Clues for Identifying MSP Calls

Clues for Identifying MSP Calls

What Should I Look for?
MSP calls come in many shapes and colors. The following guidelines will help you handle most MSP calls. However, always use your judgment when applying these guidelines.
Follow these steps to identify MSP calls:
1.  Listen and look for clues
2.  Ask probing questions, if necessary
3.  Decide if it is an MSP call.
Clues in a Letter, Form, or Bill
Listen for These Clues / ·  Caller received a letter asking about an accident.
·  Caller received a letter asking about other insurance.
·  Caller received a letter asking for a retirement date.
Ask These Questions / ·  Can you describe the letter/form/bill you are calling about?
-  Does it have a title?
-  Does it have a letterhead with return address and phone number?
-  What department is it from? Who signed it?
-  What does it say?
-  Is there a date of service/provider or name/claim number?
·  Does the letter/form/bill specify a claim?
Decide Using These Guidelines / ·  It is an MSP call if the document the caller received is from the COB contractor. There are various Coordination of Benefits (COB) contractor issued letters. COB contractor letters all have a green colored COB logo in the upper right corner.
These calls should be directed to the COB contractor. CSRs who handle MSP calls should direct these calls to the COB contractor. If there is an MSP department or MSP specialist in your center, transfer the call to them. They should direct the call to the COB contractor. If the call cannot be transferred, tell the caller to call 1-800-999-1118.
·  If the document describes a particular claim (e.g., MSN/EOMB), ask the caller to specify the claim(s) and look up the beneficiary's record.
Clues Related to a
Specific Claim
Listen for These Clues / ·  The provider has referred the caller to Medicare because the claim has a denial message related to MSP.
·  The provider has told the beneficiary that insurance is not paying his or her bills because Medicare is primary.
·  Caller uses the words “primary” or “secondary" in describing their claim.
·  The beneficiary's record indicates other insurance that is primary to Medicare.
·  The beneficiary's record indicates a denial message related to MSP.
·  A beneficiary calls to report that they have retired or they are now working.
·  A beneficiary calls to report a car accident or slip and fall type of accident.
·  A beneficiary calls to report a work injury.
·  A beneficiary calls to report a check made out to the beneficiary and Medicare.
·  A beneficiary calls to report any type of settlement.
·  A beneficiary calls to report an illness or injury caused by a defective product.
Ask These Questions
Ask These Questions (continued) / ·  What is the number on your Medicare card?
·  What provider and date of service are you calling about? (Look up the claim in the beneficiary's record.)
·  If aged:
-  Do you have insurance coverage through your current employer?
-  Are you employed?
-  Is your spouse employed?
-  What was your retirement date or last date of employment?
·  If disability:
-  Do you have insurance coverage through your current employer?
-  Are you employed?
-  What was your retirement date or last date of employment?
-  Is a family member employed?
·  If ESRD:
-  Do you have insurance coverage through an employer?
·  If Workers’ Compensation:
-  Were you injured on the job?
-  Did you receive a settlement?
·  If no-fault/liability:
-  Were you hurt in an accident?
-  Did you receive a settlement?
·  If liability, were you injured by a defective product?
·  If no-fault/Workers’ Compensation, have benefits been exhausted for this injury?
Note: If the caller does not know the answers to these questions, ask if someone is available to help. If no one is available, ask the beneficiary to call back later when he or she has the information or someone who can help is nearby.
Decide Using These Guidelines
Decide Using These Guidelines (continued) / ·  It may be an MSP call if the caller is calling regarding the following types of insurance:
-  Group Health Plan
-  Federal Black Lung
-  Workers’ Compensation
-  No-Fault Insurance
-  Liability
-  COBRA (if the beneficiary has Medicare due to ESRD, COBRA may be primary)
-  Employer Retiree Plan (if the caller has ESRD)
·  This is not an MSP call if the caller is calling regarding the following types of insurance:
-  Medigap
-  Complementary or supplemental insurance
-  Medicaid
-  TRICARE
-  Medicare exclusions such as VA, services for individuals who are incarcerated, or services furnished outside the United States.
·  It is an MSP call if the specified claim includes a denial message that reads/ or is similar to the following:
-  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.
-  Claim denied because medical services related to this injury are the liability of the no-fault carrier.
-  This claim is denied because this/these service(s) may be covered by Workers’ Compensation. Ask your provider to submit a claim to the state Workers’ Compensation agency.
-  No payment was made because your primary insurer’s payment satisfied the provider’s bill.

Page 4 of 4