Medicare Secondary Payer (MSP) Part A Electronic Claim Filing Requirements

Published 04/02/2021

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.

 

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 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  

 

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 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).