Medicare Secondary Payer (MSP) Rejections

A claim submitted as Medicare primary will reject if an open insurance policy is listed on the Common Working File (CWF). The rejected claims post to the CWF as if the claim was processed as paid. Providers are unable to submit new claims (Requests for Accelerated Payment (RAPs) and Finals) for these dates of service because the dates are now listed in the CWF as processed.

Providers must confirm eligibility for every patient to whom they render service, including payer information. The patient is the first point of contact, as they should have the most up-to-date information concerning their health care. Direct Data Entry (DDE) users have the capability of utilizing HIQA (Health Insurance Query A) for insurance information. If a record is erroneously being shown as effective, it is the responsibility of the beneficiary or the provider to contact the Coordination of Benefits (COB) at 1-800-999-1118 to have the record updated. Medicare is unable to process claims until the record has been updated in the CWF or the claim is submitted correctly. If the record is valid and the other insurance is primary over Medicare, the provider should submit the claim to that insurance, receive the payment decision, and then submit an adjustment to show Medicare as the secondary payer.

As previously stated, providers are unable to submit new claims for dates of service that have been rejected (RB9997) for other insurance that is primary over Medicare. These claims MUST be adjusted (XX7) whether the files have been updated or the claim is being submitted to show the correct payer. The following steps are instructions to submitting an adjustment via DDE for a claim that rejected due to other insurance being primary:

• From the DDE Main Menu, select Option 3-Corrections

• At the Submenu, select the appropriate line of business in the Adjustment section

• Key the Health Insurance Claim Number (HICN), provider number, change the P status to R, change TOB appropriately, and enter the From and Through Date of the claim

• Press Enter

• Tab to the appropriate claim that displays on the screen

• Select the claim with a U for update purposes

• Press Enter

• On page 1, enter the appropriate Condition Code:

D7-Adjust to make Medicare Secondary

D8-Adjust to make Medicare Primary

• Page Forward twice (F8) to page 3, enter an Adjustment Reason Code of OT

• Page Forward to page 4, key an explanation of why the claim is being adjusted

• Page Backward (F7) twice to page 2.

The rejected claim moved all of the charges to non-covered. All charges must be shown as covered. All lines, EXCEPT the Total Line (0001), will need to be deleted and re-entered as covered. Print DDE pages showing every line item or refer to the patient's chart to use as a reference when re-keying the deleted lines. NOTE: NEVER delete the 0001 Total Line.

To delete one or more lines on page 2 of DDE, tab to the first line that is to be deleted and key one d on the first digit (0=zero) of the Revenue Code. Multiple lines per page can be deleted at once by using d on each line. Page Up (F6) should not be used until all of the deletions necessary on each individual page have been completed.

After the lines that need to be deleted show the d in the Revenue Code, press the HOME key on the keyboard. This will take the cursor up to the page number in the upper right hand corner. To remove the lines completely, press Enter. When those lines are deleted, DDE will move the remaining lines up in place of the deleted lines. If these lines also need to be deleted, repeat the same process.

NOTE: NEVER delete the 0001 Total Line. The Total Line will allow the units and charges on the actual line to be corrected.

Once all of the appropriate lines are deleted, tab to the Total Line. If units are listed on the Total Line, the units showing in the Total Units field will need to be added to the Covered Units field. Tab to the Non-covered Charges field and space out these charges. Press Enter and ensure DDE kept the changes made to the 0001 Line. The 0001 Line could possibly be the only line showing on the screen.

At this time, the lines previously deleted can be re-entered. Tab to the first BLANK line underneath the 0001 Line. The cursor should be in the first space for the Revenue Code. Re-key each line that was deleted. Remember to add the Covered Units but do not list any charges in the Non-covered field unless they were submitted as non-covered on the original claim.

When one whole page is keyed, always press enter and double-check keying before moving, Page Up (F6), to the next page. Continue to key the lines until the process is complete.

Once the keying has been verified and all of the information is correct, press F9 to submit the adjustment for processing. The DDE system will then move the lines into the appropriate order by Revenue Code and begin processing the adjustment. The claim can be viewed immediately in Inquiries. It should be in an S status. This completes the process of adjusting an MSP rejected claim.

Reminder: Effective July 27, 2007, faxing MSP information to Palmetto GBA is no longer acceptable. Requested information must be mailed to the following address: Palmetto GBA Attn: AG-600 2300 Springdale Drive, Bldg. 1 PO Box 7004 Camden, SC 29201

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