COB Fact Sheets: MSP Claims Investigation Fact Sheet for
The Coordination of Benefits Contractor (COBC) initiates a Medicare Secondary Payer (MSP)
investigation when it learns that a beneficiary has other insurance. The purpose of this
investigation is to determine whether Medicare or the other insurance has primary responsibility
for meeting the beneficiary's health care costs. This process involves developing additional
information related to the beneficiary's health benefit coverage and resolving any conflicts in the
information to ensure Medicare pays only what it is obligated to pay.
The goal of these MSP information-gathering activities is to identify MSP situations rapidly, thus
ensuring correct primary and secondary payments by the responsible parties. Providers,
physicians, and other suppliers benefit from these activities because the total payments received
for services provided to Medicare beneficiaries are greater when Medicare is a secondary payer
to a group health plan (GHP) than when Medicare is the primary payer.
MSP Claims Investigation
Trauma/injury diagnosis codes submitted on a Medicare claim or information received will alert
the COBC that an accident or traumatic injury may have occurred, and the possibility of an MSP
situation warrants development. This process is known as Trauma Development (TD).
In situations where the medical services are related to a workers' compensation injury,
automobile accident, or other liability, another payer has the primary responsibility for payment
of medical claims related to the injury. When the possibility of a liability situation arises to the
extent that payment has been made or can reasonably be expected to be made by another liable
party, and the Medicare claim submitted does not contain pertinent information about the other
payer, a development questionnaire is issued. Payment may not be made under Medicare when
payment has been made or can reasonably be expected to be made promptly