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Medicare Secondary Payer – Process H

Process H is utilized to bill Medicare conditionally when disability insurance or working aged insurance is the primary payer and payment was denied or applied to deductible.

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

You must submit an adjustment to Medicare using the American National Standard Institute (ANSI) ASC X12N 837 5010 format or on a paper UB-04 claim form. For the appropriate data elements to submit on your adjustment for this MSP situation, refer to "Process H: Submit Adjustment via 5010 Format or Paper UB-04."

Process H: Submit Adjustment via 5010 Format or Paper UB-04

In addition to the information that was submitted on the original rejected claim (R B9997), complete the following UB-04 data elements on the adjustment claim 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

TYPE OF BILL

Home Health – Enter the type of bill 3X7.

Hospice – Enter the type of bill 8X7.

Note: You will need to check the type of bill on the original rejected claim. Make sure the 2nd digit of the adjustment type of bill matches the 2nd digit of the rejected claim.

18-28

CONDITION CODES

Enter the claim change reason code 'D9' in the first available blank.

31-34

OCCURRENCE CODE / DATE

MSP Coding: Enter occurrence code '24' and the date of the Explanation of Benefits (EOB) or date of last contact with the insurer.

39-41

VALUE CODES / AMOUNT

MSP Coding: Enter the appropriate value code and amount you were paid by the insurer.

12 – Working aged beneficiary/spouse with EGHP

43 – Disabled beneficiary under age 65 with large group health plan (LGHP)

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. Adjustments with value code "44" must be submitted electronically using the 5010 format. Refer to the Billing MSP Claims With Value Code 44 webpage.

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 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 " quick resource tool for the appropriate code. These codes are also available from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual

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).

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) of the FISS Guide for information about MAP 171D

EMPLOYER NAME

Enter the name of the employer that provides health care coverage to the beneficiary.

REMARKS

Enter the appropriate MSP Explanation Code (below) to indicate why services denied by primary insurer.

BE	Benefits are exhausted.
CD	Charges applied to co-payment, coinsurance or deductible.
FG	Beneficiary did not follow guidelines of their primary health plan. Use only for out of network, untimely filing or no prior authorization. Note: Indicate which of these guidelines was not followed.
NB	Not a covered benefit.
PC	Pre-existing condition.

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, you must submit an adjustment to Medicare using the American National Standard Institute (ANSI) ASC X12N 837 5010 format or on a paper UB-04 claim form. For the appropriate data elements to submit on your adjustment for this MSP situation, refer to "Process H: Submit Adjustment via 5010 Format or Paper UB-04."

Process H: Submit Adjustment via 5010 Format or Paper UB-04

UB-04 FL

Field Name

Billing Instructions

TYPE OF BILL

Home Health – Enter the type of bill 3X7.

Hospice – Enter the type of bill 8X7.

Note: You will need to check the type of bill on the original rejected claim. Make sure the 2nd digit of the adjustment type of bill matches the 2nd digit of the rejected claim.

18-28

CONDITION CODES

Enter the claim change reason code 'D9' in the first available blank.

31-34

OCCURRENCE CODE / DATE

MSP Coding: Enter occurrence code '24' and the date of the Explanation of Benefits (EOB) or date of last contact with the insurer.

39-41

VALUE CODES / AMOUNT

MSP Coding: Enter the appropriate value code and amount you were paid by the insurer.

12 – Working aged beneficiary/spouse with EGHP

43 – Disabled beneficiary under age 65 with large group health plan (LGHP)

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 disability insurance) on line A. Enter the beneficiary's name on line B.

59A, B, and C

P. REL

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).

DOCUMENT CONTROL NUMBER

EMPLOYER NAME

Enter the name of the employer that provides health care coverage to the beneficiary.

REMARKS

Enter the appropriate MSP Explanation Code (below) to indicate why services denied by primary insurer.

BE	Benefits are exhausted.
CD	Charges applied to co-payment, coinsurance or deductible.
FG	Beneficiary did not follow guidelines of their primary health plan. Use only for out of network, untimely filing or no prior authorization. Note: Indicate which of these guidelines was not followed.
NB	Not a covered benefit.
PC	Pre-existing condition.

The claim must be submitted to Medicare conditionally, using the American National Standard Institute (ANSI) ASC X12N 837 5010 format. For the appropriate data elements to submit on your claim for this MSP situation, refer to "Process H: Submit Claim via 5010 Format."

Process H: Submit Claim via 5010 Format

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

Untitled

Enter the billing provider's name, street address, city, state, zip code.

TYPE OF BILL

Home Health – Enter the type of bill 329.

Hospice – Enter the type of bill 81X or 82X

MSP information should not be submitted on the home health request for anticipated payment (RAP) and hospice notice of election (NOE).

FED TAX NO

Enter your federal tax number.

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.

BIRTHDATE

Enter the beneficiary's date of birth.

SEX

Enter the beneficiary's sex.

M – Male

F – Female

ADMISSION DATE

Home Health – Enter the start of care date on which the Medicare covered home health services began (the first Medicare billable services date).

Hospice – Enter the effective date of the hospice election or hospice transfer.

TYPE

Enter the 1-digit code indicating the Priority (Type) of Admission or Visit Codes.

SRC

Enter the code indicating the beneficiary's Point of Origin (Source of Admission).

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.

MSP Coding: Enter occurrence code '24' and the date of the Explanation of Benefits (EOB) or date of last contact with the insurer.

35-36

OCCURRENCE SPAN CODE / FROM / THROUGH

Hospice only. Enter the appropriate occurrence span code and from and through dates if applicable.

Hospice Occurrence Span Codes/Dates

Refer to the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual for coding information.

39-41

VALUE CODES / AMOUNT

Enter the appropriate value codes and amount.

MSP Coding: Enter the appropriate value code and zeros (0000.00) for the amount.

12 – Working aged beneficiary/spouse with EGHP

43 – Disabled beneficiary under age 65 with large group health plan (LGHP)

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. For more information about value code 44, refer to the "Billing MSP Claims With Value Code 44" webpage.

REV CD

Enter the appropriate revenue code for the services billed.

HCPC / 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:

SERV DATE

Enter the date the service was provided. For additional information, refer to the SERV DATE field information at:

SERV UNITS

Enter the number of covered units for the services billed.

TOTAL CHARGES

Enter the total charge for each revenue code line.

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. Valid values are:

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.

NPI

Enter your National Provider Identifier (NPI).

58A, B, and C

INSURED'S NAME

Enter the insured's name (name of the person that carries the 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 " quick resource tool for the appropriate code. These codes are also available from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual

60A, B, and C

INSURED'S UNIQUE ID

Enter the primary payer's policy number 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).

TREATMENT AUTHORIZATION CODES

Home Health providers only: Enter the Claim-OASIS Matching Key code on line B.

EMPLOYER NAME

Enter the name of the employer that provides health care coverage to the beneficiary.

67A – Q

Enter the appropriate diagnosis code(s).

ATTENDING / NPI / LAST / FIRST

Enter the attending physician's NPI, last name, and first name.

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.

REMARKS

Enter the appropriate MSP Explanation Code (below) to indicate why services denied by primary insurer.

BE	Benefits are exhausted.
CD	Charges applied to co-payment, coinsurance or deductible.
FG	Beneficiary did not follow guidelines of their primary health plan. Use only for out of network, untimely filing or no prior authorization. Note: Indicate which of these guidelines was not followed.
NB	Not a covered benefit.
PC	Pre-existing condition.

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Medicare Secondary Payer – Process H

Process H: Submit Adjustment via 5010 Format or Paper UB-04

Process H: Submit Adjustment via 5010 Format or Paper UB-04

Process H: Submit Claim via 5010 Format

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