CMS Pub. 100-05, ch. 3, § 20.2

Admission Questions

(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)

Physicians, providers and suppliers shall not deny medical services or entry to a SNF or hospital

after you discover that there is:

• an open or closed GHP (whether the beneficiary is entitled due to age, disability, or End Stage

Renal Disease) or NGHP (Liability (L), No-Fault (NF) or Workers’ Compensation (WC), MSP

record found in the HIPAA Eligibility Transaction System (HETS) 270/271, or on CWF; or,

• a claim that was previously mistakenly denied by Medicare due to an MSP occurrence.

Information about the 270/271 HETS transaction can be found on the following link:

https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/About-HETS .

MSP Online Data Elements

Providers with online capability may now access the following MSP information via the

HETS 270/271 or from the CWF MSP auxiliary file:

• MSP effective date;

• MSP termination date;

• Patient relationship;

• Subscriber name;

• Subscriber policy number;

• Insurer type;

• Insurer information: Name, group number, address, city, State, and ZIP code;

• MSP type;

• Remarks code;

• Employer information: Name, address, city, State, and ZIP code; and

• Employee data: ID number, and information.

At the provider's discretion, these data may be viewed during either the admission or the

billing process. However, the data must be viewed before a bill is submitted to Medicare,

and should ideally be viewed before the patient leaves the hospital.

If the model questions are used during the admissions process, the provider will verify

each data element by using the questions, found in section 20.2.1 of this chapter, to help

identify other payers that may be primary to Medicare. It will comply with any

instructions that follow a particular question. Note: If the provider has the ability to

submit and receive a X12 270/271 transaction, the admission staff shall ask the

beneficiary if any insurance information found on CWF, or the X12 271 response, has

changed in lieu of asking all the MSP questions. When submitting the X12 270

transaction the provider must include the beneficiary entitlement date to be sure all MSP

periods are received on the X12 271 response. If there are no changes or updates to the

beneficiary’s insurance then there is no need to ask the questions. However, having

access to CWF or the X12 270/271 transaction does not absolve the provider of its

responsibility from asking the MSP questions as necessary. If there are changes to the

insurance information, or if there is uncertainty regarding information based on

conversation, then the provider must ask the MSP questions. Providers must make a

notation for auditing purposes that all the questions were not asked upon admission, or

during the telephone interview/screening, based on the beneficiary’s statement that their

insurance information has not changed or does not require updating. The Medicare A/B

MACs shall request this notation and confirmation during its hospital review. If the

provider lacks access to CWF or it does not utilize the X12 270/271 transaction the

provider shall follow the procedures found under section 20.2.1 of this chapter.

This means the provider shall ask the beneficiary the necessary MSP questions to determine the

correct primary payer. The providers are held liable to obtain the correct MSP information so

claims are billed to the correct primary payer accordingly per the CMS regulations 42 CFR §

489.20.