Medicare Secondary Payer: Explanation Form for Secondary Insured Claims

The Administrative Simplification Compliance Act (ASCA) requires that Medicare claims be submitted electronically including claims for MSP. There is an exception; paper claims can be submitted when more than one payer is responsible for payment prior to Medicare.

After reviewing the number of paper claims that have been denied or returned for illegible, missing, invalid information, Palmetto GBA wanted to give providers a form to help clarify common problems.

Located below is an explanation form that can be submitted with any Medicare Secondary Payer paper claim. This form must be submitted in addition to the Explanation of Benefits (EOB) from the primary insurer. This form is not mandatory but it will allow Medicare to process claims more efficiently and timely.

The following information can be accepted from the explanation sheet:

• The name and/or address of the insurance company
• If the primary insurer lumps all services into a single service, you may breakdown the charges for each service. Please provide the submitted charges, allowed amount, paid amount and patient responsibility, if any.
• If the primary insurer only places column heading on the first page of a multi-page EOB, Medicare will accept the information as indicated on the Medicare Explanation Form
• Narrative description providing a more detailed explanation of the Reason for Denial or partial payment that is indicated on the EOB

The following information can not be accepted from the explanation sheet:

• The Patient’s Identification, if not on the Primary Insurer’s EOB
• The Primary Payer’s Paid Amount
• Date of Service

Reason for Denial or partial payment if not indicated on the EOB. Exception: If the EOB contains the reason for denial (reason/remark code), but the reason is not clear, a more detailed explanation can be provided on the explanation sheet.