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The Medicare Secondary Payer Questionnaire (MSPQ) is a federally mandated patient registration and revenue cycle screening instrument defined by the Centers for Medicare & Medicaid Services (CMS) under the Medicare Secondary Payer (MSP) Manual (CMS IOM Pub. 100-05, Chapter 3, Section 20.2.1). Administered during inpatient admission, outpatient registration, and clinical trial enrollment, the MSPQ determines whether Medicare is the primary payer or whether another coverage source—such as an employer Group Health Plan (GHP), Workers’ Compensation, No-Fault, Liability insurance, or a clinical research sponsor—must pay first under Social Security Act § 1862(b) (42 U.S.C. § 1395y(b)) and 42 CFR Part 411.
What Is the Medicare Secondary Payer Questionnaire (MSPQ)?
When Congress enacted the Medicare Secondary Payer provisions beginning in 1980, it shifted Medicare from being the default first payer for all beneficiaries to the secondary payer whenever specific statutory primary coverage exists. To prevent improper primary Medicare payments, CMS requires hospitals, physicians, and institutional suppliers to ask Medicare beneficiaries (or their representatives) a standardized series of model admission questions—the MSPQ—and to verify electronic eligibility records returned via the HIPAA ASC X12N 270/271 Health Care Eligibility Benefit Inquiry and Response transaction from the CMS HIPAA Eligibility Transaction System (HETS) and Common Working File (CWF).
Under CMS Chapter 3 § 20.2.1, providers must retain completed MSPQ documentation (whether captured on paper or electronically signed in the EHR registration module) for a minimum of 10 years to defend against Medicare Administrative Contractor (MAC) and Recovery Audit Contractor (RAC) post-payment audits.
The 3 Parts of the CMS Model MSPQ & Primary Payer Thresholds
The official CMS Model Admission Questionnaire is structured into three cascading parts that map directly to MSP Value Codes (12 through 47) and Condition Codes reported on the institutional UB-04 (CMS-1450 / X12 837I) and professional CMS-1500 (X12 837P) claim forms:
| MSPQ Section | Coverage Category Screened | Statutory Primary Payer Rule & Employee Size Threshold | UB-04 MSP Value Code |
|---|---|---|---|
| Part I: Non-GHP, Accident, Injury & Research | Black Lung, Research Grants, Workers’ Comp, No-Fault, & Liability | Federal Black Lung benefits (for lung-related services), medical services covered by a government or sponsor research grant, job-related illness/injury under Workers’ Compensation, automobile/premises No-Fault medical payments, or third-party Liability insurance are always primary to Medicare for the related condition. | 41 (Black Lung), 15 (Workers’ Comp), 14 (No-Fault), 47 (Liability) |
| Part II: Working Aged & Disability GHPs | Working Aged (Age ≥ 65) | An employer Group Health Plan (GHP) based on the current active employment of the beneficiary or their spouse is primary if the employer has 20 or more employees (or participates in a multi-employer plan where at least one employer has ≥20 employees). COBRA and retiree plans without active employment are secondary to Medicare. | 12 (Working Aged) |
| Part II: Working Aged & Disability GHPs | Disabled (Under Age 65) | A Large Group Health Plan (LGHP) based on the current active employment of the beneficiary or a family member is primary if the employer has 100 or more employees. | 43 (Disabled LGHP) |
| Part III: End-Stage Renal Disease (ESRD) | ESRD Entitlement | Any employer GHP (regardless of employer size—even <20 employees) is primary during the first 30-month coordination period of ESRD Medicare eligibility; Medicare becomes primary beginning in month 31. | 13 (ESRD in 30-month period) |
How Is the MSPQ Used in Clinical Research and Healthcare Workflows?
1. Clinical Trial Billing Compliance and Routine Cost Coordination
In academic medical centers and oncology research sites, the MSPQ works alongside Medicare Clinical Trial Policy (NCD 310.1) coverage analyses and clinical trial charge capture and billing reconciliation. Under MSP rules, if a clinical trial sponsor contractually agrees to pay for protocol-mandated items or services free of charge, the sponsor acts as a primary payer—meaning those items cannot be billed to Medicare without triggering False Claims Act liability in clinical trial billing. Conversely, for qualifying routine care costs billed to Medicare, registration teams combine the MSPQ with an Advance Beneficiary Notice (ABN) in clinical trial billing when frequency or medical necessity limits apply, following a structured clinical trial billing compliance checklist.
2. Coordination of Benefits (COB) Crossover Claims and Conditional Payments
When the MSPQ identifies a primary Group Health Plan, the provider bills the primary GHP first. Once the primary insurer adjudicates the claim and issues an X12 835 Electronic Remittance Advice, either the CMS Benefits Coordination & Recovery Center (BCRC) automatically transmits a COB crossover claim to the Medicare Administrative Contractor, or the provider submits a secondary Medicare claim attaching the primary payer’s Group/Claim Adjustment Reason Codes (CARCs) and MSP Value Code. In Workers’ Compensation, No-Fault, or Liability cases where the primary insurer will not pay promptly (defined under 42 CFR § 411.21 as within 120 days), the provider may submit a conditional payment claim to Medicare subject to mandatory repayment if a settlement, judgment, or award is later reached.
3. Form CMS-838 Medicare Credit Balance Reports
When MSP screening errors result in duplicate primary payments from both an employer GHP/workers’ compensation carrier and Medicare, institutional Part A providers must track and refund the overpayment. Under CMS regulations, hospitals and skilled nursing facilities must submit a quarterly Form CMS-838 (Medicare Credit Balance Report) within 30 calendar days after the close of each calendar quarter whenever they have reportable Medicare credit balances (including MSP primary-payer overpayments) remaining at quarter-end.
Frequently Asked Questions
What is the Medicare Secondary Payer Questionnaire (MSPQ)?
The Medicare Secondary Payer Questionnaire (MSPQ) is a mandatory CMS screening tool (MSP Manual Chapter 3, Section 20.2.1) completed during patient registration to identify whether a Medicare beneficiary has primary coverage through an employer Group Health Plan (Working Aged ≥20 employees or Disability ≥100 employees), the 30-month ESRD coordination period, Workers’ Compensation, No-Fault, Liability insurance, or Black Lung benefits.
How is the Medicare Secondary Payer Questionnaire used in clinical research and healthcare?
In healthcare and clinical research, the MSPQ routes claims to the legally responsible primary payer before Medicare is billed, prevents duplicate billing of sponsor-paid research items under Social Security Act § 1862(b), triggers automated Coordination of Benefits (COB) crossover claims, and feeds quarterly Form CMS-838 Credit Balance Report reconciliation.
Sources
- Centers for Medicare & Medicaid Services (CMS): Medicare Secondary Payer (MSP) Manual (CMS IOM Pub. 100-05), Chapter 3 —MSP Provider, Physician, and Other Supplier Billing Requirements (§ 20.2.1 Model Admission Questions).
- U.S. Government Publishing Office / eCFR: Social Security Act § 1862(b) (42 U.S.C. § 1395y(b)) and 42 CFR Part 411 — Exclusions From Medicare and Limitations on Medicare Payment.
- Centers for Medicare & Medicaid Services (CMS): Form CMS-838 Medicare Credit Balance Report Instructions and CMS Benefits Coordination & Recovery Center (BCRC) Guidelines.
