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Submitting MSP Claims Electronically

Electronic Claims Submission - Submitting Medicare Secondary Payer (MSP) Claims via ANSI 837 v4010A1
 This posting contains important information regarding the data element requirements for billing a Medicare Secondary Payer (MSP) claim electronically.
  • The data format referenced is the HIPAA ANSI, version 4010A1
  • The loops, segments and elements identified in this document are not all inclusive data element requirements, rather the data elements necessary to provide information for an MSP claim
  • The ANSI 837 v4010A1 Professional Implementation Guide (IG) must be referenced for all required data elements
For purposes of this instructional document, MSP amounts are defined as the Primary Payer’s Paid Amount, Primary Payer’s Allowed Amount and Claim Reason Adjustment amounts (submitted via the CAS segment). The Rules for Usage differ between the defined MSP Amounts as you will notice. Following are some rules that apply to the usage of MSP amounts based on notes in the IG and Medicare MSP Processing Guidelines.
 
Rules for Usage of MSP Amounts
 Primary Paid and Primary Allowed:
  1. According to the IG, the Primary Payer’s Paid amount is always required at the claim level when billing MSP claims
    • If other Primary Payer’s Paid amount is given only at the claim level and there is only one service line on the claim, then you do not have to repeat any of these amounts at the service line level
    • If the allowed amount is given at the service line, the Paid amount is then also required at the service line
  2. The only time service line level MSP amounts (paid, allowed, applicable adjustments) do not have to be given is when the claim has only one service line and all MSP amounts (paid, allowed, applicable adjustments) are given at the claim level
  3. When billing more than one service line on a claim, both the claim level and line level MSP amounts must be utilized. See the Claim Adjustment Amounts section below for information regarding the usage of adjustment amounts.
  4. It is advised to design the software with the flexibility to provide both claim level and service line level amounts
  5. According to the IG, if the service line level Primary Payer’s Paid amount (2430/SVD/02) is given, then the Payment Date (DTP/573/02) of the same 2430 Loop is also a required segment. Therefore, if the 2430 Loop is being used, both the SVD and the DTP/573 segments must be included.
Claim Adjustment Amounts:
 The CAS segments are used to convey payment/adjustment information for the claim by the primary payer. While these segments are not required, there are rules that apply.
  1. MSP claims must balance at the Claim Level. The formula used to ensure balancing is: The amount paid by the Primary Payer (Loop 2320/AMT/D02) plus any submitted claim level and line level adjustment amounts (Loop 2320 and/or Loop 2430 CAS03, 06,09, 12, 15 or 18) must be equal to the submitted charges (loop 2300/CLM02). Out-of-balance MSP claims will be rejected at our front-end prepass editing level. To summarize, the balancing formula is: Primary Paid amount at the claim level plus any adjustments must equal the billed amount.
  2. The Claim Adjustment Reason Codes submitted in 2320 or 2430 CAS/02, 05, 08, 11, 14 and/or 17 must be valid reason codes based on the current listing of Claim Adjustment Reason Codes found on Washington Publishing’s Web site at: www.wpc-edi.com. MSP claims containing invalid Claim Adjustment Reason Codes will be rejected at our front-end prepass editing level.
  3. Unlike other MSP amounts (Primary Paid and Primary Allowed), the adjustment amounts provided in the CAS segments do not necessarily apply to both the claim level and the service line level. If an adjustment (i.e., co-insurance) applies to the entire claim, the claim level CAS segment (Loop 2320) should be utilized and not repeated at any of the service lines. The service line level CAS segment should only be used in addition to the claim level CAS segment if there was an adjustment made to that specific service only and that adjustment amount is not included in any adjustments identified in the claim level CAS segment.
  4. If both the claim level CAS segment (Loop 2320) and the service line level CAS segment (Loop 2430) are being given, there is a requirement noted in the IG concerning this scenario that must be met in order to be in compliance with the IG.
    • On page 361 of the IG, it is noted under data element 2330B/NM1/PR/09 that the Other Primary Payer Identification Code must be identical to the Other Primary Payer Identification Code given in 2430/SVD/01. Additionally, on page 555 of the IG, it is noted under data element 2430/SVD/01 that the Other Primary Payer Identification Code should match the Other Primary Payer Identification Code given in 2330B/NM1/PR/09.

ANSI 837 v4010A1 Field Values
Loop, Segment, Element
Description
Value(s)
2000B, SBR, 01
Payer Responsibility Code
S
2000B, SBR, 02
Relationship Code
18
2000B, SBR, 05
Insurance Type Code
12, 13, 14, 15, 16, 41, 42, 43, 47
2000B, SBR, 09
Claim Filing Indicator Code
MB
2010BA, NM1/IL, 09
(08 = MI)
Subscriber Primary Identifier
Medicare Health Insurance Claim Number (HIC)
2320, SBR, 01 (claim level)
Payer Responsibility Code
P
2320, SBR, 02
Relationship Code
Refer to IG for values.
2320, SBR, 03
Group or Policy Number
Free Format
2320, SBR, 05
Insurance Type Code
Refer to IG for values
2320, SBR, 09
Claim Filing Indicator Code
Refer to IG for values.
2320, CAS, 01 (claim level)
Claim Adjustment Group Code
*The CAS segment is Optional and is used to provide adjustments made to the claim by the Primary Payer. See "Rules for Usage of MSP Amount" for additional information.
CO, CR, OA, PI, PR
2320, CAS, 02
Claim Adjustment Reason Code
*The CAS segment is Optional and is used to provide adjustments made to the claim by the Primary Payer. See "Rules for Usage of MSP Amount" for additional information.
See listing of value codes at www.wpc-edi.com
2320, CAS, 03
Monetary Amount
*The CAS segment is Optional and is used to provide adjustments made to the claim by the Primary Payer. See "Rules for Usage of MSP Amount" for additional information.
Numeric
2320, AMT/D, 02
(claim level)
Payer Paid Amount
*This is the claim level paid amount. This element is always required at the claim level when billing MSP. It may be additionally provided at each service line.
Numeric
2320, AMT/B6, 02
(claim level)
Allowed Amount
*This is the claim level allowed amount. The allowed amount may be given at the claim level or service line level or both. See ‘Rules for usage of MSP amounts’ for additional information.
Numeric
2320, DMG, 01
Date Time Period Format Qualifier
D8
2320, DMG, 02
Date of Birth – Subscriber
Numeric
2320, DMG, 03
Gender – Subscriber
F, M, U
2320, OI, 03
Assignment of Benefits Indicator
Y
2320, OI, 04
Patient Signature Source Code
B, C, M, P, S
2320, OI, 06
Release of Information Code
A, I, M, O, Y
2330A, NM1/IL, 01
Entity Identifier Code
IL
2330A, NM1/IL, 02
Entity Type Qualifier
1
2330A, NM1/IL, 03
Subscriber Last Name
Free Format
2330A, NM1/IL, 04
Subscriber First Name
Free Format
2330A, NM1/IL, 08
Identification Code Qualifier
MI
2330A, NM1/IL, 09
Other Subscriber Primary Identifier
Free Format
2330B, NM1/PR, 01
Entity Identifier Code
PR
2330B, NM1/PR, 02
Entity Type Qualifier
2
2330B, NM1/PR, 03
Other Payer Name
Free Format
2330B, NM1/PR, 08
Identification Code Qualifier
PI
2330B, NM1/PR, 09
Other Payer Primary Identifier
Free Format
2400, AMT/AAE, 02
(service line)
Approved Amount (Primary Payer allowed amount)
*This is the service line level allowed amount. The allowed amount may be given at the claim level or service line level or both. See ‘Rules for usage of MSP amounts’ for additional information.
Numeric
2430, SVD, 02
(service line)
Paid Amount (Primary Payer paid amount)
*This is the service line level paid amount. The paid amount must be given at the claim level, but may additionally be given at the service line level. See ‘Rules for usage of MSP amounts’ for additional information.
Numeric
2430, CAS, 01 (service level)
Claim Adjustment Group Code
*The CAS segment is Optional and is used to provide adjustments made to the claim by the Primary Payer. See "Rules for Usage of MSP Amount" for additional information.
CO, CR, OA, PI, PR
2430, CAS, 02
Claim Adjustment Reason Code
*The CAS segment is Optional and is used to provide adjustments made to the claim by the Primary Payer. See "Rules for Usage of MSP Amount" for additional information.
See listing of value codes at www.wpc-edi.com
2430, CAS, 03
Monetary Amount
*The CAS segment is Optional and is used to provide adjustments made to the claim by the Primary Payer. See "Rules for Usage of MSP Amount" for additional information.
Numeric

 

last updated on 09/23/2009
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