Further Clarification of Instructions on Using 837 Institutional Claim Adjustment Segments (CAS) for Medicare Secondary Payer (MSP) Part A Claims
MLN Matters® Number: SE0928
Related Change Request (CR) #: 6426
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A
Provider Types Affected
Providers submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), Medicare Administrative Contractors (MACs), and/or Regional Home Health Intermediaries (RHHIs)) for services provided to Medicare beneficiaries.
Provider Action Needed
STOP – Impact to You
In change request (CR) 6426, the Centers for Medicare & Medicaid Services (CMS) instructed providers that it must utilize the CAS segment in the 837I when submitting MSP claims to their Medicare contractor. CR 6426 also informed providers that they cannot submit MSP claims using direct data entry (DDE) since the DDE process does not support the CAS segment adjustments as found in the 837. CR 6426 elicited questions from providers that CMS is addressing in this Special Edition (SE) article.
CAUTION – What You Need to Know
CMS wants providers, who normally submit claims via DDE, to know that they may use the PCAce product Pro32 free billing software which has MSP billing capabilities including the required CAS segment to identify CAS segment adjustments. However, providers may use any 837 billing software deemed warranted to submit MSP claims.
GO – What You Need to Do
In addition to submitting MSP claims with the CAS segments via the billing software, MSP adjustments should be submitted for MSP claims that were originally submitted via DDE on and prior to October 4, 2009 using the 837 transaction and billing software as noted above. DDE MSP adjustment claims will not be accepted. See the Background and Additional Information Sections of this article for further details regarding these changes.
Background
As stated in CR 6426, MSP provisions apply to situations where Medicare is not the beneficiary’s primary insurance. Medicare’s secondary payment for Part A MSP claims is based on:
- Medicare-covered charges, or the amount the physician (or other supplier) is Obligated to Accept as Payment in Full (OTAF), whichever is lower;
- What Medicare would have paid as the primary payer; and
- The primary payer(s) payment.
CR 6426 reminded you to include CAS segment related group codes, claim adjustment reason codes and associated adjustment amounts on your MSP 837 claims you send to your Medicare contractor. Medicare contractors need these adjustments to properly process your MSP claims and for Medicare to make a correct payment. This includes all adjustments made by the primary payer, which, for example, explains why the claim’s billed amount was not fully paid.
As already mentioned, you may use the PCAce product Pro32 free billing software which has MSP billing capabilities including the required CAS segment to identify CAS segment adjustments. However, providers may use any 837 billing software deemed warranted to submit MSP claims. Check the website of your Medicare contractor for more details on billing software that they have available for you at www.PalmettoGBA.com.
NOTE: This article does not alter the credit balance reporting process.
Additional Information
If you have questions, please contact the Palmetto GBA Provider Contact Center at our toll-free number, (866) 801-5301.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association.