CMS Medicare Specialist Benefits Coordination & Secondary Payer Rules 2 — Questions and Answers
Question 1: What is the purpose of the Medicare Coordination of Benefits (COB) contractor?
- To identify other insurance coverage and coordinate payment between Medicare and other payers (Correct answer)
- To process Medicare claims submitted by providers
- To adjudicate Medicare appeals and redeterminations
- To enroll beneficiaries in Medicare Advantage plans
Correct answer: To identify other insurance coverage and coordinate payment between Medicare and other payers
The COB contractor collects and maintains data on Medicare beneficiaries' other insurance coverage to coordinate payments correctly.
Question 2: Under the MSP rules, which of the following is NOT a situation where Medicare pays secondary?
- A Medicare beneficiary who has no other insurance coverage (Correct answer)
- A beneficiary with a large employer group health plan
- A beneficiary with workers' compensation for a work injury
- A beneficiary with no-fault auto insurance after an accident
Correct answer: A Medicare beneficiary who has no other insurance coverage
When a Medicare beneficiary has no other insurance, Medicare pays as the primary (and only) payer.
Question 3: What is a Coordination of Benefits Agreement (COBA) in the Medicare system?
- An agreement between Medicare and other insurers to electronically share claims data for crossover billing (Correct answer)
- A contract between a beneficiary and Medicare for cost-sharing responsibilities
- A legal document authorizing Medicare to sue secondary payers
- An agreement between Medicare and providers about billing rates
Correct answer: An agreement between Medicare and other insurers to electronically share claims data for crossover billing
A COBA is an electronic data-sharing arrangement allowing Medicare to automatically send crossover claims to secondary insurers after Medicare processes them.
Question 4: When a Medicare beneficiary is covered by both Medicare and Medicaid, which program typically pays first?
- Medicare pays first; Medicaid pays last as the payer of last resort (Correct answer)
- Medicaid pays first; Medicare pays secondary
- Both programs split costs equally
- The state decides which pays first on a case-by-case basis
Correct answer: Medicare pays first; Medicaid pays last as the payer of last resort
Medicaid is always the payer of last resort; Medicare pays primary and Medicaid may cover remaining cost-sharing for dual-eligible beneficiaries.
Question 5: What is the MSP conditional payment process?
- Medicare pays for services when another insurer should be primary, then seeks reimbursement from that payer once a settlement is reached (Correct answer)
- Medicare conditions payment on the beneficiary meeting a deductible first
- A process where Medicare pays only part of a claim pending appeal
- An arrangement where Medicare pays in advance of services being rendered
Correct answer: Medicare pays for services when another insurer should be primary, then seeks reimbursement from that payer once a settlement is reached
Medicare may make a conditional payment when another payer is primary but has not yet paid; Medicare then recovers that payment once the primary payer settles.
Question 6: Which CMS database system tracks Medicare Secondary Payer information and other insurance coverage for beneficiaries?
- The Benefits Coordination & Recovery Center (BCRC) database (Correct answer)
- The National Provider Identifier (NPI) registry
- The Physician Quality Reporting System (PQRS)
- The Medicare Administrative Contractor (MAC) portal
Correct answer: The Benefits Coordination & Recovery Center (BCRC) database
The BCRC is responsible for identifying, collecting, and managing information on Medicare Secondary Payer situations and other health insurance coverage.
CMS Medicare Specialist Benefits Coordination & Secondary Payer Rules 2
What is the purpose of the Medicare Coordination of Benefits (COB) contractor?