Medicare Secondary Payer (MSP) Part A Electronic Claim Filing Requirements
The following tables of loops, segments, and elements should assist programmers, software vendors, and clearinghouses with billing Part A Medicare Secondary Payer (MSP) claims electronically. These instructions include only the segments and elements required for submitting MSP claims.
| Loop, Segment, Element | Description | Value(s) | Comments |
|---|---|---|---|
|
2000B, SBR, 01 |
Payer Responsibility Code |
S |
|
|
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) |
| 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 12-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 www.nex12.org | |
|
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 | |
| 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.
| 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 nex12.org. | |
|
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 A MSP Electronic claim submission, please contact the Palmetto GBA Provider Contact Center at 855–696–0705 (JM) or 877–567–7271 (JJ).