Medicare Secondary Payer – Process A
Process A is utilized when the patient has working aged or disability insurance that is primary to Medicare, and payment for some or all of the services has been made by the primary insurer.
1. Have you already submitted a claim to Medicare, showing Medicare as the primary payer, and the claim is in a rejected (R BXXXX) status/location?
Yes No
2. Is the claim in the rejected status/location R B9997 for this MSP situation?
Yes No
An adjustment must be submitted to Medicare as the secondary payer electronically using the American National Standard Institute (ANSI) ASC X12N 837 5010 format or on a paper UB-04 claim form. To determine the appropriate data elements to submit on your adjustment for this MSP situation, refer to "Process A: Submit an Adjustment showing Medicare as Secondary."
Process A: Submit an Adjustment Showing Medicare as Secondary
In addition to the information that was submitted on the original rejected claim (R B9997), complete the following UB-04 data elements when submitting the adjustment claim via the 5010 format or on a paper UB-04 claim form. A complete listing of all codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual
.
| UB-04 FL | Field Name | Billing Instructions |
|---|---|---|
| 4 | TYPE OF BILL | Home Health – Enter the type of bill 3X7. |
| 18-28 | CONDITION CODES | Enter the claim change reason code 'D9' in the first available (blank) field. |
| 39-41 | VALUE CODES / AMOUNT | MSP Coding: Enter the appropriate value code and amount you were paid by the primary insurance. Enter value code "44" and amount if you are contractually obligated to accept an amount less than the total charges and higher than the payment received as your payment in full. Refer to the Billing MSP Claims With Value Code 44 webpage for information on the appropriate use of VC 44. |
| 48 | NON-COVERED CHARGES | Remove any charges that incorrectly appear as non-covered. |
| 50A, B, and C | PAYER NAME | Enter the primary insurer's name (as it appears on the beneficiary's eligibility file) on line A. Enter "Medicare" on line B. |
| 51A, B, and C | HEALTH PLAN ID | Enter your provider number for the primary payer (if known), on line A. |
| 52A, B, and C | REL INFO | Release of Information. Enter the appropriate valid value on line A and line B: I – Informed consent to release medical information for condition or diagnosis regulated by Federal Statutes Y – Yes, provider has a signed statement permitting release of information. |
| 58A, B, and C | INSURED'S NAME | Enter the insured's name (the name of the employee that carries the working aged/disability insurance) on line A. Enter the beneficiary's name on line B. |
| 59A, B, and C | P. REL | Enter the code for the patient's relationship to the insured on line A. Refer to page 11 of the Medicare Secondary Payer Billing & Adjustments |
| 60A, B, and C | INSURED'S UNIQUE ID | Enter the primary payer's policy number (if available on the beneficiary's eligibility file) on line A. Enter the beneficiary's Medicare Health Insurance Claim (HIC) number on line B. |
| 61A, B, and C | GROUP NAME | Enter the group name or plan through which the insurance is provided on line A (if known). |
| 62A, B, and C | INSURANCE GROUP NUMBER | Enter the insurance group number of the plan through which the insurance is provided on line A (if known). |
| 63 | TREATMENT AUTHORIZATION CODES | Home Health providers only: Enter the Claim-OASIS Matching Key code on line B. |
| 64 | DOCUMENT CONTROL NUMBER | Enter the original claim's document control number (DCN). The DCN can be found in the ICN field on the Medicare Remittance Advice for the original claim, or in FISS on MAP 171D of the original claim. Refer to the Inquiry Menu (Chapter 3) |
| 65 | EMPLOYER NAME | Enter the name of the employer that provides health care coverage to the beneficiary. |
| 80 | REMARKS | Enter the reason for the adjustment and the employer's address. |
The original claim must be in R B9997 status/location to adjust it. If the claim is in R B7501 or R B7516, you must wait to submit the adjustment until the claim moves to R B9997. This will take at least 75 days. Once the original claim is in status/location R B9997, submit an adjustment to Medicare as the secondary payer electronically using the American National Standard Institute (ANSI) ASC X12N 837 5010 format or on a paper UB-04 claim form. To determine the appropriate data elements to submit on your adjustment for this MSP situation, refer to "Process A: Submit an Adjustment showing Medicare as Secondary."
Process A: Submit an Adjustment Showing Medicare as Secondary
In addition to the information that was submitted on the original rejected claim (R B9997), complete the following UB-04 data elements when submitting the adjustment claim via the 5010 format or on a paper UB-04 claim form. A complete listing of all codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual.
| UB-04 FL | Field Name | Billing Instructions |
|---|---|---|
| 4 | TYPE OF BILL | Home Health – Enter the type of bill 3X7. |
| 18-28 | CONDITION CODES | Enter the claim change reason code 'D9' in the first available (blank) field. |
| 39-41 | VALUE CODES / AMOUNT | MSP Coding: Enter the appropriate value code and amount you were paid by the primary insurance. Enter value code "44" and amount if you are contractually obligated to accept an amount less than the total charges and higher than the payment received as your payment in full. Refer to the Billing MSP Claims With Value Code 44 webpage for information on the appropriate use of VC 44. |
| 48 | NON-COVERED CHARGES | Remove any charges that incorrectly appear as non-covered. |
| 50A, B, and C | PAYER NAME | Enter the primary insurer's name (as it appears on the beneficiary's eligibility file) on line A. Enter "Medicare" on line B. |
| 51A, B, and C | HEALTH PLAN ID | Enter your provider number for the primary payer (if known), on line A. |
| 52A, B, and C | REL INFO | Release of Information. Enter the appropriate valid value on line A and line B: I – Informed consent to release medical information for condition or diagnosis regulated by Federal Statutes Y – Yes, provider has a signed statement permitting release of information. |
| 58A, B, and C | INSURED'S NAME | Enter the insured's name (the name of the employee that carries the working aged/disability insurance) on line A. Enter the beneficiary's name on line B. |
| 59A, B, and C | P. REL | Enter the code for the patient's relationship to the insured on line A. Refer to page 11 of the Medicare Secondary Payer Billing & Adjustments |
| 60A, B, and C | INSURED'S UNIQUE ID | Enter the primary payer's policy number (if available on the beneficiary's eligibility file) on line A. Enter the beneficiary's Medicare Health Insurance Claim (HIC) number on line B. |
| 61A, B, and C | GROUP NAME | Enter the group name or plan through which the insurance is provided on line A (if known). |
| 62A, B, and C | INSURANCE GROUP NUMBER | Enter the insurance group number of the plan through which the insurance is provided on line A (if known). |
| 63 | TREATMENT AUTHORIZATION CODES | Home Health providers only: Enter the Claim-OASIS Matching Key code on line B. |
| 64 | DOCUMENT CONTROL NUMBER | Enter the original claim's document control number (DCN). The DCN can be found in the ICN field on the Medicare Remittance Advice for the original claim, or in FISS on MAP 171D of the original claim. Refer to the Inquiry Menu (Chapter 3) |
| 65 | EMPLOYER NAME | Enter the name of the employer that provides health care coverage to the beneficiary. |
| 80 | REMARKS | Enter the reason for the adjustment and the employer's address. |
The claim must be submitted to Medicare electronically using the American National Standard Institute (ANSI) ASC X12N 837 5010 format and show Medicare as the secondary payer. For the appropriate data elements to submit on your claim for this MSP situation, refer to "Process A: Submit Claim showing Medicare as Secondary".
Process A: Submit Claim Showing Medicare as Secondary
Submit the following UB-04 data elements via the 5010 format. A complete listing of all codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual.
| UB-04 FL | Field Name | Billing Instructions |
|---|---|---|
| 1 | Untitled | Enter the billing provider's name, street address, city, state, zip code. |
| 4 | TYPE OF BILL | Home Health – Enter the type of bill 329. |
| 5 | FED TAX NO | Enter your federal tax number. |
| 6 | STATEMENT COVERS PERIOD | Enter the beginning and ending dates for this billing period. |
| 8a – 8b | PATIENT NAME | Enter the beneficiary's name as it appears on the beneficiary's eligibility file. |
| 9a – d | PATIENT ADDRESS | Enter the beneficiary's street address, city, state, zip code. |
| 10 | BIRTHDATE | Enter the beneficiary's date of birth. |
| 11 | SEX | Enter the beneficiary's gender. |
| 12 | ADMISSION DATE | Home Health – Enter the start of care date the Medicare covered home health services began (the first Medicare billable service date). |
| 14 | TYPE | Enter the 1-digit code indicating the Priority (Type) of Admission or Visit Codes. |
| 15 | SRC | Enter the code indicating the beneficiary's Point of Origin (Source of Admission). |
| 17 | STAT | Enter the beneficiary's Discharge Status Code as of the 'THROUGH' date in the STATEMENT COVERS PERIOD field (FL 6). |
| 18-28 | CONDITION CODES | Enter the appropriate condition codes, if applicable. |
| 31-34 | OCCURRENCE CODE / DATE | Enter the appropriate occurrence code and date, if applicable. |
| 35-36 | OCCURRENCE SPAN CODE / FROM / THROUGH | Hospice only. Enter the appropriate occurrence span code and from and through dates if applicable. Refer to the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual |
| 39-41 | VALUE CODES / AMOUNT | Enter the appropriate value codes and amount: MSP Coding: Enter the appropriate value code and amount you were paid by the primary insurance. Enter value code "44" and amount if you are contractually obligated to accept an amount less than the total charges and higher than the payment received as your payment in full. Refer to the Billing MSP Claims With Value Code 44 webpage for information on the appropriate use of VC 44. |
| 42 | REV CD | Enter the appropriate revenue code for the services billed. |
| 44 | HCPCS / RATE / HIPPS CODE | Enter the appropriate HCPCS code for the services billed. |
| — | MODIFIER | Enter the appropriate modifier to the right of the HCPCS code for the services being billed. For additional information, refer to the MODIFS field information at: |
| 45 | SERV DATE | Enter the date the service was provided. For additional information, refer to the SERV DATE field information at: |
| 46 | SERV UNITS | Enter the number of covered units for the services billed. |
| 47 | TOTAL CHARGES | Enter the total charge for each revenue code line. |
| 48 | NON-COVERED CHARGES | Enter any noncovered charges billed per revenue code. |
| 50A, B, and C | PAYER NAME | Enter the primary insurer's name (as it appears on the beneficiary's eligibility file) on line A. Enter "Medicare" on line B. |
| 51A, B, and C | HEALTH PLAN ID | Enter your provider number for the primary payer (if known), on line A. |
| 52A, B, and C | REL INFO | Release of Information. Enter the appropriate valid value on line A and line B: |
| 56 | NPI | Enter your National Provider Identifier (NPI). |
| 58A, B, and C | INSURED'S NAME | Enter the insured's name (the name of the employee that carries the working aged/disability insurance) on line A. Enter the beneficiary's name on line B. |
| 59A, B, and C | P. REL | Enter the code for the patient's relationship to the insured on line A. Refer to page 11 of the "Medicare Secondary Payer Billing & Adjustments |
| 60A, B, and C | INSURED'S UNIQUE ID | Enter the primary payer's policy number (if available on the beneficiary's eligibility file) on line A. Enter the beneficiary's Medicare Health Insurance Claim (HIC) number on line B. |
| 61A, B, and C | GROUP NAME | Enter the group name or plan through which the insurance is provided on line A (if known). |
| 62A, B, and C | INSURANCE GROUP NUMBER | Enter the insurance group number of the plan through which the insurance is provided on line A (if known). |
| 63 | TREATMENT AUTHORIZATION CODES | Home Health providers only: Enter the Claim-OASIS Matching Key code on line B. |
| 65 | EMPLOYER NAME | Enter the name of the employer that provides health care coverage to the beneficiary. |
| 67A – Q | DX | Enter the appropriate diagnosis code(s). |
| 76 | ATTENDING / NPI / LAST / FIRST | Enter the attending physician's NPI, last name, and first name. |
| 78 | OTHER / NPI / LAST / FIRST | Home Health – Enter the NPI, last name, and first name of the physician who certified/recertified the patient's home health eligibility (if different than the attending physician) (for episodes beginning on/after July 1, 2014). Hospice – Enter the NPI, last name, and first name of the physician responsible for certifying the patient as terminally ill, if different than the attending physician. |
| 80 | REMARKS | Enter the employer's name and address that provides the primary insurance. |
Join Electronic Mailing List
Print
Bookmark
Email
Facebook
YouTube
LinkedIn
CGS Medicare Mobile App