Submitting Medicare secondary claim – cms 1500 primary insurance info
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
accordingly.
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.