Description
The claim is billed as Medicare primary and occurrence code 24 and date are present; however, the MSP value code is not present. This billing is incorrect based on the IOM direction for conditional payment claim requests.

Resolution
Conditional payment claim requests require several claim processing elements for 837 institutional claims format that consist of the following:

  • Appropriate OC needed for non-group health plan (NGHP) such as 01, 02, 03 or 04 (2300 HI)
  • OC 24 and date of denial (2300 HI)
  • MSP value code with the zeroed paid amount (2300 HI)
  • CAS segment which indicates the provider attempted to bill primary insurer and received a denial (2320 LOOP)
  • Must include remarks explaining why the primary insurer did not pay the claim

Resource
CMS Internet Only Manual (IOM), Publication 100-05, chapter 5 (PDF, 1.12 MB), section 40.6 and 40.6.1.

Contact Palmetto GBA JJ Part A Medicare

Provider Contact Center: 877-567-7271

Email JJ Part A

Contact a specific JJ Part A department


Click to Chat Now