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Questionnaire to Decide Medicare Secondary Payer (MSP)

The following questionnaire contains questions that can be used to ask Medicare beneficiaries upon each inpatient and outpatient admission. Providers may use this as a guide to help identify other payers that may be primary to Medicare. This questionnaire is a model of the type of questions that may be asked to help identify Medicare Secondary Payer (MSP) situations. If you choose to use this questionnaire, please note that it was developed to be used in sequence. Instructions are listed after the questions to facilitate the transition between questions. The instructions will direct the patient to the next appropriate question to determine Medicare Secondary Payer situations. 

Part 1

  1. Are you receiving Black Lung (BL) Benefits? (Yes/No)
    • Yes. In this case, BL is the primary payer only for claims related to BL
  2. Are the services to be paid for by a government research program? (Yes/No)
    • Yes. In this case, the government research program will pay primary benefits for these services. 
  3. Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for your care at this facility? (Yes/No)
    • Yes. In this case, DVA is primary for these services.
  4. Was the illness/injury due to a work-related accident/condition? (Yes/No)
    • Yes. In this case, WC is the primary payer only for claims for work-related injuries or illness, go to part 3.
    • No. Go to part 2

Part 2

  1. Was illness/injury due to a non-work-related accident? (Yes/No)
    • No. Go to part 3. 
  2. Is liability insurance available? (Liability insurance is insurance that protects against claims based on negligence, inappropriate action, or inaction, which results in injury to someone or damage to property.) (Yes/No)
    • No. A no-fault insurer is a primary payer only for those services related to the accident. Liability insurance is the primary payer only for those services related to the liability settlement, judgment, or award. Go to part 3.

Part 3

  1. Are you entitled to Medicare based on:
    1. Age; Go to part 4.
    2. Disability; Go to part 5.
    3. End-Stage Renal Disease (ESRD); Go to part 6. 

Please note that both ‘Age’ and ‘ESRD’ or ’Disability’ and ‘ESRD’ may be selected simultaneously. An individual cannot be entitled to Medicare based on ‘Age’ and ‘Disability’ simultaneously. 

Part 4: Age

  1. Are you currently employed? (Yes/No)
  2. Do you have a spouse who is currently employed? (Yes/No)
    • If the patient answered ‘No’ to questions 1 and 2, then Medicare is primary unless the patient answered ‘Yes’ to questions in parts 1 and 2. Do not proceed further. 
  3. Do you have group health plan (GHP) coverage based on your own or a spouse’s current employment? (Yes, both/Yes, self/Yes, spouse/No)
    • No. STOP. Medicare is the primary payer unless the patient answered ‘Yes’ to the questions in parts 1 or 2.
  4. If you have GHP coverage based on your own current employment, does your employer that sponsors or contributes to the GHP employ 20 or more employees? (Yes/No)
    • Yes. GHP is primary. 
  5. If you have GHP coverage based on your spouse’s current employment, does your spouse’s employer, which sponsors or contributes to the GHP, employ 20 or more employees? (Yes/No)
    • Yes. GHP is primary.
    • No. If the patient answered ‘No’ to both questions 4 and 5, Medicare is primary unless the patient answered ‘Yes’ to questions in the past 1 or 2. 

Part 5: Disability

  1. Are you currently employed? (Yes/No)
  2. Do you have a spouse who is currently employed? (Yes/No)
  3. Do you have group health plan (GHP) coverage based on your own or a spouse’s current employment? (Yes, both/Yes, self/Yes, spouse/No)
  4. Are you covered under the GHP of a family member other than your spouse? (Yes/No)
    • If the patient answered ‘No’ to questions 1,2,3 and, 4. STOP. Medicare is primary unless the patient answered ‘Yes’ to questions in part 1 or 2. 
  5. If you have GHP coverage based on your own current employment, does your employer that sponsors or contributes to the GHP employ 100 or more employees? (Yes/No)
    • Yes. GHP is primary. 
  6. If you have GHP coverage based on your spouse’s current employment, does your spouse’s employer, which sponsors or contributes to the GHP, employ 100 or more employees? (Yes/No)
    • Yes. GHP is primary.
  7. If you have GHP coverage based on a family member’s current employment, does your family member’s employer, that sponsors or contributes to the GHP, employ 100 or more employees? (Yes/No)
    • Yes. GHP is primary.
    • No. If the patient answered ‘No’ to questions 5,6 and 7, Medicare is primary unless the patient answered ‘Yes’ to questions in parts 1 or 2. 

Part 6: ESRD

  1. Do you have group health plan (GHP) coverage? (Yes/No)
    • Yes. If applicable, get (patient’s and spouse’s/ family member’s) GHP information.
    • No. STOP. Medicare is primary. 
  2. Are you within the 30-month coordination period that starts MM/DD/CCYY? (The 30-month coordination period starts the first day of the month an individual is eligible for Medicare (even if not yet enrolled in Medicare) because of kidney failure (usually the fourth month of dialysis). If the individual is participating in a self-dialysis training program or has a kidney transplant during the 3- month waiting period, the 30-month coordination period starts with the first day of the month of dialysis or kidney transplant.) (Yes/No)
    • No. STOP. Medicare is primary. 
  3. Was your initial entitlement to Medicare (including simultaneous or dual entitlement) based on ESRD? (Yes/No)
    • Yes. STOP. GHP continues to pay primary during the 30-month coordination period. 
    • No. Initial entitlement is based on ‘Age’ or ‘Disability’.
  4. Does the working-aged or disability Medicare Secondary Payer provision apply (i.e., is the GHP already primary based on age or disability entitlement)? (Yes/No)
    • Yes. GHP continues to pay primary during the 30-month coordination period. 
    • No. Medicare continues to pay primary. 

We shared a questionnaire to be asked to Medicare beneficiaries while admitted to deciding on Medicare Secondary Payer (MSP). You can refer CMS document for detailed information. Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. Our billing services include benefits verification, charge entry, payment posting, denial management, AR management, provider enrollment, provider credentialing, and many other RCM services. If you are looking for any assistance in medical billing for your practice, contact us at info@medicalbillersandcoders.com/ 888-357-3226

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