100-05 Medicare Secondary Payer Manual: Chapter 5 Crosswalk

Medicare Secondary Payer (MSP) Manual
Chapter 5 - Contractor Prepayment Processing Requirements
Crosswalk
New
Chap
New
Section
Int.
Pub. 13
Carrier
Pub. 14
HO
Pub. 10
HHA
Pub. 11
SNF
Pub. 12
PMs 	Subject
5 	10 	AB-00-107 	Coordination With the Coordination of
Benefits Contractor (COBC)
5 	10.1 	AB-00-107 	FI and Carrier MSP Auxiliary File Update
Responsibility	AB-02-022
AB-02-107
5 	10.2 	AB-00-107 	COBC Electronic Correspondence Referral
System (ECRS)
5 	10.2.1 	AB-00-107 	ECRS Functional Description
5 	10.2.2 	AB-00-107 	Technical Overview - Impact on FI/Carrier
Data Centers
5 	10.2.2.1 	AB-00-107 	CWF Assistance Request - Data Elements and
Definitions
5 	10.2.2.2 	AB-00-107 	MSP Inquiry Information - Data Elements and
Definitions	B-01-033
5 	10.3 	AB-00-107 	Providing Written Documents to the COBC
5 	10.4 	AB-00-107 	FI and Carrier Record Retention
5 	10.5 	AB-00-107 	Notification to FI or Carrier of MSP Auxiliary
File Updates
5 	10.6 	AB-00-107 	Referring Calls to the COBC
5 	10.7 	AB-00-107 	Changes in FI and Carrier Initial MSP
Development Activities	B-01-033

New
Chap
New
Section
Int.
Pub. 13
Carrier
Pub. 14
HO
Pub. 10
HHA
Pub. 11
SNF
Pub. 12
PMs 	Subject
5 	10.8 	AB-00-107 	Additional Activities Arranged by Non-GHP
MSP Type	AB-02-022
5 	10.8.1 	AB-00-107 	No-Fault Development
5 	10.8.2 	AB-00-107 	Workers' Compensation (WC) Development
5 	10.8.3 	AB-00-107 	Liability Development
5 	10.9 	AB-00-107 	COBC Numbers
5 	20 	A3-3489.3
A3-3492.J
B3-3328.6
B3-4301
B3-3338.2
SNF-337 	Sources That May Identify Other Insurance
Coverage
5 	20.1 	A3-3418.5
A3-3489
A3-3489.3A
B3-3340.4
B3-4305
B3-3338.2A
B3-4301
HO-262.8 	HHA-248 	SNF-334 	AB-00-107 	Identification of Liability and No-Fault
Situations
5 	20.2 	A3-3409
A3-3409.1
A3-3409.2
B3-3330.1
B3-3330.2
B3-4305
Identify Claims with Possible WC Coverage
5 	20.3 	B3-4304 	Medicare Claims Where Veterans' Affairs
(VA) Liability May Be Involved
5 	20.3.1 	B3-4304.1
B3-4304.2
VA Payment Safeguards
5 	30 	A3-3686 	Develop Claims for Medicare Secondary
Benefits
5 	30.1 	A3-3686.1 	Further Development Is Not Necessary
5 	30.2 	Further Development Is Required

New
Chap
New
Section
Int.
Pub. 13
Carrier
Pub. 14
HO
Pub. 10
HHA
Pub. 11
SNF
Pub. 12
PMs 	Subject
5 	30.3 	A3-3491
A3-3686
A3-3492.I
B3-4302
B3-3328.6
HO-253 	HHA-253 	SNF-336 	GHP May Be Primary to Medicare
5 	30.3.1 	B3-4301.1D 	B-01-033 	Limits on Development
5 	30.3.2 	B3-4303 	Develop ESRD Claims Where Basis for
Medicare Entitlement Changes
5 	30.4 	A3-3409.3
A3-3409.9
B3-3330.3 	HHA-250.19 	SNF-329.7 	Workers' Compensation Responses
5 	30.4.1 	B3-3330.4 	Patient Receives Concurrent Services Which
Are Not Work-Related
5 	30.5 	A3-3489.3B 	No-Fault Responses
5 	30.5.1 	B3-3338.4 	No-fault Insurer Denies That It Is the Primary
Payer
5 	30.5.2 	A3-3489.4 	B3-3338.5 	HO-262.12 	HHA-248.4 	SNF-334.4 	No-Fault Insurance Does Not Pay All Charges
Because of a Deductible or Coinsurance
Provision in Policy
5 	30.5.3 	A3-3489.5 	B3-3338.6 	HO-262.12
HO-262.13
HHA-248.4
HHA-248.5
SNF-334.4
SNF-334.5
State Law or Contract Provides That No-Fault
Insurance Is Secondary to Other Insurance
5 	30.6 	A3-3489.6 	B3-3338.7
B3-3340.7
Liability Claim Is Filed and There is Also
Coverage Under Automobile or Non-
Automobile Medical or No-Fault Insurance
5 	30.7 	A3-3686 	B3-3328.7 	Beneficiary Refuses to Provide Requested
Information
5 	30.8 	A3-3491.5
A3-3490.3
HO-263.3 	HHA-252.7
HO-264.7 	HHA-253.6
SNF-335.7
SNF-336.6
Audit Trail of Primary Coverage
5 	40 	FI and Carrier Claim Processing Rules
5 	40.1 	A3-3490.3
IM3491
B3-3328.7 	Claim Indicates Medicare is the Primary Pay

New
Chap
New
Section
Int.
Pub. 13
Carrier
Pub. 14
HO
Pub. 10
HHA
Pub. 11
SNF
Pub. 12
PMs 	Subject
5 	40.1.1 	A3-3409.4 	B3-3330.5 	Facts Indicate Reasonable Likelihood of
Workers' Compensation Coverage (Other Than
Federal Black Lung Benefits)
5 	40.1.1.1 	A3-3409.5 	B3-3330.6A 	The Beneficiary Is on the Black Lung
Entitlement Rolls
5 	40.1.2 	A3-3490.16A
A3-3491.17A
B3-3329.4A 	HO-263.17
HO-264.17
HHA-253.16
HHA-253.17
SNF-335.17
SNF-336.17
Services by Outside Sources Not Covered
5 	40.1.2.1 	A3-3490.16B
A3-3491.17B
B3-3329.4B 	HO-263.17
HO-264.17
HHA-252.17
HHA-253.16
SNF-335.17
SNF-336.17
Exception
5 	40.1.3 	A3-3490.16C
A3-3491.17C
B3-3329.4 	HO-263.17
HO-264.17
HHA-252.17
HHA-253.16
SNF-335.17
SNF-336.17
Notice to Beneficiary
5 	40.2 	A3-3490.16D
A3-3491.17DC
B3-3329.4D 	HO-264.17 	HHA-252.17 	SNF-335.17 	Update CWF MSP Auxiliary File
5 	40.2.1 	B3-3338.2C.1 	HO-263.17 	HHA-253.16 	SNF-336.17 	Action if Payment Has Been Made Under No-
Fault Insurance
5 	40.3 	B3-3328.7 	Processing Part B Claims Involving GHPs
5 	40.3.1 	A3-3491.9
A3-3490.3D
A3-3490.3F
B3-3328.4
B3-3328.C1
B3-3328.5
HO-263.10 	HHA-253.10 	SNF-336.10 	GHP Denies Payment for Primary Benefits
5 	40.3.2 	B3-3328.8 	GHP Does Not Pay Because of Deductible or
Coinsurance Provision
5 	40.3.3 	B3-3328.9 	GHP Gives Medicare Beneficiary Choice of
Using Preferred Provider
5 	40.4 	B3-3328.2 	GHP Pays Primary
5 	40.4.1 	B3-3328.2 	GHP Pays Charges in Full
5 	40.4.2 	B3-3328.3 	GHP Pays Portion of Charges

New
Chap
New
Section
Int.
Pub. 13
Carrier
Pub. 14
HO
Pub. 10
HHA
Pub. 11
SNF
Pub. 12
PMs 	Subject
5 	40.4.3 	A3-3490.13 	B3-3328.16 	GHP Pays Primary Benefits When Not
Required
5 	40.5 	B3-3328.14 	Primary Payer Is Bankrupt or Insolvent
5 	40.5.1 	B3-3328.14B 	Billing Beneficiaries During the Liquidation
Process
5 	40.5.2 	B3-3328.14C 	When to Make a Medicare Secondary Payment
5 	40.5.3 	B3-3328.14D 	Amount of Secondary Payment
5 	40.5.4 	B3-3328.14E 	Time Limits for Filing Secondary Claims After
Liquidation Process
5 	40.6 	A3-3490.3E
A3-3682.5B
A3-3682.5E
A3-3682.5G
Conditional Primary Medicare Benefits
5 	40.6.1 	A3-3407.6B
A3-3682
B3-3338.3
B3-2370.6
Conditional Medicare Payment
5 	40.6.2 	A3-3690.3F
A3-3489.8
A3-3682.5D
A3-3682.5E
A3-3682.5G
B3-3338.3 	HO-262.14 	HHA-248.6 	SNF-334.6 	When Primary Benefits and Conditional
Primary Medicare Benefits Are Not Payable
5 	40.6.3 	B3-3328.C1 	Conditional Primary Payment in Cases
Involving a Denied Claim That Was Appealed
5 	40.7 	B3-4301.1 	Carrier Processing Procedures for Medicare
Secondary Claims
5 	40.7.1 	Crediting the Part B Deductible
5 	40.7.2 	B3-4301.1
B3-3328.20
Medicare Payment Calculation Methodology

New
Chap
New
Section
Int.
Pub. 13
Carrier
Pub. 14
HO
Pub. 10
HHA
Pub. 11
SNF
Pub. 12
PMs 	Subject
5 	40.7.3 	B3-3328.20 	Medicare Secondary Payment Calculation
Methodology for Services Reimbursed on
Reasonable Charge or Other Basis Under Part
B
5 	40.7.4 	B3-3328.20B 	Effect of Medicare Limiting Charge on
Medicare Secondary Payments
5 	40.7.4.1 	B3-3328.20C 	GHP Does Not Pay for Certain Services
5 	40.7.4.2 	B3-3328.20D 	Third Party Payment Includes Both Medicare
Covered and Noncovered Services
5 	40.7.5 	B3-3328.21 	Effect of Failure to File Proper Claim
5 	40.7.6 	B3-3328.23 	Medicare Secondary Payment for Managed
Care Organizations' (MCO) Copayments
5 	40.7.7 	B3-3328.25 	Charging Expenses Against Annual Limit on
Incurred Expenses for Services of
Independently Practicing Physical Therapists
5 	40.8 	A3-3490.3
A3-3685.B
A3-3685.C
HO-475 	Intermediary Processing Procedures for
Medicare Secondary Claims
5 	40.8.1 	IM3497.2
IM3497.5
A3-3407B3
A3-3490.7
A3-3491.11
A3-3682
IM3497.5
A3-3685.A.1
HO-475 	Medicare Secondary Payment Calculation
Methodology When Proper Claim Has Been
Filed

New
Chap
New
Section
Int.
Pub. 13
Carrier
Pub. 14
HO
Pub. 10
HHA
Pub. 11
SNF
Pub. 12
PMs 	Subject
5 	40.8.2 	IM3497.5B
A3-3685.A1
A3-3683
A3-3682.3B6
A3-3682.4B4
A3-3685.D
HO-473 	HHA-498
HO-475
SNF-573 	Rule to Determine the Amount of Secondary
Benefits
5 	40.8.3 	A3-3682.1B6
A3-3683
A3-3685.C
HO-472.3 	HHA-498
HO-473
HO-475
SNF-574 	Application of the MSP Formula
5 	40.8.4 	A3-3682.2 	PIP Reduction
5 	40.8.5 	A3-3682.2.A
A3-3682.1C
HO-472.3 	MSP Part B Claims (Outpatient and Other Part
B Services, Home Health Part B and Ancillary
Services When Part A Benefits are Exhausted)
5 	40.8.6 	A3-3695.A 	HO-477 	MSP Outpatient Claims Involving LAB
Charges Paid by Fee Schedule
5 	40.8.6.1 	A3-3695.B 	Prorating Primary Payments
5 	40.8.6.2 	A3-3695.C 	Calculation of Deductible and Coinsurance
5 	40.8.7 	IM3497.5
IM3497.6
Calculating Medicare Secondary Payments
When Proper Claim Has Not Been Filed With
Third Party Payer
5 	40.8.8 	A3-3682.B3
A3-3682.1B
A3-3685.A3
IM3497.6
IM3497.7
HO-472.3
HO-475
Determining Patient Utilization Days,
Deductible, and Coinsurance Amounts
5 	40.8.9 	A3-3684 	HO-474 	SNF-574 	Benefits Exhausted Situations When Medicare
Is Secondary Payer for Reasonable Cost
Providers

New
Chap
New
Section
Int.
Pub. 13
Carrier
Pub. 14
HO
Pub. 10
HHA
Pub. 11
SNF
Pub. 12
PMs 	Subject
5 	40.8.10 	A3-3688 	HO-476 	SNF-575 	Deductible and/or Coinsurance Rates Spanning
Two Calendar Years
5 	40.8.11 	A3-3682.1A
A3-3682.3A
HO-472.3 	Submit Data to CWF When Full Payment
Made by Primary Payer
5 	40.8.12 	A3-3682.1A
A3-3682.B7
A3-3682.1B7
A3-3682.2B5
HO-472.3 	Submit Data to CWF When Partial Payment
Made by Primary Payer
5 	50 	B3-4306 	MSP Pay Modules to Calculate Medicare
Secondary Payment Amount
5 	50.1 	B3-4306 	Medicare Secondary Payer (MSP) Payment
Modules (MSPPAY) for Carriers
5 	50.1.1 	A3-3697.B 	B3-4306.B 	Payment Calculation Processes for MSP
Claims
5 	50.1.2 	B3-4306C 	MSPPAY "Driver" Module
5 	50.1.3 	B3-4306D 	Return Codes
5 	50.1.4 	B3-4306E 	Executing and Testing MSPPAY Software
5 	50.1.5 	B3-4306F 	Carrier MSPPAY Processing Requirements
5 	50.1.6 	B3-4306G 	Error Resolution
5 	50.1.7 	B3-4306.1 	Payment Calculation for Physician/Supplier
Claims (MSPPAYB Module)
5 	50.1.8 	B3-4306.2 	Payment Calculation for Physician/Supplier
Claims (MSPPAYBL)
5 	50.2 	A3-3697 	Medicare Secondary Payer (MSP) Payment
Modules (MSPPAY) For Intermediaries
5 	50.2.1 	A3-3697 	Payment Calculation Processes for MSP
Claims
5 	50.2.2 	A3-3697.C 	MSPPAY "Driver" Module

New
Chap
New
Section
Int.
Pub. 13
Carrier
Pub. 14
HO
Pub. 10
HHA
Pub. 11
SNF
Pub. 12
PMs 	Subject
5 	50.2.3 	A3-3697.D 	Return Codes
5 	50.2.4 	A3-3697.E 	Installation
5 	50.2.5 	A3-3697.F 	Intermediary Processing Requirements
5 	50.2.6 	A3-3697.G 	Error Resolution
5 	50.2.7 	A3-3697.1
A3-3697.1A
Payment Calculation for Inpatient Bills
(MSPPAYAI Module)
5 	50.2.8 	A3-3697.2 	Payment Calculation for Outpatient Claims
(MSPPAYOL)
5 	50.2.8.1 	A-03-006 	MSPPAY Update to Apportion Prospective
Payment System (PPS) Outlier Amounts to All
Service Lines with Potential Outlier
Involvement
5 	50.2.9 	A3-3697.3
A3-3697.3B
Payment Calculation for Outpatient Bills
(MSPPAYAO Module)
5 	50.3 	AB-03-011 	Multiple Primary Payer Amounts For a Single
Service
5 	60 	A3-3899 	B3-13450 	MSP Reports
5 	60.1 	A3-3899.1 	B3-13450.1 	Monthly Intermediary Report (Form CMS-
1563) and Monthly Carrier Report (Form
CMS-1564) on Medicare Secondary Payer
Savings
5 	60.1.1 	A3-3899.2
A3-3899.3
A3-3899.4
B3-13450.2
B3-13450.3
B3-13450.4
Overview of Report
5 	60.1.2 	A3-3899.5
A3-3418.25
B3-13450.5 	Savings Calculations
5 	60.1.3 	A3-3899.6 	B3-13450.6 	Recording Savings
5 	60.1.3.1 	A3-3899.7 	B3-13450.7 	Source of Savings

New
Chap
New
Section
Int.
Pub. 13
Carrier
Pub. 14
HO
Pub. 10
HHA
Pub. 11
SNF
Pub. 12
PMs 	Subject
5 	60.1.3.2 	A3-3899.8 	B3-13450.8 	Type of Savings
5 	60.1.3.2.1 	A3-3899.8A 	B3-13450.8 	Unpaid (Cost Avoided) MSP Claims
5 	60.1.3.2.2 	A3-3899.8 	B3-13450 	Full Recoveries
5 	60.1.3.2.3 	A3-3899.8 	B3-13450 	Partial Recoveries
5 	60.1.3.2.4 	A3-3899.8 	B3-13450 	Totals
5 	60.1.3.2.5 	A3-3899.8 	B3-13450.8 	Pending Claims/Cases
5 	60.1.3.3 	A3-3899.9 	B3-13450.9 	Electronic Submission
5 	60.1.3.3.1 	A3-3899.9 	B3-13450.9 	Data Entry of the Forms CMS-1563 and CMS-
1564
5 	60.1.3.3.2 	A3-3899.9 	B3-13450.9 	Edits for Forms CMS-1563 and CMS-1564
5 	60.2 	A3-3418.26 	Liability Settlement Tracking Report
5 	70 	A3-3693 	HO-480 	Hospital Review Protocol for Medicare
Secondary Payer
5 	70.1 	A3-3691.1 	HO-480.1
HO-480.2
HO-480.4
Reviewing Hospital Files
5 	70.1.1 	A3-3693.2 	HO-480.3
HO-480.6
Frequency of Reviews and Hospital Selection
Criteria
5 	70.1.2 	A3-3693.3 	HO-480.5 	Methodology for Review of Admission and
Bill Processing Procedures
5 	70.2 	A3-3693.4 	HO-480.7 	Selection of Bill Sample
5 	70.3 	A3-3693.5 	HO-480.8 	Methodology for Review of Hospital Billing
Data
5 	70.3.1 	A3-3693.5C 	HO-480.5C 	Review of Form CMS-1450
5 	70.3.1.1 	A3-3693.5C1 	General Review Requirements
5 	70.3.1.2 	A3-3693.5C2 	Working Aged Bills

New
Chap
New
Section
Int.
Pub. 13
Carrier
Pub. 14
HO
Pub. 10
HHA
Pub. 11
SNF
Pub. 12
PMs 	Subject
5 	70.3.1.3 	A3-3693.5C3 	Accident Bills
5 	70.3.1.4 	A3-3693.5C4 	Workers' Compensation Bills
5 	70.3.1.5 	A3-3693.5C5 	ESRD Bills
5 	70.3.1.6 	A3-3693.5C6 	Bills for Federal Government Programs
5 	70.3.1.7 	A3-3693.5C7 	Disability Bills
5 	70.3.2 	A3-3693.5D 	Use of Systems Files for Review
5 	70.3.3 	A3-3693.6 	HO-480.6 	Review of Hospitals With Online Admissions
Query
5 	70.4 	A3-3693.7 	HO-480.7 	Assessment of Hospital Review
5 	70.5 	A3-3693.8 	Exhibits
5 	70.5.1 	Exhibit 1: Assessment of Medicare Secondary
Payer Hospital Review
5 	70.5.2 	Exhibit 2: Survey of Bills Reviewed
5 	70.5.3 	Exhibit 3: Entrance Interview Checklist
5 	70.5.4 	Exhibit 4: Entrance Interview Checklist:
Billing Procedures
5 	Att 1 	AB-03-081a 	Electronic Correspondence Referral System
(ECRS) User Guide v6.0
5 	Att 2 	AB-03-081b 	Electronic Correspondence Referral System
(ECRS) - Quick Reference Card