BCRC Module 5: MSP Investigations and Questionnaires Study Guide

Developmental Activities and Information Processing in Medicare

• Medicare Entitlement Timeline: Approximately $3$ months before a beneficiary becomes entitled to Medicare, they receive a "Welcome to Medicare" package.
  • Enrollment Options: The package explains options to enroll in Part A and Part B.
    • Part A: Enrollment is automatic provided the work history requirement is met.
    • Part B: Enrollment is optional.
• History of the Initial Entitlement Questionnaire (IEQ):
  • Prior to May 19, 2011: Paper IEQ questionnaires were mailed to all Medicare beneficiaries.
  • Effective May 20, 2011: Paper IEQ questionnaires were no longer mailed to beneficiaries.
  • Effective January 2016: The Medicare Welcome Package ceased requesting beneficiaries to complete the IEQ.
• System Identification: Within the Beneficiary Coordination and Recovery System (BCRS), IEQs may still be visible under the questionnaire tab; however, these records were initiated prior to January $2016$.

Managing Open Initial Entitlement Questionnaires (IEQs)

• Identification of Open Status: IEQs with an "Open" status originate from before May $2011$.
• Actionable Status Codes: If a record displays a status field of $02$, $04$, $06$, or $08$, it is considered an Open IEQ.
• CSR Protocol for Open IEQs: The Customer Service Representative (CSR) is required to ask probing questions and perform one of the following actions:
  • Termination Code 63: Terminate the record as "No MSP" (Medicare Secondary Payer).
  • Termination Code 68: Terminate as "MSP Exists" and subsequently complete the Secondary Paper Development (SPD).
• Mandatory Compliance: If an IEQ remains open, the CSR must act by either closing the record or completing an SPD.

BCRS Questionnaire Navigation and Status Codes

• Navigation Path: Questionnaires are managed through the BCRS interface under specific tabs: Questionnaires, MSP Records, and Drug Records.
• Status and Reason Codes in BCRS:
  • Status 06: Development.
  • Status 99: Completed.
  • Reason 22: HUSP GEN (Hospital/Unknown Secondary Payer General).
  • Reason 33: Incomplete Data.
• Example Record Formats:
  • Row Type 0003: SELF RPT DEV (Self Report Development).
    • Mail Date: $04/04/2018$.
    • Status: $06-DEVELOPMENT$.
  • Row Type 0004: SELF RPT DEV.
    • Mail Date: $04/04/2018$.
    • Status: $99-COMPLETED$.
    • MSP Type: A – Working Aged.
• Comprehensive List of Termination/Reason Codes:
  • $54$: $100+$ Workers.
  • $55$: $20+$ Workers.
  • $56$: OBRA NO APPLY.
  • $57$: Already Updated.
  • $58$: Non-Comply GHP.
  • $59$: Employer Verify.
  • $60$: Invalid HICN.
  • $61$: No Part A Entitlement.
  • $62$: CL No Response.
  • $63$: DEVCMP-NOMSP (Development Complete - No MSP).
  • $64$: Letter Sent.
  • $65$: Deceased.
  • $66$: ESRD/DIB CON.
  • $67$: No Response CWF.
  • $68$: CL SR. MSP (Close IEQ - MSP Exists).
  • $69$: No Response GHP.
  • $70$: No Rose NGHP.
  • $71$: No Response Beneficiary.
  • $72$: No Response Information.
  • $73$: Beneficiary Retired.
  • $74$: Spouse Retired.
  • $75$: GHP Life Max.
  • $76$: No Insurance Coverage.
  • $77$: Supplemental Plan.
  • $78$: Less than $20$ Workers.
  • $79$: No Spouse Coverage.
  • $80$: Less than $100$ Workers.
  • $81$: Primary-ESRD.
  • $82$: Seasonal Employer.

Mandatory Probing Questions and Scripts

• Definition: Probing questions ensure that no other insurance is primary to Medicare, maintaining up-to-date records.
• Standard Probing Questions:
  • 1. Do you have any group health plan (GHP) coverage based upon your current employment?
  • 2. Do you have any group health plan coverage based upon your spouse's/other family member's current employment?
  • 3. Are you receiving any Black Lung benefits?
  • 4. Are you receiving any Workers' Compensation benefits?
  • 5. Are you receiving treatment for an injury or illness for which another party could be held liable or could be covered under no-fault or auto insurance?
• Part D Specific Questions: If the beneficiary is enrolled in a Part D plan, ask: "Do you have any supplemental/additional prescription drug coverage under your policy or another family member?"
• Opening Scrips (Legal Requirement): The CSR must explain the purpose of the call using one of the following statements combined with the mandatory Trust Fund statement:
  • "I will ask you a few questions to ensure we have correct insurance information" OR "I will verify with you that there is no other insurance that should be primary to Medicare."
  • AND: "…To Protect the Medicare Trust Fund."
• Contextual Phrasing:
  • Age Entitlement: Phrase question 2 as "…based upon your spouse's current employment."
  • Disability (DIB) Entitlement: Phrase question 2 as "…based upon your or other family member's current employment."
• When to Ask Probing Questions:
  • Every time a record is terminated or deleted.
  • When calling to verify primary vs. secondary status.
  • When using SPD questions as a basis for investigation.
• Exceptions (When Questions are NOT required):
  • Caller only seeking entitlement date and reason.
  • Calls requiring transfer to an ESRD CSR.
  • Calls requesting only a phone/fax number or address.
  • Calls regarding inability to reach another department.
  • Attorney calls verifying if a specific Non-Group Health Plan (NGHP) was reported/obtaining Medicare's interest only.

Criteria for MSP Record Creation

• Mandatory Data Fields: To create a valid MSP record, the following must be provided:
  • MSP Type.
  • Effective Date of Insurance (or Date of Loss for D, E, L records).
  • Insurer Type (A, J, K, R).
  • Insurer Name.
  • Validity Indicator (Y, N, I).
  • Contractor Number.
  • Patient Relationship (Relationship to the policyholder).
  • Diagnosis (DX) Codes (Required for D, E, and L records).

MSP Record Creation: Type and Detail Specifics

• MSP Type Categories:
  • GHP Oriented (Entitlement-Based):
    • A: Working Aged.
    • G: Disabled.
    • B: ESRD (End-Stage Renal Disease).
    • W: Workers' Compensation Set-Aside.
  • NGHP Oriented (Investigation-Based):
    • D: Auto/No-Fault.
    • E: Workers' Compensation.
    • L: Liability.
  • Miscellaneous:
    • C: Conditional Payment.
    • F: Federal Programs.
    • I: Veterans (VA).
• Determination of Effective Date:
  • Generally the date insurance coverage began.
  • Before Entitlement: If the coverage began before Medicare entitlement and the exact date is unknown, use the Medicare Part A entitlement date for GHP records.
  • NGHP (D, E, L): The effective date is the Date of Loss (date of accident).
  • If the accident occurred prior to Medicare entitlement, use the Medicare Part A entitlement date.
• Insurer Types:
  • A: Other (Combined Hospital and Medical).
  • J: Hospital only.
  • K: Medical only.
  • R: Health Reimbursement Account (HRA) - refer to "HRA SOP".
  • Note: All NGHP records are automatically assigned Insurer Type A.
• Insurer Name Requirements:
  • For D, E, L records, collect the name of the at-fault party's insurance first.
  • If unknown, collect the beneficiary's insurance.
  • Default Names: If the carrier is unknown, use: "Auto No Fault Insurance" (D), "Workers Compensation Insurance" (E), "Liability Insurance" (L), or "Black Lung" (H).

Validity Indicators and Contractor Hierarchy

• Indicator Types:
  • Y: Valid record - MSP exists.
  • N: No MSP exists (Created only through IEQ responses).
  • I: Possible MSP - Requires investigation. These are created by Medicare Administrative Contractors (MACs) and prevent Medicare from paying a claim.
• Updating "I" Validity Records:
  • Associated specifically with Secondary Claim Development (SCD) questionnaires.
  • If MSP exists: Change "I" to "Y", add missing info, and save.
  • If NO MSP exists: Change "I" to "Y" and place a "Y" in the Delete field.
• Contractor Numbers: Define hierarchy and update permissions.
  • $11100$: Updated by Supervisor or Manager.
  • $11101$: IEQ.
  • $11102$: Data Match.
  • $11103$: HMO.
  • $11104$: Litigation Settlement BCBS.
  • $11105$: Employer Voluntary Reporting.
  • $11106$: Insurer Voluntary Reporting.
  • $11109$: Secondary Claims Investigation.
  • $11110$: Self Report (BCRC Call Center/CSR).

Relationship and Diagnosis (DX) Codes

• Patient Relationship Codes:
  • $01$: Patient is the policyholder.
  • $02$: Spouse is the policyholder (Includes "Family Member").
  • $03$: Natural Child (Insured beneficiary has financial responsibility).
  • $04$: Natural Child (Insured doesn't have financial responsibility).
  • $20$: Life Partner.
• Diagnosis (DX) Code Rules for NGHP:
  • Use dropdown menus; do not type in text descriptions of injuries.
  • Coding standard (ICD-9 vs. ICD-10) is determined by the Date of Loss (DOL).
  • Capacity: CSRs can add up to $5$ DX codes. Supervisors can add up to $25$.
  • If a code is missing, complete the SPD/PDC with available info and advise the caller that accurate info is necessary for record creation.

Specific Questionnaire Types

• Secondary Payer Development (SPD): Used when the caller lacks complete information (e.g., insurer name, DX codes) to create a valid record.
• $411.25$: The same form as an SPD but specifically tailored/geared toward an insurance company.
• Prescription Drug Coverage (PDC): Used to gather both primary and supplemental (secondary) drug info.
• Direct Add: Utilized only by seasoned agents when the caller provides all necessary fields for immediate record creation.

Post-Questionnaire Correspondence (Confirmation Letters)

• GHP & NGHP (Auto/Workers' Comp): A follow-up letter is sent. Beneficiaries must check for errors. If correct, they file/destroy the letter. If incorrect, they must call BCRC or mail back the enclosed questionnaire with corrections.
• NGHP (Liability Only):
  • Receives a standard confirmation letter.
  • Rights and Responsibility (R&R) Letter: All parties involved in a Liability case receive this additional letter regarding next steps, consent to release forms, and subrogation/liens/interest amounts owed to Medicare.

Practical Application Scenarios

• GHP Practice Scenarios:
  • Scenario 1: Reporting new employment insurance (e.g., Target).
  • Scenario 2: Reporting insurance through a spouse.
  • Scenario 3: Insurer (e.g., Cigna) reporting health insurance for a client.
• NGHP Practice Scenarios:
  • Scenario 1: Auto accident involving a lawsuit against another driver.
  • Scenario 2: Slip and fall incident at a public location (e.g., Subway).
  • Scenario 3: Injury sustained while at work.