J11 Part A Medicare Secondary Payer (MSP ... - Palmetto GBA

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End-Stage Renal Disease(ESRD)Example:• Beneficiary diagnosed with ESRD and begins dialysis on1/1/2009 Medicare entitlement begins 4/1/2009(Remember: Entitlement begins once a 3 month waiting period afterbeginning dialysis is completed) Medicare is secondary beginning 4/1/2009(Remember: Medicare is secondary for 30 months after entitlement begins)• Beneficiary enrolls in Self-Dialysis Training on 1/15/2009 Therefore, Medicare entitlement begins 1/1/2009(Remember: Entitlement begins at the beginning of the month a beneficiaryenrolls in Self-Dialysis Training)March 201122End-Stage Renal Disease(ESRD)Medicare coverage ends:• 12 months after the month the individual nolonger requires maintenance dialysis; or• 36 months after a successful kidney transplant.March 201123Special ESRD SituationsMarch 2011Dual Entitlement: Beneficiary is entitled toMedicare based on ESRD and also on the basis ofage or disability at the same time.• ESRD law applies regardless of the age of the Medicarebeneficiary.When a beneficiary becomes entitled on the basis ofage or disability after being entitled based on ESRD,the coordination period continues for the remainderof the 30 months.As long as dual eligibility/entitlement exists, theESRD MSP provision applies exclusively.248
Special ESRD SituationsBeneficiaries entitled to Medicare based on WorkingAged or Disability before being diagnosed withESRD are not subject to the coordination period ifMedicare was already primary.• Medicare remains the primary payer.If Medicare is secondary at the time the beneficiaryis diagnosed with ESRD, a 30-month coordinationperiod begins at the time the ESRD entitlementbegins.• Once the coordination period has ended, Medicarebecomes and remains primary for the duration of thebeneficiary’s entitlement.March 201125MSP Value CodesValue codes are used to identify the different typesof MSP categories• Working Aged: 12• Disability: 43• ESRD: 13• No-Fault: 14• Liability: 47• Workers’ Compensation: 15• Black Lung: 41• Government Programs: 16• Veterans’ Affairs: 42March 201126Identifying Other PrimaryPayer Sources279
Page 1: The Medicare SecondaryPayer (MSP) P
Page 5 and 6: Worker’s Compensation(WC)Medicare
Page 7: End-Stage Renal Disease(ESRD)The ES
Page 11 and 12: MSP Questionnaire (MSPQ)Part I: Rel
Page 13 and 14: Top 10 Errors Found in MSPAudits6.
Page 15 and 16: Coordination of BenefitsContractor
Page 17 and 18: MSP Billing Tips andProcedures49MSP
Page 19 and 20: March 2011CAS Segment - Claim Level
Page 21 and 22: Submitting Claims via VendorSoftwar
Page 23 and 24: Requesting a ConditionalPayment Do
Page 25 and 26: Billing Condition Code 77Indicates
Page 27 and 28: Questions?7927

J11 Part A Medicare Secondary Payer (MSP ... - Palmetto GBA

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