U6805

FISS Narrative
Requesting conditional payment on a MSP claim, however, no MSP record is available at CWF.

Please verify value code and primary payer code against CWF to ensure the correct code has been used.

If you have information indicating CWF is not correct, please contact the Benefits Coordination and Recovery Center (BCRC) (formerly known as the Coordination of Benefits Contractor (COBC)) for file correction. You may contact the BCRC for correction at:

Medicare - MSP General Correspondence
P.O. Box 138897
Oklahoma City, OK 73113-8897
Telephone: 1-855-798-2627 (8 a.m. to 8 p.m. ET)

Explanation and Suggestion
When the claim was received, the value code entered reflects that the patient has a Group Health Plan (GHP) that is the primary payer to Medicare and the amount entered with the value code was zero (0.00) dollars. When no payment is made by the primary payer, the system automatically identifies the claim as a potential 'conditional payment' request.

A valid MSP record must exist on CWF for the dates of service submitted on the claim. If a valid record exists, the value code reported on the claim must also match the specific type (Working Aged, Disability, or ESRD) of MSP record reflected on the CWF.

Medicare cannot make payment on a claim when there is more than one payer responsible for making primary payment. Ensure that there is not also a valid Liability, No-Fault or Workers’ Compensation record on the CWF record. If there is, then verify whether or not the services rendered were related to the illness or injury the patient sustained as a result of the accident. If the services are not related, then ensure that the diagnosis codes on the claim do not reflect any trauma-related conditions (800-999). If the services are related, then the claim is considered to be a Medicare Tertiary claim and will need to be submitted hard copy.

If any information on the CWF record is incorrect, please contact the BCRC as noted above.

Correcting Your Claim
Remember that claims with MSP data cannot be corrected through the DDE system. However, the information submitted on the claim can be viewed on Claim pages 1, 4, 5 and 6 can be viewed in DDE when the claim is RTPd. Detailed billing instructions can be viewed on the Interactive Medicare Secondary Payer (MSP) Process Tool on the JJ Part A or JM Part A website. In addition, the Medicare Secondary Payer (MSP) Conditional Payment Tip Sheet (use the search function to find the most up-to-date article) provides a detailed explanation of when Medicare conditional payment can be made. Listed below are the basic tips for correcting the claim, which will have to be submitted through electronic billing software as a new claim. If the claim being submitted is an adjustment (XX7) to a claim that posted to the CWF, then the adjusted claim must contain the correct cross-reference Document Control Number (DCN).

  • Verify that the following information on the claim matches the information on the CWF record:
    • The dates of service on the claim fall within the effective and termination dates of the valid MSP record on CWF
    • Value code - Working Aged = 12, Disability = 47 and ESRD = 13
  • Name and address of the primary insurer (Claim pages 5 and 6 can be viewed in the Direct Data Entry (DDE) system to verify the information that was submitted on the claim)
    • Patient Relationship
    • Policy Number
    • Remarks must be entered on the claim to why payment was not made by the primary payer (claim page 4 in the DDE system can be viewed to verify what was submitted on the claim)
  • If all of the above are correct, and no payment was made by the primary payer, ensure that the Claim Adjustment Segments (CAS) contain the correct group code(s) and Claim Adjustment Reason Code(s)

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