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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. In general, claims and adjustments that include MSP information must be submitted electronically using the ANSI ASC X12N 837 format.

Note: Providers that meet the small provider exception, (CMS Pub. 100-04, Ch. 24 §90), may submit paper (UB-04) claims.

MSP Situation MSP Claims/Adjustments must be submitted:
Group Health Plan (working aged, ESRD, or disability) Electronically using 5010 format showing Medicare as secondary with MSP coding
Non-group Health Plan (no-fault, liability, worker’s compensation) and claim includes related diagnosis codes Electronically using 5010 format showing Medicare as secondary with MSP coding
Non-group Health Plan (no-fault, liability, worker’s compensation) and claim does not include related diagnosis codes (i.e., services unrelated) Electronically (5010) or via FISS showing Medicare as the primary payer

Note: Do not include any MSP coding.
Black Lung and claim includes related diagnosis codes Paper (UB-04) with MSP coding, and denial notice from Federal Black Lung Program. In addition, also provide the workers’ compensation insurer denial notice (if applicable).
Black Lung and claim does not include related diagnosis codes Electronically (5010) or via FISS showing Medicare as the primary payer

Note: Do not include any MSP coding.

For detailed instructions on billing MSP claims, including the 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.

Correcting MSP Claims and Adjustments

The above information also applies when you are correcting a claim that has been returned to you (RTP file, status location T B9997). Claims that are corrected out of the RTP file are considered to be submitted DDE, regardless of whether they were originally submitted electronically (5010 format). Therefore, rather than correcting a claim (from the RTP file) it must be resubmitted electronically (with the error corrected) in order to meet the electronic billing requirement.

References

Updated: 08.06.14


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