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Jurisdiction 11 Home Health and Hospice
Medicare Secondary Payer (MSP) UB04 Billing Fields

Providers should understand that when a beneficiary has insurance that pays before Medicare, claims must be filed to that insurance before filing a claim to Medicare. In addition, regardless of whether or not the provider expects payment from Medicare, the provider is required to submit the claim to Medicare. The following are some guidelines for providers to follow when submitting claims to Medicare for secondary payment consideration.

When submitting claims involving a Medicare Secondary Payer (MSP) situation, certain data are required to be reported on the claim. Instructions for completing the appropriate billing fields of the UB04 claim form begin on Page 3 of this job aid. Providers should also be familiar with the most commonly used terminology under the MSP program, which are as follows:
  • Charge Amount – the amount the provider billed for services rendered. This amount should match the amount billed to both the primary insurer and Medicare.
  • Medicare Allowable – the amount Medicare approved for reimbursement. The total amount of Medicare reimbursement varies among different types of bills.
  • Primary Insurance Allowable/Primary Allowed – the amount the primary insurer approved for services
  • Primary Obligated to Accept Payment in Full (OTAF) – this is the discount payment amount as a network member or the contract amount received through an agreement with primary insurer
  • Primary Paid – the amount the primary insurer agreed to pay the provider for services rendered
In addition to completing the appropriate fields on the claim form, Change Request (CR) 6426, which was issued on June 26, 2009, and effective October 1, 2009, mandates that providers also enter the Claim Adjustment Segments (CAS) either at the line-level or claim-level. The CAS information includes codes which delineate what was paid by the primary insurer as well as any amounts not paid by the primary insurer. Amounts not paid by the primary insurer are identified by Group Codes and Claim Adjustment Reason Codes (CARCs). A list of CARCs can be accessed at www.wpc-edi.com. Group codes are defined as follows:
  • CO = Contractual Obligation
  • CR = Correction and Reversals
  • OA = Other Adjustments
  • PI = Payer Initiated Reductions
  • PR = Patient Responsibility
It is the provider’s responsibility to understand the information provided on the primary insurer’s Remittance Advice (RA); Explanation of Benefits (EOB) and the various codes; or messages printed on the RA/EOB. In accordance with the business requirements provided in CR 6426, the Medicare claims processing system (Fiscal Intermediary Shared System) is set to automatically calculate the amount due (if any) as secondary payment based on the information entered on the claim and in the CAS. Therefore, providers should ensure that the information reported on the claim and the CAS is accurate and correct.

Other factors used to evaluate MSP payments include:
  • Primary allowed amount
  • Medicare's allowable
  • Contractual agreements or network limits (OTAF)
  • Primary insurer’s payment 
  • Date of claim submission 
  • Medicare deductibles
  • Reasons for primary payment denials
    • Identified by CARCs
    • Entered as part of the CAS
There are two distinct levels of reporting the CAS information, which is also known as the MSP Coordination of Benefits (COB):
  • Claim-level COB reporting
  • Line-level COB reporting
The decision to report the CAS information at the claim-level versus the line-level is made based upon the information communicated to the provider via the primary insurer’s RA or EOB. The primary insurer’s RA/EOB may be in electronic (ANSI-835) or paper format. The primary payer’s RA/EOB serves as the source for CAS data to be entered into the claim form's appropriate fields.
  • Claim-level COB reporting is done when the primary insurer’s RA/EOB contains data that is not specific to a particular service line. The location of the screens in which the reporting of the CAS information takes place will vary between electronic billing software programs.
  • Line-level COB reporting is done when the primary insurer’s RA/EOB contains data that is specific to a particular service line(s). The location of the screens in which the line-level reporting of the CAS information takes place will vary with each type of electronic billing software. However, the line-level COB reporting information will include the following:
    • Service line adjudication (SVD) information
    • Line-level adjustment (CAS) and miscellaneous adjudication information
    • Procedure code description
    • Adjusted payment date
    • Remaining amount owed

Entering of the CAS information, regardless of whether or not it is reported at the claim or line level, is vital to the calculation of payment (if any) to be made on a secondary basis. Therefore, providers are encouraged to ensure that they know and understand the primary insurer’s RA/EOB and how to enter the information in their Medicare billing software.

Please select one of the following MSP types for instructions on how to submit a claim:

Working Aged/Disability/ESRD (Billing Medicare as secondary when the primary insurer makes payment)

Step 1: Submit your claim to the primary insurance. For home health providers, this includes only the final (end of episode) claim. Do not submit MSP information on the Request for Anticipated Payment (RAP).

Step 2: Once payment is received, submit the secondary claim to Medicare. Note that the payment amount for claims submitted for secondary payment must be greater than zero (0.00) dollars. For claims on which no payment was made (i.e., 0.00 dollars paid by the primary insurer) see Page 5 of this job aid.

Step 3: Fill in all fields of the claim as usual with the exception of the information presented in the table below. The table depicts the appropriate fields which correspond to the UB04 Claim form. MSP claims cannot be submitted through the Direct Data Entry (DDE) System effective October 1, 2009.

Field DescriptionUB-04 FLMSP Billing Instructions
Condition Codes 18-28 

Enter appropriate condition code if applicable

Occurrence Code & Date 31-34

Enter appropriate condition occurrence code and date when applicable

Value Codes & Amounts 39-41  Enter appropriate value code which correlates to the specific type of MSP record on CWF and amount paid by the primary.

When applicable, enter the appropriate value code and the amount you were obligated to accept as payment in full (OTAF), if more than the actual payment amount from the primary.
Payer Code 50 Enter the appropriate primary payer code in line A
Payer Name 50 Enter primary payer’s name on line A. Enter 'Medicare' on line B when Medicare is secondary or line C when Medicare is tertiary.
Health Plan ID 51 Enter the Health Plan Identification Number for the payer on line A
Insured Name  58 Enter the insured’s name on line A. Enter the beneficiary’s name on line B when Medicare is secondary or line C when Medicare is tertiary.
Rel Info 59 Enter appropriate patient relationship code to primary insured on line A and Medicare on line B when Medicare is secondary or line C when Medicare is tertiary
Insured's Unique ID   Enter insured's primary payer number on line a. Enter beneficiary's HIC number on line B when Medicare is secondary or line C when Medicare is tertiary.
Group Name  61 Enter Insurance Group Name
Insurance Group No.  62 Enter Insurance Group number on line A
Employer Name 65 Enter employer’s name providing the primary insurance
Remarks 80 Enter remarks, if applicable

Notes:

  1. A listing of all condition occurrence, value, payer ID and patient relationship codes is available on the National Uniform Billing Code (NUBC) website at www.nubc.org.
  2. Never enter the 77 condition code and value code 44 on the claim at the same time
  3. Check the CWF to ensure that the appropriate value code and Payer ID codes are entered. A valid MSP segment must exist on the CWF for the claim to process for secondary payment.
  4. Check the CWF for beneficiary dual entitlement. If beneficiary is dually entitled to Medicare based on ESRD and working aged or disability, follow the billing guidelines for ESRD.

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Working Aged/Disability/ESRD
(Billing Medicare when the primary insurer does not make payment)

Step 1: Submit claim to primary insurer. For home health providers, this includes only the final claim. Do not submit MSP information on the RAP.

Step 2: Once the denial is received, submit claim to Medicare for conditional payment if appropriate.

Step 3: Fill in all fields of the claim as usual with the exception of table below. (The table depicts the appropriate fields which correspond to the UB-04 Claim form. MSP claims cannot be submitted through the DDE System effective October 1, 2009.)

Field DescriptionUB-O4 FLMSP Billing Instructions
Condition Codes 18-28 Enter appropriate condition code if applicable
Occurrence Code & Date 31-34

Enter appropriate occurrence code and date when applicable

Value Codes & Amounts 39-41 Enter appropriate value code which correlates with the type of MSP record on CWF and zero (0.00) dollars in the amount field
Payer Code 50 Enter appropriate primary payer code on line A. Enter appropriate payer code for Medicare on line B when Medicare is secondary or line C when Medicare is tertiary.
Payer Name 50 Enter payer’s name on line A.
Enter 'Medicare' on line B when Medicare is secondary or line C when Medicare is tertiary.
Health Plan ID 51 Enter plan identification number for each respective payer on line A and B when Medicare is secondary or line C when Medicare is tertiary
Insured Name 58 Enter the insured’s name on line A.
Enter the beneficiary’s name on line B when Medicare is secondary or line C when Medicare is tertiary.
Rel Info 59 Enter appropriate patient relationship code to primary insured on line A, on line B when Medicare is secondary or line C when Medicare is tertiary
Insured's Unique ID 60 Enter the insured’s ID on line A. Enter beneficiary’s HIC number on line B when Medicare is secondary or line C when Medicare is tertiary
Group Name 61 Enter the group name on line A
Insurance Group No 62 Enter insurance group number on line A
Employer Name 65 Enter employer’s name providing the primary insurance
Remarks 80 Enter remarks to explain why primary insurer did not make payment (e.g., benefits exhausted) as stated on the primary insurer’s RA/EOB

Notes:

  1. A listing of all condition, occurrence, value, payer ID and patient relationship codes can be found on the National Uniform Billing Committee (NUBC) website at www.nubc.org.
  2. Providers may refer to the Filing for Conditional Payment job aid for more details regarding the conditions under which a conditional payment may be requested. The job aid can be accessed at www.PalmettoGBA.com/j11a or www.PalmettoGBA.com/hhh.
  3. Check CWF to ensure that the appropriate Value Code and Payer ID Code are entered.  A valid MSP segment must exist on the CWF for the claim to process for secondary payment.
  4. Check the CWF for beneficiary dual entitlement. If beneficiary is dually entitled to Medicare based on ESRD and working aged or disability, follow the billing guidelines for ESRD.
  5. If the policy was either terminated or the beneficiary/spouse retired, the COBC must be contacted to have the records updated. Once the CWF records have been updated and reflect Medicare as the primary payer, submit the claim to Medicare for primary payment. This means that all MSP data will be omitted from the claim.

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No-Fault, Liability or Workers’ Compensation (Payment made by the No-Fault, Liability or Workers’ Compensation)

Step 1: Submit your claim to the primary insurance. For home health providers, this includes only the final claim. Do not submit MSP information on the RAP.

Step 2: Once payment is received, submit secondary claim to Medicare.

Step 3: Fill in all fields of the claim as usual with the exception of table below. The table depicts the appropriate fields which correspond to the UB-04 Claim form. MSP claims cannot be submitted through the DDE System effective October 1, 2009.

Field DescriptionUB-04 FLMSP Billing Instructions
Occurrence Codes & Dates 31-34 Enter appropriate occurrence code and date when applicable
Value Codes & Amounts 39-41 Enter appropriate value code which correlates to the MSP record on CWF and the amount paid by the primary
Payer Code 50 Enter appropriate primary payer code on line A and for Medicare on line B when Medicare is secondary or line C when Medicare is tertiary.
Payer Name 50 Enter primary payer’s name on line A.
Enter 'Medicare' on line B when Medicare is secondary or line C when Medicare is tertiary.
Health Plan ID 51 Enter the Health Plan Identification Number for the payer on line A.
Insured's Name 58 Enter primary insured’s name on line A and enter Beneficiary’s name on line B when Medicare is secondary or line C when Medicare is tertiary.
Rel Info 59 Enter appropriate code for patient’s relationship to insured on line A. Enter '18' on line B when Medicare is secondary or line C when Medicare is tertiary.
Insured's Unique ID 60 Enter primary payer number on line A.
Enter beneficiary’s HIC number on line B when Medicare is secondary or line C when Medicare is tertiary.
Group Name 61 Enter group name on line A.
Enter 'Medicare' on line B when Medicare is secondary or line C when Medicare is tertiary.
Insurance Group No. 62 Enter primary insurance group number on line A (if applicable)
Employer Name 65 Enter employer’s name if available for Workers’ Compensation
Remarks 80 Enter remarks if applicable

Note: A listing of all condition, occurrence, value, payer ID and patient relationship codes can be found on the NUBC website at www.nubc.org.

In addition, please refer to the CMS Internet-Only Manual (IOM), Publication 100-05, Medicare Secondary Payer Manual, Chapter 2, Section 50.B (PDF, 190 KB) for additional information on situations which involve the Workers' Compensation Medicare Set-Aside Arrangements (WCMSAs).

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No-Fault, Liability or Workers’ Compensation (Prompt payment (over 120 days) not received by the No-Fault, Liability or Workers’ Compensation plan)

Step 1: Fill in all fields of the claim as usual with the exception of table below. (The table depicts the appropriate fields which correspond to the UB04 Claim form. MSP claims cannot be submitted through the DDE System effective October 1, 2009.)

Field DescriptionUB-04 FLMSP Billing Instructions
Occurrence Code & Date 31-34 Enter appropriate occurrence code and date when applicable
Value Codes & Amounts 39-41 Enter appropriate value code which correlates to the specific MSP record on CWF and zero (0.00) dollars in the amount field
Payer Code 50 Enter appropriate primary payer code on line A and Medicare code on line B when Medicare is secondary and line C when Medicare is tertiary
Payer Name 50 Enter primary payer’s name on line A.
Enter 'Medicare' on line B when Medicare is secondary or line C when Medicare is tertiary.
Health Plan ID 51 Enter the appropriate health plan ID for each respective payer on line A.
Enter the beneficiary’s information on line B when Medicare is secondary or line C when Medicare is tertiary.
Insured's Name 58 Enter primary insured’s name on line A.
Enter beneficiary’s name on line B when Medicare is secondary or line C when Medicare is tertiary.
Rel Info 59 Enter appropriate patient’s relationship code to the primary insured on line A and on line B when Medicare is secondary or line C when Medicare is tertiary
Insured's Unique ID 60 Enter primary insured’s ID number on line A.
Enter beneficiary’s HIC number on line B when Medicare is secondary or line C when Medicare is tertiary.
Group Name 61 Enter primary group name or plan on line A (if applicable).
Enter 'Medicare' on line B when Medicare is secondary or line C when Medicare is tertiary.
Insurance Group No. 62 Enter primary insurance group number on line A (if applicable)
Employer Name 65 Enter employer’s name if available for Workers’ Compensation
Remarks 80 Enter remarks to indicate reason for requesting conditional payment (e.g., prompt payment not received or payment not received within 120 days of the date of service). Identify whether or not the case was settled or if the case is still in litigation.

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No-Fault, Liability or Workers’ Compensation (Received Denial - Benefits Exhausted)

Step 1: Upon receipt of the denial from the No-Fault, Liability or Workers’ Compensation plan, contact the COBC to have the record updated on CWF.

Step 2: Once the record has been updated on CWF, submit the claim to Medicare as primary and enter remarks (Field Locator 80) to explain that benefits are exhausted.

Services Unrelated to No-Fault, Liability or Workers’ Compensation

Step 1: Bill Medicare as primary indicating that the services are unrelated to the open MSP record and ensure that the diagnosis codes on the claim do not match the diagnosis codes on the CWF record.

Step 2: Fill in all fields on the claim as usual and submit claim to Medicare.

Step 3:  Enter remarks stating that services are not related to the open MSP segment. Check the CWF to ensure that your remarks relate to the open MSP segment.

Step 4: When services rendered were related to an accident but not related to the accident reported on the open MSP segment on the CWF, enter occurrence code 05 (Field Locator 31 through 34) and the date of the accident. Enter remarks to explain the accident. If there is a potential that a No-fault, liability, or Workers’ Compensation plan other than the one listed in the open segment on CWF may make primary payment, ensure that the COBC is notified of the accident.

Note: A listing of all condition, occurrence, value, payer ID, and patient relationship codes can be found on the NUBC Web site at www.nubc.org. Providers may refer to the Filing for Conditional Payment job aid for more details regarding the conditions under which a conditional payment may be requested. The job aid is available at www.PalmettoGBA.com/j11a or www.PalmettoGBA.com/hhh. Select Learning and Education and then select Job Aids.

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Black Lung

Step 1: Bill to Department of Labor (DOL)

Step 2: Fill in all fields of the claim as usual with the exception of table below. The table depicts the appropriate fields which correspond to the UB04 Claim form. MSP claims cannot be submitted through the DDE System effective October 1, 2009.

Field DescriptionUB-04 FLMSP Billing Instructions
Value Codes & Amounts 39-41 Enter appropriate value code and the amount paid other than zero (0.00) dollars, by the DOL
Payer Code 50 Enter appropriate on line A which correlates to the DOL and the Medicare code on line B
Payer Name 50 Enter primary payer name on line A.
Enter 'Medicare' on line B.
Health Plan ID 51 Enter provider number for each respective payer on line A and B
Insured's Name 58 Enter beneficiary’s name on line A and B
Rel Info 59 Enter appropriate patient relationship codes on lines A and B
Insured's Unique ID 60 Enter Black Lung Identification Number on line A.
Enter beneficiary’s HIC number on line B.
Group Name  61 Enter 'Black Lung' on line A
Remarks 80 Enter remarks, as applicable

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When the Department of Labor Denies Payment on the Claim

Step 1: Bill to DOL.

Step 2: When the denial notification is received, submit the claim to Medicare as primary.

Step 3: Fill in all fields of the claim as usual.

Step 4: Enter in Remarks (Field Locator 80) the reason the Black Lung/DOL denied payment.

Notes:

  1. A listing of all condition occurrence, value, payer ID and patient relationship code can be found on the NUBC website at www.nubc.org.
  2. Black Lung claims are not paid conditionally. Therefore, if no payment is made by the DOL, the provider must follow the above steps when submitting the claim to Medicare.
  3. The Medicare payment determination will be made based on the reason the DOL did not make payment.

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Veterans Administration (VA)

Step 1: Bill to VA

Step 2: Fill in all fields of the claim as usual with the exception of table below and submit the claim to Medicare for services not covered by VA or for sequential billing (Hospice only). The table depicts the appropriate fields which correspond to the UB04 Claim form. MSP claims cannot be submitted through the DDE System effective October 1, 2009.

Field DescriptionUB-04 FLMSP Billing Instructions
Value Codes & Amounts 39-41 Enter appropriate value code and the amount authorized by the VA when applicable. Enter the appropriate value code and the amount you were OTAF, if more than the actual payment amount from the VA if applicable
Code 50 Enter the appropriate VA payer code on line A and Medicare code on line B
Payer 50 Veterans Administration on line A.
Enter 'Medicare' on line B.
Health Plan ID 51 Enter the appropriate health plan ID for each respective payer on line A and B
Insured's Name 58 Enter beneficiary's name on line A and B
Rel Info 59 Enter appropriate patient relationship codes on lines A and B
Insured's Unique ID 60 Enter Veterans Administration Identification # on line A.
Enter beneficiaries HIC # on line B.
Group Name 61 Enter 'Veterans Administration' on line A.
Enter 'Medicare' on line B.
Remarks 80 Enter remarks if applicable

Note: A listing of all condition, occurrence, value, payer ID and patient relationship codes can be found on the NUBC Web site at www.nubc.org.

In addition, beneficiaries who receive VA benefits have a choice as to who will be billed as the primary payer. The provider may not bill both the VA and Medicare as primary. If the beneficiary chooses to have the VA billed as primary, a claim may be submitted to Medicare for secondary payment consideration if the VA did not make full payment. If Medicare is billed as the primary payer, the provider may not bill the VA for secondary payment. Medicare does not make conditional payment when the VA does not make payment.

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Public Health Services (PHS) or Federal Agency

Step 1: Bill to the appropriate Public Health Services (PHS) or other federal agency.

Step 2: Fill in all fields of the claim as usual with the exception of table below. The table depicts the appropriate fields which correspond to the UB04 Claim form. MSP claims cannot be submitted through the DDE System effective October 1Step 2: When the denial notification is received, 2009.

Field DescriptionUB-04 FLMSP Billing Instructions
Value Codes & Amounts 39-41 Enter value code '16' for PHS and the amount paid by the health plan
Code 50 Enter payer code 'F' on line A. Enter payer code 'Z' on line B.
Payer 50 Enter payers name on line A. Enter 'Medicare' on line B.
Health Plan ID 51 Enter the Health Plan ID for each respective payer on line A and B
Remarks 80 Enter remarks
Rel Info 59 Enter relationship code '18' on lines A and B
Insured's Unique ID 60 Enter the PHS identification # on line A. Enter beneficiaries HIC # on line B.

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Note: Medicare does not make conditional payment if the PHS or other federal agency does not make payment. If the PHS or federal agency does not make payment, submit the claim to Medicare for primary payment, and enter in remarks why the PHS or federal agency denied payment.

Resources:

The information provided in this job aid was current as of August 18, 2011. Any changes or new information superseding the information in this handout will be provided in articles and publications with publication dates after August 18, 2011, posted at www.PalmettoGBA.com/hhh or www.PalmettoGBA.com/j11a.

 

last updated on 12/01/2011
ver 1.0.43