U6825

FISS Narrative
Requesting conditional payment on a Medicare Secondary Payer (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 non-Group Health Plan (GHP) that is the primary payer to Medicare and the amount entered with the value code was zero (0.00) dollars. The system automatically identifies the claim as a request for conditional payment, but is not finding a valid MSP record on CWF that will allow the claim to finalize. This reason code will also be appended to the claim if the dates reported with the respective occurrence code (01, 02, or 04) do not match the CWF record or if at least one of the diagnosis codes on the claim do not match or are not related to the codes on the CWF record, or fall within the trauma diagnosis range (800-999).

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 (Liability, No-Fault, or Workers’ Compensation) of MSP record reflected on the CWF, the diagnosis codes reported must either match, be related to or contain a trauma diagnosis code. The date reported with the respective occurrence code must also be the date of the accident, which should be the same as or very close to the effective date of the MSP record.

If the services rendered are related to the accident, verify that the CWF record does not also have a valid Working Aged, Disability or ESRD MSP record on the CWF record. Medicare cannot make a conditional payment for accident-related services if there is a Group Health Plan (GHP) that is also primary to Medicare. The claim must be submitted to the GHP before submitting to Medicare. After the GHP issues a payment decision, the claim is then submitted to Medicare as Tertiary, and will need to be submitted hard copy. If the services are not related to the accident, then ensure that the diagnosis codes on the claim do not reflect any trauma-related conditions (800-999).

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 for JJ Part A, JM Part A or Home Health and Hospice. 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:
    • Date reported with Occurrence code 01 (Liability), 02 (No-Fault), or 04 (Workers’ Compensation) is the date of the accident
    • Date reported with Occurrence code 24 (120 days has passed since the claim was filed to the liability insurer or from the "Through" date on the claim)
    • The dates of service on the claim fall within the effective and termination dates of the valid MSP record on CWF
    • Value code - Liability = 47, No-Fault = 14 and Workers’ Compensation = 15
    • 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
    • At least one diagnosis code on the claim should be an exact match or be related to the diagnosis code(s) on the MSP record on CWF or be a trauma diagnosis (800-999)
    • Remarks must be entered on the claim to indicate that payment was not received within the 120-day prompt payment period (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, ensure that the Claim Adjustment Segments (CAS) contain the correct group code(s) and Claim Adjustment Reason Code(s).

***NOTE: if the services rendered are not related to the injury or illness that the patient sustained as a result of the accident, the claim is submitted to Medicare as primary. See detailed billing instructions on the Interactive Medicare Secondary Payer (MSP) Process Tool.

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