The claims filing requirements for claims submitted to Medicare as the secondary insurer vary slightly from the requirements of claims submitted to Medicare as the primary insurer.

• If you submit paper claims to Medicare for a secondary payment, the provider of service is required to attach a copy of the Explanation of Benefits (EOB) from the primary insurer indicating the allowed amounts, paid amounts or denial reason if the claim was denied, must be submitted with the claim
  • Palmetto GBA will not accept a recreated document from the provider/supplier. Only copies of the actual Explanation of Benefits (EOB) from the primary payer will be accepted.
  • The EOB must contain the name and address of the primary payer. If the EOB does not contain the information, it may be typed or handwritten directly on the document.
  • An explanation of the remark/denial codes must also be submitted with the EOB
• If you determine that a beneficiary has other insurance that may pay primary to Medicare, you may file a claim with the primary insurer on the beneficiary’s behalf. If you receive a determination on the claim directly from the primary payer, you are also responsible for submitting a claim to Medicare for secondary payment.
  • A beneficiary who submits a claim to the primary insurer might personally submit a secondary claim to Medicare on a CMS-1500 claim form or might forward the primary payer information to the physician/supplier to submit the MSP claim
  • If the beneficiary chooses the latter, you must submit the secondary claim to Medicare for the beneficiary in accordance with the mandatory claims filing requirements

Submitting Medicare Secondary Payer (MSP) Claims via ANSI 837 v4010A1
This document contains important information regarding the data element requirements for submitting 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 Adjustment Amounts (submitted via the CAS segment). The ‘Rules for Usage’ differ between the defined MSP amounts as you will notice in the next portion of this document. 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)

• According to the IG, the Primary Payer’s Paid amount is always required at the claim level when billing MSP claims
  • If the Primary Payer’s Allowed 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 being given at the service line, the paid amount is then also required at the service line
• 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 already given at the claim level
• When submitting more than one service line on a claim, both the claim level and line level Primary Paid and Primary Allowed MSP amounts must be used
  • See the Claim Adjustment Amounts section below for information regarding the usage of adjustment amounts
• It is advised to design the software with the flexibility to provide both claim level and service line level MSP amounts
• 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. If the 2430 Loop is being used, both the SVD and the DTP/573 segments must be included.

Rules for Usage of MSP Amounts (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, if the segments are used, there are rules that apply.

• MSP claims must balance at the Claim Level. The formula used to ensure balancing is as follows:
  • 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
• 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
• 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 used and not repeated at any of the service lines
    • Additionally, 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
• 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 which 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
  • 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

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