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Submitting Medicare Secondary Payer (MSP) Claims and Adjustments

When your dates of service fall within the Effective and Termination dates of an MSP record, the claims must acknowledge the MSP record by reporting appropriate MSP coding on your claim.

MSP claims are submitted using the ANSI ASC X12N 837 format, or by entering the claim directly into the Fiscal Intermediary Standard System (FISS) via Direct Data Entry (DDE).  Change Request (CR) 8486External PDF, effective for claims received on or after January 1, 2016, implemented changes that allow providers to submit MSP claims via FISS DDE.  If you need access to FISS in order to enter claims/adjustments via FISS DDE, contact the CGS EDI department at 1.877.299.4500 (select Option 2).

Submitting MSP Claims via FISS DDE

If you submit an MSP claim via FISS DDE, claim adjustment segment (CAS) information must be reported on the “MSP Payment Information” screen (MAP1719), which is accessed from Claim Page 03 by pressing F11.  This is in addition to the normal MSP coding information. 

The CAS information associated with the primary payer’s claim determination is found on the primary payer’s 835 remittance advice.  This information is entered on the “MSP Payment Information” screen, which accommodates up to 20 entries for primary payer 1, and 20 entries for primary payer 2 (if there is one).  Refer to the following field name and description for additional information.

For detailed instructions on reporting other MSP required data elements (value codes, occurrence codes, primary insurer information, etc.) refer to the CGS 'Medicare Secondary Payer (MSP) Billing and Adjustments'PDF quick resource tool or the ‘Medicare Secondary Payer (MSP) Billing and Adjustments’ Online tool.

Field Name Description
PAID DATE Enter the paid date shown on the primary payer’s remittance advice.
PAID AMOUNT Enter the paid amount shown on the primary payer’s remittance advice.  This amount must equal the dollar amount entered for MSP Value Code 12, 13, 14, 15, 41, 43 or 47.
GRP Enter the Group Code shown on the primary payer’s remittance advice.
CARC Enter the Claim Adjustment Reason Code (CARC) shown on the primary payer’s remittance advice.
AMT Enter the dollar amount associated with the group code and CARC.

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Press F6 to access the “MSP Payment Information” screen for primary payer 2 (if there is one). 
Press F5 to move back to the primary payer 1 “MSP Payment Information” screen.

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Additional Information

  • Paper (UB-04) claims can only be submitted to CGS for Black Lung related services, or when a provider meets the small provider exception, (CMS Pub. 100-04, Ch. 24External PDF §90).
  • When a beneficiary is entitled to benefits under the Federal Black Lung (BL) Program, and services provided are related to BL, a paper (UB-04) claim must be submitted with MSP coding and the denial notice from the Federal BL Program.  If applicable, also provide the workers’ compensation insurer denial notice.  If the services provided are not related to BL and does not inlcude a BL related diagnosis code, the claim can be submitted via 5010 or FISS DDE showing Medicare as the primary payer. 
  • When submitting non-group Health Plan (no fault, liability, worker’s compensation) claims for services unrelated to the MSP situation, and no related diagnosis codes are reported, do not include any MSP coding on the claim.

Correcting MSP Claims and Adjustments

Return to Provider (RTP): MSP claims may be corrected out of the RTP file (status/location T B9997).  However, providers must ensure that claim adjustment segment (CAS) information is reported on the “MSP Payment Information” screen (MAP1719), accessed from Claim Page 03 by pressing F11. 

Adjustments: Providers may submit adjustments to MSP claims via 5010 or FISS DDE.  However, if using FISS DDE, as with claims in RTP, providers must ensure the MSP information is entered on the “MSP Payment Information” screen. 

References

  • Change Request 8486External PDF - Instructions on Using the Claim Adjustment Segment (CAS) for Medicare Secondary Payer (MSP) Part A CMS-1450 Paper Claims, Direct Data Entry (DDE), and 837 Institutional Claims Transactions

Updated: 01.12.16


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