Verification of Medicare Secondary Payer (MSP) Online Data and Use of

20.2 - Verification of Medicare Secondary Payer (MSP) Online Data and Use of Admission Questions (Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23) Physicians, providers and suppliers shall not deny medical services or entry to a SNF or hospital after you discover that there is: • an open or closed GHP (whether the beneficiary is entitled due to age, disability, or End Stage Renal Disease) or NGHP (Liability (L), No-Fault (NF) or Workers’ Compensation (WC), MSP record found in the HIPAA Eligibility Transaction System (HETS) 270/271, or on CWF; or, • a claim that was previously mistakenly denied by Medicare due to an MSP occurrence. Information about the 270/271 HETS transaction can be found on the following link: https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information- Technology/HETSHelp/About-HETS . MSP Online Data Elements Providers with online capability may now access the following MSP information via the HETS 270/271 or from the CWF MSP auxiliary file: • MSP effective date; • MSP termination date; • Patient relationship; • Subscriber name; • Subscriber policy number; • Insurer type; • Insurer information: Name, group number, address, city, State, and ZIP code; • MSP type; • Remarks code; • Employer information: Name, address, city, State, and ZIP code; and • Employee data: ID number, and information. At the provider's discretion, these data may be viewed during either the admission or the billing process. However, the data must be viewed before a bill is submitted to Medicare, and should ideally be viewed before the patient leaves the hospital. If the model questions are used during the admissions process, the provider will verify each data element by using the questions, found in section 20.2.1 of this chapter, to help identify other payers that may be primary to Medicare. It will comply with any instructions that follow a particular question. Note: If the provider has the ability to submit and receive a X12 270/271 transaction, the admission staff shall ask the beneficiary if any insurance information found on CWF, or the X12 271 response, has changed in lieu of asking all the MSP questions. When submitting the X12 270 transaction the provider must include the beneficiary entitlement date to be sure all MSP periods are received on the X12 271 response. If there are no changes or updates to the beneficiary’s insurance then there is no need to ask the questions. However, having access to CWF or the X12 270/271 transaction does not absolve the provider of its responsibility from asking the MSP questions as necessary. If there are changes to the insurance information, or if there is uncertainty regarding information based on conversation, then the provider must ask the MSP questions. Providers must make a notation for auditing purposes that all the questions were not asked upon admission, or during the telephone interview/screening, based on the beneficiary’s statement that their insurance information has not changed or does not require updating. The Medicare A/B MACs shall request this notation and confirmation during its hospital review. If the provider lacks access to CWF or it does not utilize the X12 270/271 transaction the provider shall follow the procedures found under section 20.2.1 of this chapter. This means the provider shall ask the beneficiary the necessary MSP questions to determine the correct primary payer. The providers are held liable to obtain the correct MSP information so claims are billed to the correct primary payer accordingly per the CMS regulations 42 CFR § 489.20.