Monday, October 11, 2010

Submitting Medicare secondary claim - cms 1500 primary insurance info

If there is insurance primary to Medicare for the service date(s), enter the insured’s policy or group number within the confines of the box and proceed to items 11a-11c. Items 4, 6, and 7 must also be completed. If item 11 is left blank, the claim will be denied as unprocessable.

NOTE: Enter the appropriate information in item 11c if insurance primary to Medicare is indicated in item 11.

If there is no insurance primary to Medicare, do not enter “n/a,” “not,” etc., enter the word NONE within the confines of the box and proceed to item 12. If the insured reports a terminating event with regard to insurance which had been primary to Medicare (e.g., insured retired), enter the word NONE and proceed to item 11b.

If a lab has collected previously and retained MSP information for a beneficiary, the lab may use that information for billing purposes of the nonface- to-face lab service. If the lab has no MSP information for the beneficiary, the lab will enter the word NONE in item 11 of the CMS-1500 Form, when
submitting a claim for payment of a reference lab service. Where there has been no face-to-face encounter with the beneficiary the claim will then follow the normal claims process. When a lab has a face-to-face encounter with a beneficiary, the lab is expected to collect the MSP information and bill

Insurance Primary to Medicare- Circumstances under which Medicare payment may be secondary to other insurance include:

• Group Health Plan Coverage
o Working Aged (Type 12);
o Disability (Large Group Health Plan – Type 43); and
o End Stage Renal Disease (ESRD – Type 13);
• No Fault (Type 14) and/or Other Liability (Type 47); and
• Work-Related Illness/Injury:
o Workers' Compensation (Type 15);
o Black Lung (Type 41); and
o Veterans Benefits (Type 42).

NOTE: For a paper claim to be considered for Medicare secondary payer benefits, a policy or group number must be entered in this item. In addition, a copy of the primary payer’s explanation of benefits (EOB) notice must be forwarded along with the claim form. (See Pub. 100-05, Medicare Secondary Payer Manual, Chapter 3.) Without an attached EOB from the primary
insurance, the claim will be denied.

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