CorporateBusiness Services

Submitting Medicare Secondary Payer (MSP) Claims and Adjustments

The instructions below will assist you in determining how your MSP claims and adjustments must be submitted to Medicare (i.e. electronically, direct data entry (DDE) or on paper). 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' quick resource tool or the ‘Medicare Secondary Payer (MSP) Billing and Adjustments’ Online tool

When another insurance has made a payment primary to Medicare, CMS requires that Claim Adjustment Segments (CAS) be submitted on the MSP claim or adjustments. CAS segments are only utilized when MSP claims and adjustments are submitted electronically (using the American National Standard Institute (ANSI) ASC X12N 837 format). Therefore, it is important to understand the rules for submitting MSP claims to Medicare.

General Rule:

If the primary insurer did not/will not make a payment (i.e. the primary insurer denied payment or the primary insurer benefits were exhausted), the claim must be submitted to Medicare DDE (i.e. keyed directly into the Fiscal Intermediary Standard System (FISS)). In this case, the claim must include MSP coding to acknowledge the MSP record. If the claim is submitted with Medicare as primary, and an open MSP record exists, the claim may be rejected.

If the primary insurer did/will make a payment, the claim must be submitted to Medicare electronically (837 format). If the claim is submitted to Medicare DDE, and indicates a payment by the primary insurer, the claim will be returned to the provider (RTP) with reason code 31265 (MSP claims and adjustments cannot be entered via direct data entry (DDE) thru FISS).

Exception to General Rule: If an open Black Lung record exists, and the claim includes a Black Lung diagnosis, a paper (UB-04) claim must be submitted, along with a denial notice from the Federal Black Lung Program. For more information about Black Lung, refer to the Federal Black Lung Program Web page.

The table below provides a summary of various MSP situations, and how the claim must be submitted (FISS DDE, electronically, or paper). Detailed instructions for billing MSP claims, including the required data elements (value codes, occurrence codes, primary insurer information, etc.) can be found on the CGS 'Medicare Secondary Payer (MSP) Billing and Adjustments' quick resource tool or the ‘Medicare Secondary Payer (MSP) Billing and Adjustments’ Online tool.

MSP Situation MSP Claims/Adjustments must be submitted via:

Services are unrelated to an open MSP record (liability, workers' compensation, no-fault, Federal Black Lung, etc.).

Either Electronically or FISS DDE, without the MSP coding

The primary insurance* denied payment for the services.
*Claims denied by the Black Lung Program must be submitted on a paper (UB-04) claim. (See Black Lung situation below).

FISS DDE, including MSP coding

Another insurer is primary and, the primary insurer has paid some or all of the services.

Electronically (i.e., a billing software in the American National Standard Institute (ANSI) ASC X12N 837 5010-A1 format (e.g., PC-Ace Pro32)), including MSP coding

Another insurer is primary and the insurer has not paid promptly (within 120 days of the 'TO' date on your claim, or 120 days from when the claim was billed to the primary insurer) / is not expected to pay promptly

Electronically including MSP coding (if software allows billing a zero dollar amount ($0000.00) with a value code)
OR
Paper claim, including MSP coding (if your agency meets the small provider exception, (CMS Pub. 100-04, Ch. 24, §90))
OR
FISS DDE without MSP coding. The claim will reject to R B7501 or R B7516. (When the claim moves to R B9997 (after approximately 75 days), a paper adjustment must then be submitted, including the MSP coding

Another insurer is primary; however the charges were applied to the deductible.

Electronically including MSP coding (if software allows billing a zero dollar amount ($0000.00) with a value code)
OR
Paper claim, including MSP coding (if your agency meets the small provider exception, (CMS Pub. 100-04, Ch. 24, §90))
OR
FISS DDE without MSP coding. The claim will reject to R B7501 or R B7516. When claim moves to R B9997 (after approximately 75 days), a paper adjustment must then be submitted, including the MSP coding

The beneficiary has coverage through Black Lung (BL), and your claim includes black lung diagnoses.

Paper claim, including MSP coding and the BL Explanation of Benefits (EOB) showing the services denied and the reason for the denial

Correcting MSP Claims and Adjustments

The above rules will also hold true 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) that was required to be submitted electronically, it must be resubmitted electronically (with the error corrected) in order to meet the electronic billing requirement.

References

Updated: 07.30.13


Two Vantage Way, Nashville, TN 37228 ©2014 CGS Administrators, LLC. All Rights Reserved