Clues for Identifying MSP Calls

Identifying MSP Specifics

Note: This resource is designed for:

MSP specialists
CSRs in call centers without MSP specialists

What Should I Look For?
In order to know whether and how you need to resolve an MSP call or whether to refer it to the COB contractor, you need to look for some specific information in the beneficiary’s claim. To do this, you read trailers (which indicate other insurance) and denial messages, ask the caller some probing questions to obtain more information, and check to see if you have the correct information. This resource provides guidelines that will help you with most MSP calls. However, always use your judgment when applying these guidelines.
Follow these steps to identify MSP calls:

Read trailers and denial messages
Ask probing questions, if necessary
Check to see if information in a beneficiary’s record is correct
Resolve the caller’s issue, or refer to COB contractor

Specifics in a Claim
Read these trailers which indicate other insurance. / Note: A trailer is a code present within the beneficiary’s claim information on your system, which indicates the beneficiary has other insurance.

Working Aged
Disability
Workers’ Compensation
No-fault insurance
Liability
Black Lung
ESRD
VA (exclusion)
Federal Public Health (exclusion)

Read these denial messages.
Read these denial messages. (Continued) /

Our records show that Medicare is your secondary payer. This claim must be sent to your primary insurer first.
Claim denied because this care may be covered by another payer per coordination of benefits.
Our records show that an automobile, medical, liability, or no-fault insurance plan is primary for these services. Submit this claim to the primary payer.
Claim denied because this injury is the liability of the no-fault carrier.
This claim is denied because this service may be covered by the Workers’ Compensation plan. Ask your provider to submit a claim to that plan.
Medicare does not pay for these services because they are payable by another government agency. Submit this claim to that agency.
Medicare does not pay for this item or service. No payment was made because your primary insurer’s payment satisfied the provider’s bill.

Ask these questions for each type of trailer you find.
Ask these questions for each type of trailer you find. (Continued) /

Working Aged:

-Are you currently employed? If not, are you retired? As of what date?
-Is your husband/wife currently employed? If not, is he/she retired? As of what date?
-Are you receiving health benefits from your employer?
-Are you receiving health benefits from your husband’s/wife’s employer?
-Do 20 or more employees, including yourself, work for the employer from whom you get health benefits?

Disability:

-Are you receiving group health plan (GHP) coverage from an employer for whom you work?
-Are you receiving GHP coverage through the current employment of a family member?
-Do 100 or more employees, including yourself, work for the employer from whom you get group health benefits?

Workers’ Compensation:

-Are you now getting any medical services, related to an illness or injury that occurred on the job, for which you have filed or will file a Workers’ Compensation claim?
-Have you received a Workers’ Compensation settlement?

No-Fault Insurance:

-Are you getting any treatment for an injury for which another party could be held responsible and could be covered under no-fault insurance?

Liability: Are you getting any treatment for an illness or injury for which another party could be held responsible and could be covered under liability insurance?
Black Lung: Are you getting Black Lung (coal miner’s) Medical Benefits?
ESRD:

-Do you have End-Stage Renal Disease (ESRD)?
-What is the date of your first dialysis? What type of dialysis?
-Did you have a kidney transplant? If so, what was the date of the transplant?
Note: Some MSP Customer Service Representatives (CSRs) confirm the first three items through the Renal Management Information System (REMIS). Individual call center procedures may be different. For example, if the caller disagrees with the information in the trailer your procedures may require you to refer the caller to the COB contractor to verify the information.
-Are you receiving GHP coverage through your own or a family member’s current or former employer?
-Are you also entitled to Medicare based on age or disability?
Check to see if information in the beneficiary’s record is correct.
Check to see if information in the beneficiary’s record is correct. (Continued) /

Research the records on your system.
Research the records on the CWF.

Look for discrepancies between your system’s information and the CWF information.

Note: The information on the CWF is the only information that CMS recognizes as valid.
Resolve the caller’s issue using these guidelines.
Resolve the caller’s issue using these guidelines. (Continued)
Resolve the call using these guidelines. (Continued) /

The claim was denied. Tell the beneficiary whether or not it was denied correctly and, if not, what action you are taking to correct it.
The CWF record is correct but your of the beneficiary’s information is incorrect. Correct your information.

An individual is calling to report that his or her Large Group Health Care coverage has ended. Update your system to show that the coverage is terminated.

Note: You can do a simple termination for all records, except those terminating more than 6 months before the date of accretion (or date the trailer is added to CWF. If the termination date is more than 6 months before the date of accretion, transfer to the COB contractor. The date of accretion ruling applies only to records with origination contractor numbers that are maintained by the COB. These numbers are 11100 – 11114, 33333, 55555, 77777, 88888, and 99999.

If any other insurance coverage has ended, update your system and CWF to show that the coverage is terminated.
If an individual is calling to report that he or she has retired, update your system and CWF to show the coverage is terminated. If you are unable to update an MSP record, refer the call to the COB contractor (see page 6).

An individual is calling because he or she received written correspondence that his or her benefits are exhausted for an automobile case. Instruct the beneficiary to send the information to the lead contractor. If you have an MSP department, send them any written documentation.

Note: The lead contractor is a CMS predetermined intermediary by state who has lead recovery responsibility on third party liability cases (e.g., no-fault, liability, Workers’ Compensation). The COB contractor assigns the lead based on the CMS contractor list.

If an individual is calling to report that he or she has received information that a liability case is no longer being pursued, instruct the beneficiary to send the information to the lead contractor. If you have an MSP department, send them any written documentation.

Note: If there is no matching record on the CWF, send an MSP inquiry to the COB contractor through ECRS to set up the record on the CWF.

If the provider/supplier receives a denial from an insurance company indicating that Medicare is the primary payer, determine why Medicare is primary, e.g., is the insured person retired, or did the insurance terminate? If the provider/supplier is unable to provide this information, tell them to contact the beneficiary. Then, have the provider submit the claim to Medicare for consideration.
If you encounter an MSP record that does not require additional development by the COB contractor or when records do not have an existing termination date, follow these directions:

In the case of a claim for secondary or conditional payment, create an “I” record or terminate an existing record on CWF according to your call center procedures.
IF you are unable to perform the above task because additional development is necessary, use ECRS.

If the beneficiary called the COB contractor and the COB contractor told him or her to call the carrier because they want to know where claim information originated, probe the beneficiary to try to locate the claim.

If any other claims-specific information needs to be resolved. Research the claim as needed or instruct the beneficiary to contact the provider.

If an attorney is calling to ascertain Medicare’s interests, check to see if the file is already present on CWF. If so, direct the attorney to the lead contractor.
If an attorney is calling to report that he or she is representing a beneficiary, check to see if the file is already present on the CWF. If so, direct the attorney to the lead contractor.

Refer the call to the COB contractor using these guidelines.
Note: You may refer the call to the COB contractor by taking any of the following actions:

A CWF assistance request may be submitted through ECRS by the MSP specialist/MSP department.

You may refer the caller to the COB contractor instead of entering the information on ECRS.

For information on whether or not to use ECRS, consult your call center trainer or manager. /

If information on the beneficiary’s record in CWF is incorrect.
If you are unable to update an MSP record.
If an individual is calling to report a beneficiary accident or any type of MSP situation.
If a beneficiary questions a development letter sent by the COB Contractor.
An attorney is calling to ascertain Medicare’s interests, and there is no file on the CWF.
An attorney is calling to report that he or she is representing a beneficiary, and there is no file on the CWF.

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