10 - General Information
(Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23)
A/B Medicare Administrative Contractors (MACs) (Part A), A/B MACs (Part B), or A/B
MACs (Part HHH) (collectively referred to as A/B MACs) and Durable Medical
Equipment MACs (DME MACs) obtain information pertinent to the identification of MSP
for each beneficiary via the CWF, MSP auxiliary file. The auxiliary file is associated with
the beneficiary's master record within CWF.
The MSP Contractor completes MSP updates on a daily basis upon receipt of notice that
another payer is primary to Medicare (e.g., an explanation of benefits, a beneficiary
questionnaire, a notice from a third-party payer, Section 111 reporting, etc.). Every claim
for a given beneficiary is validated against the same MSP data housed in a CWF, MSP
auxiliary file, thus permitting uniform processing. Contractor claims data inconsistent
with a CWF, MSP auxiliary file will cause rejects and/or error conditions. An MSP
auxiliary record consistent with an identified MSP situation must be present before a
payment is approved for an MSP claim. An MSP auxiliary record is established by an
MSP maintenance transaction submitted to CWF. The claim must agree with the MSP
auxiliary record that was established, or it will not process.
The MSP Contractor is the source for establishing new MSP records, with the exception
of four situations described in §10.1, below. The MSP Contractor submits MSP
maintenance transactions on the basis of information obtained outside the claims process.
Examples include, voluntary MSP insurer data match agreements, MMSEA Section 111
reporting, attorney, beneficiary, provider information, and 411.25 Notices.
10.1 - Overview of CWF MSP Processing
(Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23)
The CWF MSP auxiliary file is updated with maintenance transactions from the MSP
contractor responsible for coordination of benefits (formerly known as the Benefits
Coordination & Recovery Center or Coordination of Benefits Contractor and hereafter
termed the “MSP contractor”), except for the following situations:
1. If the A/B Medicare Administrative Contractor (MAC) (Part A), A/B MAC
(Part B), or A/B MAC (HHH) (collectively referred to as A/B MACs) or Durable
Medical Equipment Medicare Administrative Contractor (DME MAC) receives a phone
call or correspondence from an attorney/other beneficiary representative, beneficiary,
third-party payer, provider, another insurer’s Explanation of Benefits (EOB) or other
source that establishes, exclusive of any further required development or investigation,
that MSP no longer applies, it must add termination dates to MSP auxiliary records
already established by the MSP contractor with a "Y" validity indicator where there is no
discrepancy in the validity of the information contained on CWF. (See §20.1.4)
2. If the A/B MAC receives a claim for secondary benefits and could, without
further development (for example, the EOB from another insurer or third-party payer
contains all necessary data) add an MSP occurrence and pay the secondary claim, it
submits a validity indicator of "I" to add any new MSP occurrences (only if no MSP