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

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

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Working Aged insurance is primary.

Submit a claim to the primary insurance.
If you receive a payment from the primary insurance, submit a Medicare Secondary Payer (MSP) claim to Medicare.

The following screens illustrate the required MSP codes. Place your cursor on the highlighted area(s) to view detailed information.

Enter any Condition Codes or Occurrence Codes that apply to the claim. The following codes are required on MSP claims (when applicable).

Enter any Value Codes that apply to the claim. The following codes are required on MSP claims for this scenario.

Value Code 12 (Working Aged) and the amount paid by the primary insurance as indicated on the primary payer's Explanation of Benefits (EOB)
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).

Line A = Primary Payer: Enter Payer Code A (Working Aged), the primary insurance name and provider number (as it appears on the Common Working File (CWF)).

Line B = Secondary Payer: Enter Payer Code Z, Medicare and Medicare provider number.

All MSP claims require Claim Adjustment Segment (CAS) information. Enter the information as it appears on the primary payer’s EOB. If the information does not appear on the primary payer’s EOB, reference the Washington Publishing Company website for a list of valid CARC codes and the CAQH website for the current version of the CORE Code Combinations.

Paid Date: Enter the date shown on the primary payer’s EOB.
Paid Amount: Enter the paid amount shown on the primary payer’s EOB.
NOTE: This amount must equal the dollar amount entered with Value Code 12 or 43.
GRP: Enter the Group Code shown on the primary payer’s EOB.
- CO - Contractual Obligation
- PI - Payer Initiated Reductions
- OA - Other Adjustment
- PR - Patient Responsibility
CARC: Enter the Claim Adjustment Reason Code (CARC) shown on the primary payer’s EOB.
AMT: Enter the dollar amount associated with the GRP and CARC code combination.
- PAID AMOUNT + AMT (adjusted charge for each GRP/CARC combination) = Total Charges
- If Value Code 44 is billed, the AMT field must = total charges - the VC 44 amount.

Line A = Primary Insured: Enter the name of the employee who receives the primary insurance, patient's relationship to the insured (see below), the primary insurance policy number, the primary insurance group name and number (as it appears on the CWF).

Line B = Medicare Beneficiary: Enter the Medicare beneficiary's name, gender, date of birth, patient's relationship to the insured (see below) and Medicare Identifier (MID).

Enter the primary insurer's address exactly as it appears on the CWF.

Copyright © 2019, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816

Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association.
To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816 or Laryssa Marshall at (312) 893-6814. You may also contact us at ub04@healthforum.com.

The American Hospital Association (the “AHA”) has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

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")

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