CMS-1500 (02-12) claim form instructions when Medicare is secondary

Complete the items below on the CMS-1500 (02-12) claim form or electronic equivalent, in addition to all other claim form requirements, when Medicare is the secondary payer.

The necessary fields outlined below for Medicare secondary payer (MSP) must be completed. Completion of item 11 (i.e., insured's policy/group number or "none") is required on all claims. Claims without this information will be rejected.

For instructions on completing the 1500 claim form, please refer to Completion of the Centers for Medicare & Medicaid Services, CMS-1500 Claim form.

For instructions on adding MSP information to electronic claims, please refer to Electronic Billing Guide: Chapter 11 – Medicare as a supplemental payer.

Note: The normal Medicare claims timely filing rules apply.

There has been a substantial volume of incorrect submissions where the below fields (blocks) were incomplete or were not completed correctly.

If there is insurance primary to Medicare, the insured's policy or group number must be entered in item 11. Also, 11a - 11c, 4, 6, 7 and 10 must also be completed. If there is no insurance primary to Medicare, the word "none" should be entered in block 11. Completion of item 11 (i.e., insured's policy/group number or "none") is required on all claims. Claims without this information will be rejected.

Item 4-Insured's name: If the patient has insurance primary to Medicare, either through their own or their spouse’s employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word “Same.” If there is no insurance primary to Medicare, leave blank.

Completion of this item is conditional for insurance information.

Item 6 - Patient relationship to insured

Check the appropriate box for patient's relationship to the insured when item 4 is completed. Completion of this item is conditional for insurance information when item 4 is completed.

Item 7-Insured's address: Enter the insured’s address and telephone number. Enter the street address on the first line, the city and state on the second line and the ZIP code on the third line. When the address is the same as the patient’s, enter the word “Same.”

Complete this item only when items 4 and 11 are completed. Completion of this item is conditional for insurance information when items 4, 6 and 11 are completed.

Item 10 - 10a through 10c is patient's condition related to: Check "yes" or "no" to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in item 24.

Enter the state postal code.

Any item checked "yes" indicates there may be other insurance primary to Medicare. Identify primary insurance information in item 11.

Completion of items 10a-c is required for all claims; "yes" or "no" must be indicated.

Item 10d Reserved for local use

Use this item exclusively for Medicaid (MCD) information. If the patient is entitled to MCD, enter the patient's MCD number preceded by "MCD".

Item 11-Insured's policy group or FECA number:

When submitting paper or electronic claims, item 11 must be completed. By completing this information, the physician / supplier acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer. Claims without this information will be rejected.

If there is insurance primary to Medicare, enter the insured’s policy or group number and then proceed to Items 11a–11c. Items 4, 6, and 7 must also be completed.  

Circumstances under which Medicare may be secondary to another insurer, includes:

If there is no insurance primary to Medicare, enter the word “none”.

If there has been a change in the insured’s insurance status, e.g., retired, enter the word “none” and proceed to item 11b.

Item 11a-Insured's date of birth: Enter the insured’s eight-digit birth date (MM/DD/CCYY) and sex if different from Item 3.

Item 11b-Employer's name or school name: Provide this information to the right of the vertical dotted line. Enter the employer’s name, if applicable. If there is a change in the insured’s insurance status, e.g., retired, enter the word "retired" followed by the six-digit or eight-digit retirement date (MM/DD/CCYY).

Item 11c-Insurance plan name or program name: Enter the nine-digit payer identification (ID) number of the primary insurance plan or program.

If no payer ID number exists, enter the complete primary payer’s program name or plan name.

If the primary payer’s explanation of benefits (EOB) does not contain the claims processing address, record the claims processing address directly on the EOB. Completion of this item is conditional for insurance information primary to Medicare.

ITEM 11d Is there another health benefit plan?

Leave blank. Not required by Medicare.

Item 29-Amount paid: Enter only the amount the patient paid on Medicare covered services. Note: Providers should never enter the amount the primary insurance paid in Item 29 or the electronic equivalent.

For a paper claim to be considered for MSP benefits, a copy of the primary payer’s EOB notice must be forwarded along with the claim form.

Paper claim submission

If you qualify for a waiver/exception under the Administrative Simplification Compliance Act to submit paper claims rather than electronic claims, send MSP claims to one of the appropriate addresses below.

Jurisdiction H:

Novitas Solutions
Attn: Part B Claims
PO Box XXXX (replace the X's with the P.O. Box number from the table below)
Mechanicsburg, PA 17055-XXXX (fill in the +4 from the table below)

Jurisdiction L:

Novitas Solutions
Attn: Part B Claims
PO Box XXXX (replace the X's with the P.O. Box number from the table below)
Mechanicsburg, PA 17055-XXXX (fill in the +4 from the table below)

Reminder: Medicare will not cover claims submitted on paper that do not meet the limited exception criteria. Claims denied for this reason will contain a claim adjustment reason code and remark code indicating that the claim will not be considered unless submitted via an electronic claim.

References