Medicare Secondary Payer (MSP) Electronic Claim Filing Requirements


The following tables of loops, segments and elements should assist programmers, software vendors and clearinghouses with billing Part B Medicare Secondary Payer (MSP) claims electronically. These instructions include only the segments and elements required for submitting MSP claims.

 

Subscriber Information - Secondary Payer (Medicare)
Loop, Segment, Element Description Value(s) Comments
2000B, SBR, 01 Payer Responsibility Code  
2000B, SBR, 02 Relationship Code  18   
2000B, SBR, 09  Claim Filing Indicator Code MA   
2010BA, NM1/IL, 08 Subscriber Primary Identifier Code MI  
2010BA, NM1/IL, 09 Subscriber Primary Identifier Medicare Beneficiary Identifier (MBI)  

 

Primary Payment Information - Claim Level
 Loop,  Segment, Element   Description   Value(s)  Comments
2300, HI, 01-1 Value Information BE   
2300, HI, 01-2 Value Code for MSP Type 12 = Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan

13 = Medicare Secondary End-Stage Disease Beneficiary in the 30 Month Coordination Period With an Employer's Group Health Plan

14 = Medicare Secondary, No-fault Insurance Including Auto is Primary

15= Medicare Secondary Worker's Compensation

16 = Medicare Secondary Public Health Services (PHS) or Other Federal Agency

41 = Medicare Secondary Black Lung

43 = Medicare Secondary Disabled Beneficiary Under Age 65 with Large group Health Plan (LGHP)

47 = Medicare Secondary, Other Liability Insurance is Primary
 
2300, HI, 01-5 Monetary Amount    Total Amount paid by the primary payer
2300, HI, 02-1 Value Information BE If provider is obligated to accept, or voluntarily accepts, an amount as payment in full from the primary payer, this segment is required.
2300, HI, 02-2 Value Information  44  
2300, HI, 02-5  Monetary Amount    Obligated to Accept as Full Payment (OTAF)
2320, SBR, 01 Payer Responsibility Code P  
2320, SBR, 02 Relationship Code Refer to Implementation Guide  
2320, SBR, 05 Insurance Type Code Refer to Implementation Guide  
2320, SBR, 09 Claim Filing Indicator Code Refer to Implementation Guide  
2320, CAS, 01 Claim Adjustment Group Code Refer to Implementation Guide  
2320, CAS, 02 Claim Adjustment Reason Code See listing of valid codes at https://x12.org/codes  
2320, CAS, 03 Monetary Amount Numeric   
2320, CAS, 05-17 Use as needed to show additional payer adjustments  
2320, AMT, 01 Amount Qualifier Code C4  
2320, AMT, 02 Monetary Amount   Amount paid  by the primary payer for the claim
2320, AMT, 01 Amount Qualifier Code B6  
2320, AMT, 02 Monetary Amount   Amount allowed by the primary payer for the claim
2320, AMT, 01 Amount Qualifier Code T3  
2320, AMT, 02 Total Submitted Charges    
2320, DMG, 01 Date Time Period Qualifier D8   
2320, DMG, 02 Subscriber Date of Birth    
2320, DMG, 03 Subscriber Gender    
2320, OI, 03 Assignment of Benefits Indicator Refer to Implementation Guide  
2320, OI, 06 Release of Information Code  Refer to Implementation Guide  

 

Primary Payer Information (Other than Medicare)
 Loop, Segment, Element  Description  Value(s)  Comments
2330A, NM1, 01 Identifier Code IL  
2330A, NM1, 02 Type Qualifier 1 = Person  
2330A, NM1, 03 Last Name    
2330A, NM1, 04 First Name    
2330A, NM1, 08 Identification Code Qualifier MI  
2330A, NM1, 09 Subscriber Primary Identifier    
2330B, NM1, 01 Identifier Code PR  
2330B, NM1, 02 Identifier Code 2  
2330B, NM1, 03 Primary Payer Name    
2330B, NM1, 08 Primary Payer ID Code Identifier PI  
2330B, NM1, 09 Primary Payer ID   Must match 2430, SVD, 01
2330B, DTP, 01 Date Time Qualifier 573  
2330B, DTP, 02 Date Time Format Qualifier D8  
2330B, DTP, 03 Primary Payer Adjudication Date    

The following loop is required if the service line has adjustments applied to it. If no service line exists, this loop is not required.

 

Primary Payer Payment Information - Service Line Level
 Loop, Segment, Element  Description  Value(s)   Comments
2430, SVD, 01 Primary Payer ID   Must match 2330B, NM1, 09
2430, SVD, 02 Monetary Amount   Amount paid by the primary payer for the service line
2430, CAS, 01 Claim Adjustment Group Code Refer to Implementation Guide  
2430, CAS, 02 Claim Adjustment Reason Code   See listing of valid codes at https://x12.org/codes
2430, CAS, 03 Monetary Amount    
2430, CAS, 05-17 Use as needed to show additional payer adjustments  
2430, DTP, 01 Date Time Qualifier 573 Use if service line's adjudication date is different than what is given in 2330B, DTP, 03
2430, DTP, 02 Date Format Qualifier D8  
2430, DTP, 03 Primary Payer Adjudication Date    

If you have questions regarding Part B MSP Electronic claim submission, please contact the Palmetto GBA Provider Contact Center at 855-696-0705 (JM) or 877-567-7271 (JJ).





Last Updated: 04/05/2021