Situations in Which MSP Billing Applies

10.2 - Situations in Which MSP Billing Applies (Rev.11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23) Medicare secondary billing procedures apply in the following situations: • Where the Veterans Affairs (VA) authorized services, Medicare does not make payment for items or services furnished by the VA or other non-Federal provider. pursuant to such an authorization. Note, although certain MSP billing procedures apply, VA is not an MSP provision. Rather, it represents a Medicare payment exclusion. • Where services are payable under Workers’ Compensation (WC), no-fault or liability insurance, Medicare does not make payment for otherwise covered items or services to the extent that payment has been made, or can reasonably be expected to be made. Under certain circumstances, Medicare may make conditional payments, subject to reimbursement, if the WC, no-fault, or liability insurer has not paid or will not pay promptly. Medicare is secondary to WC, no-fault, and liability insurance even if State law or a private contract of insurance stipulates that its benefits are secondary to Medicare benefits or otherwise limits its payments to Medicare beneficiaries. • Medicare benefits are secondary to benefits payable under a GHP for individuals eligible for or entitled to Medicare Part A based on ESRD during a Medicare coordination period as described in Pub. 100-05, Chapter 2, §20. • Medicare benefits are secondary to benefits payable under a GHP for individuals age 65 or over who have GHP coverage as a result of their own current employment status or the current employment status of a spouse of any age. (See Pub. 100-05, Chapter 2§10, for an explanation of this provision.) • Medicare benefits are secondary to benefits provided by GHPs for certain disabled individuals under age 65 (entitled to Medicare on the basis of disability) who have coverage based on their own current employment status or the current employment status of a family member, e.g., a spouse or other family member of a disabled beneficiary. (See Pub. 100-05, Chapter21, §30, for an explanation of this provision.) • Payment made by any of these primary payers can be used to satisfy unmet deductibles and the individual's coinsurance. Inpatient, psychiatric hospital, Skilled Nursing Facility (SNF), or Religious Non-medical Institution care that is paid for by a primary payer is not counted against the number of lifetime psychiatric days available to the beneficiary.