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How to Determine When Medicare is the Secondary Payer

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What is MSP?

Medicare Secondary Payer or MSP refers to Medicare benefits when Medicare is not the primary insurance. Medicare requires all health care providers to know how to determine when Medicare is the primary or secondary insurance for their Medicare patients.

Become familiar with the CWF

The CWF or Common Working File is Medicare's application that maintains information regarding coverage for Medicare Beneficiaries. Be sure to always check the CWF in order to review the MSP information to obtain other health insurance coverage.

Medicare is primary when the patient is:
  • 65 or older and has a small group health plan through their own current employer or through their spouse's current employer
  • 65 or older with insurance through a retirement plan
  • Disabled and has a small group health plan through their own current employer or through their spouse's current employer
Medicare is secondary when the patient is:
  • 65 or older and has a large group health plan through their own current employer or through their spouse's current employer
  • Disabled and has a large group health plan through their own current employer or through their spouse's current employer
  • Is covered by Worker's Compensation
  • Is covered by accident or liability insurance
What does Medicare do if the Primary insurance denies the claim?

In instances that the primary insurance denies the claim, Medicare may pay only for the certain denial reasons, such as:

  • The subscribers policy has terminated
  • Worker's compensation has determined that services are not covered
  • Accident or liability insurance denies or takes too long to pay. The provider may be eligible for a conditional payment if the claim is expected to take an extensive amount of time to pay.
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