Medicare-participating providers are required to determine whether Medicare is a primary or secondary payer for each admission, start of care, or encounter with a beneficiary prior to submitting a bill by asking the beneficiary about any insurance coverage that may be primary to Medicare. The Centers for Medicare & Medicaid Services (CMS) has a model questionnaire containing the information questions that should be asked of beneficiaries at each start of care.
In response to recent questions, CMS has issued a Transmittal and MLN Matters article (Transmittal 123/Change Request 10863/MM10863) that updates Chapters 3 and 5 of the Medicare Secondary Payer Manual to provide clarification of requirements for provider-based entities as well as to re-emphasize that providers may also view the Common Working File (CWF) or reference the X12 270/271 Transaction Set to access current information on file and confirm with the patient if insurance information has changed. If there are no changes, the MSP questions do not need to be asked.
Of particular relevance to home health and hospice providers are CMS’ reemphasis (as part of the Medicare Secondary Payer manual revisions and as part of MM10863) that a provider may, in lieu of initially asking the patient to complete the model questionnaire, refer to information contained in the CWF or X12 279/271 Transaction Set to confirm with the patient whether the information has changed. CMS gives the following guidance:
– Provided by National Association for Home Care & Hospice (NAHC) staff.
- If you have access to the Common Working File (CWF), your admission staff may ask the beneficiary if any insurance information it contains has changed. If there are no changes to the beneficiary’s insurance, then there is no need to ask the questions. Further, you are required to:
- Notate (for auditing purposes) that all the questions were not asked upon admission based on the beneficiary’s statement that their insurance information has not changed. Notations may be cited on the CWF screen print verifying the MSP information in the system is correct or the notations may be attached to the CWF print out. Your MAC may request this notation and confirmation during review
- Alternatively, the HIPAA Eligibility Transaction System (HETS) Health Care Eligibility Benefit Inquiry and Response (270/271) Transaction Set may be used to make an inquiry about the Medicare eligibility of an individual and to identify insurance that is primary or secondary to Medicare. Similar to the CWF process (above), if you have the ability to submit and receive a HETS 270/271 transaction set and, upon review, there are no changes to the beneficiary’s insurance then there is no need to ask the questions.
- Further, you must notate (for auditing purposes) that all the questions were not asked upon admission based on the beneficiary’s statement that their insurance information has not changed as your MAC may request this notation and confirmation during review. Notations may be cited on the 270/271 screen print verifying the MSP information in the system is correct or the notations may be attached to the HETS 270/271 print out.
- If, upon checking either the CWF or 270/271 information with the beneficiary you find that there ARE changes to the insurance information, you must ask the MSP questions.