Medicare_Secondary_Payer_Manual / Transmittal_11

Why This Topic Matters

The update affects how certain providers handle Medicare Secondary Payer information and how some claims are treated in MSP audit samples. It matters to billing and compliance staff who need to understand the scope of the manual change and the surrounding MSP policy framework.

Article Sections

1. Summary of Changes

   Overview of the transmittal purpose, effective and implementation dates, and the manual sections revised in this update.

2. Attachment - Business Requirements

   Administrative requirements and implementation details associated with the transmittal, including responsibility assignments and supporting information.

3. General Information

   Background on the statutory change and the related Medicare Secondary Payer policy update for hospital and independent reference laboratory services.

4. Business Requirements

   High-level requirements for intermediaries and carriers regarding the updated MSP-related handling of reference laboratory services and claim review activity.

5. 20.1 - General Policy

   Broader Medicare Secondary Payer policy background covering beneficiary information collection, primary payer determination, and related provider responsibilities.

6. 1. Policy for Hospital Reference Lab Services and Independent Reference Lab Services

   Policy background and general guidance specific to hospital reference laboratory services and independent reference laboratory services within the MSP framework.

7. 2. Policy for Recurring Outpatient Services

   Guidance concerning recurring outpatient services and periodic verification of MSP information.

8. 3. Policy for Medicare + Choice Organization (M+CO) Members

   Guidance addressing MSP information collection for beneficiaries enrolled in Medicare managed care arrangements.

9. 4. Policy for Medicare Secondary Payer (MSP) Retirement Dates

   Instructions addressing retirement date handling when beneficiaries or spouses cannot recall exact dates during intake or eligibility review.

10. 5. Policy for Provider Records Retention of MSP Information

    Requirements and examples related to maintaining MSP documentation and retaining records for audit support.

11. A - Obtain Auto, Non-Auto Liability or No-Fault Insurance Information

    Discussion of gathering information related to accident or liability coverage that may affect Medicare as payer.

12. B - Obtain Workers' Compensation (WC) Information

    Guidance on identifying possible workers' compensation involvement and related information gathering.

13. C - Obtain GHP Data from Working Aged Beneficiaries

    General guidance on collecting group health plan information from beneficiaries with current or prior employment-based coverage.

14. D - Obtain GHP Data from Disabled Beneficiaries

    General guidance on identifying employment-based coverage for beneficiaries under age 65 who may qualify under disability provisions.

15. E - Obtain GHP Data from ESRD Beneficiaries

    General guidance on coordination-of-benefits review for ESRD beneficiaries and potential group health plan involvement.

16. 70.2 - Selection of Bill Sample

    Procedures for selecting hospital claim samples for MSP review and audit purposes.

17. Bill Sample Composition and Reference Laboratory Service Exclusion

    Criteria for sample composition and the exclusion of certain reference laboratory service claims from MSP hospital review samples.