 

Last Updated Sep 25, 2018