- Determine if Medicare is Primary or Secondary for a Beneficiary's Services
- What is Medicare Secondary Payer?
- Identify the Proper Order of Payers for a Beneficiary's Services
- Set Up a Beneficiary's MSP Record
- Prevent an MSP Rejection on a Medicare Primary Claim
- Correct a Beneficiary's MSP Record
- Prepare and Submit an MSP Claim
- Prevent an MSP Rejection on a Medicare Primary Claim
- Collect and Report Retirement Dates on Medicare Claims
- Prepare and Submit an MSP Claim
- Prepare and Submit a Medicare Tertiary Claim
- Prepare and Submit an MSP Conditional Claim
- Determine if Medicare Will Make Payment on an MSP Claim
- Determine Beneficiary Responsibility on an MSP Claim
- Correct or Adjust a Claim Due to an MSP-Related Issue
- Determine if Medicare will Make an MSP Payment
- Correct or Reopen a Claim Due to an MSP-Related Issue
- Populating MSP Insurance Type Code on Electronic Claims
- Determine Beneficiary Responsibility on an MSP Claim
- Medicare Overpayments Are Not Redeterminations
- Medicare Secondary Payer: Don’t Deny Services & Bill Correctly
Prepare and Submit an MSP Claim
Table of Contents
- Step 1: Determine if you Must Submit an MSP Claim
- Step 2: Prepare MSP (Partial-Payment or Full-Payment) Claim
- Step 3: Check for Matchong MSP Record for the Beneficiary on the CWF
- Step 4: If Matching MSP Record is on the CWF, Submit the MSP Claim
- Step 5: If Matching MSP Record is not on CWF, Submit the MSP Claim and Wait for Medicare to Contact the BCRC with the new MSP Information You Reported on the Claim
- Step 6: Return Your MSP Claim After the New MSP Record is on the CWF
- Related Content
Step 1: Determine if you Must Submit an MSP Claim
Before you can bill Medicare, you are first required to bill the payer you have identified as primary for the beneficiary’s services. Refer to the 'Identify the Proper Order of Payers for a Beneficiary’s Services' instructions linked on the left.
Once you bill and receive payment from the primary payer for the beneficiary’s services, use the following guidelines to determine whether or not to submit a MSP claim to Medicare:
- Primary payer partially paid - If the primary payer made payment greater than zero but less than full payment, you are required to submit an MSP claim (known as an MSP partial-payment claim). The receipt of less than full payment may be due to a variety of reasons such as the primary payer’s application of a deductible, coinsurance, or co-payment.
- Primary payer fully paid - Determine if the services were inpatient or outpatient
- If the primary payer made full payment and the claim is for inpatient services, you are required to submit an MSP claim (known as an MSP full-payment claim).
- If the primary payer made full payment and the claim is for outpatient services but the beneficiary has not met the annual Medicare Part B deductible, you are required to submit an MSP claim (known as an MSP full-payment claim).
Note: You can submit an MSP full-payment claim for the beneficiary’s outpatient services even if the beneficiary has met the annual Medicare Part B deductible. - Home health and hospice providers should submit MSP full-payment claims regardless of whether or not the beneficiary met their annual Medicare Part B deductible.
Step 2: Prepare MSP (Partial-Payment or Full-Payment) Claim
To prepare the MSP claim, use the following guidelines:
- Use a covered TOB – do not use a noncovered TOB, e.g., 110 or 130, etc.
- Complete the claim (UB-04CMS-1450 claim form, FISS DDE claim entry or 837I claim) in the usual manner.
- Report all claim coding usually required for the services including charges for all Medicare-covered services, not just the balance remaining after the primary payer’s payment.
- If submitting an inpatient MSP claim, report the covered and noncovered days/charges as usual. Do not report the days and/or charges paid for by the primary payer as noncovered.
- Follow Medicare’s technical, medical, and billing requirements since these requirements apply to MSP claims (just as they do to Medicare primary claims).
- Hospice providers: Submit the NOE showing Medicare as primary regardless of the order of payers. You will report the applicable MSP information on your claim(s).
- Home health providers: Submit the RAP showing Medicare as primary regardless of the order of payers. You will report the applicable MSP information on your final episode claim(s).
- Follow your Medicare “frequency of billing” guidelines. For example, if your provider type is required to submit claims to Medicare every 30 days or every 60 days, this remains true even though Medicare is not the primary payer.
- In addition, report the following MSP billing codes from the MSP Billing Code Table (below) on the claim, if applicable.
- Report on the claim any applicable adjustment(s) made by the primary payer by including the CAGC(s), CARC(s) and associated amount(s) from the primary payer’s RA. Refer to CRs 6426 and 8486.
CAGC(s):
- Required when primary payer adjusts billed charges
- Identifies the general category of the payment adjustment
- Options:
- CO (Contractual Obligations)
- OA (Other Adjustments)
- PI (Payer Initiated Reductions)
- PR (Patient Responsibility)
CARC(s):
- Required when the primary payer adjusts billed charges
- Explains why the primary payer paid differently than it was billed
- Options:
- Primary payer’s RA shows the CARC(s) for each CAGC. For CARC definitions, refer to X12.
If using FISS DDE to enter an MSP claim:
- Enter the information from the primary payer’s RA in the new Claim Entry page 03 (MAP1719).
- To reach MAP1719, press F11/PF11 from MAP1713 (the original Claim Entry page 03).
- You can enter information for up to two primary payers (up to 20 entries for each payer).
- Once you enter the information for primary payer #1, you can enter information for primary payer #2 on the second page of MAP1719 (press F6/PF6 from the first page of MAP1719).
- MAP1719 fields:
- Paid date: Enter paid date from primary payer’s RA
- Paid amount: Enter paid amount from primary payer’s RA. This amount must equal MSP VC amount reported on claim and must equal charges less amount(s) with the CAGC(s) and CARC(s).
- GRP: Enter CAGC(s)
- CARC: Enter CARC(s)
- AMT: Enter dollar amount associated with each CAGC and CARC pair
MSP Billing Code Table
Code | UB-04 (CMS-1450) | Associated Field on 837I Claim | Page in FISS DDE Claim Entry | Instruction |
---|---|---|---|---|
Condition Code | FL 18–28 | 2300.HI (BG) | Page 01 (MAP1711) | In addition to any other required CC, report, as applicable:
|
Occurrence Code & Date | FL 31–34 | 2300.HI (BH) | Page 01 (MAP1711) | In addition to any other required OC and date, report, as applicable:
|
Value Code & Amount | FL 39–41 | 2300.HI (BE) | Page 01 (MAP1711) | In addition to any other required VC and amount, report the MSP VC that represents MSP Provision (see options below) and the dollar amount primary payer paid toward Medicare covered charges on claim.
|
Payer code (Code ID) | N/A | N/A | Page 03 (MAP1713) | For first 3 payers (payers marked A, B and C), report payer ID for Payers A and Payer B (for MSP claims) or Payers A, B and C (for Medicare Tertiary claims). Use payer code Z for Medicare. Payer codes (Code IDs):
|
Primary Insurer name | FL 50A, B, C | 2320.SBR04 | Page 03 (MAP1713) | Report name of primary insurer(s). Report full, actual, complete names; not vague names such as “no-fault”, “GHP”, etc. Report Medicare on line 50B (Medicare secondary) or on line 50C (Medicare tertiary). Note: If using FISS DDE, “Medicare” will populate for lines on which you reported the payer code (code ID) “Z”. |
Insured’s Name | FL 58 A, B, C | 2330A.NM104 | Page 05 (MAP1715) | Report insured’s name for each payer. |
Patient’s Relationship to Insured | FL 59A, B, C | 2320.SBR02 | Page 05 (MAP1715) | Report beneficiary’s relationship to insured for each payer. Options: 01 = spouse 18 = self 19 = child 20 = employee 21 = unknown 39 = organ donor 40 = cadaver 53 = life partner G8 = other relationship |
Insured’s Unique ID | FL 60A, B, C | 2330A.NM109 | Page 05 (MAP1715) | Report insured’s ID for each payer (beneficiary’s HICN for Medicare line). |
Insurance Group Name | FL 61A, B, C | 2320.SBR04 | Page 05 (MAP1715) | Report name of primary insurance group for each primary payer. |
Insurance Group Number | FL 62A, B, C | 2320.SBR03 | Page 05 (MAP1715) | Report primary insurance group number for each primary payer. |
Employer Name | FL 65 A, B, C | N/A | N/A | For UB-04 (CMS-1450) only, report name of employer that provides health care coverage for individual. |
Primary Insurer’s Address | Use FL 80 (Remarks) | 2300.NTE | Page 06 (MAP1716) | For UB-04 (CMS-1450) and 837I claims, report primary insurer’s full address in Remarks. For FISS DDE Claim Entry, report primary insurer(s) full address in Page 06. |
Step 3: Check for a Matching MSP Record for the Beneficiary on the CWF
Before you submit a MSP claim to Medicare, check for a matching MSP record on the CWF. You can use the provider self-service tools listed under Step 2 in the Identify the Proper Order of Payers for a Beneficiary’s Services. A matching MSP record is one that has the same MSP information you are reporting on your MSP claim. If there is no such record, the submission of your claim notifies us of the new MSP information and allows us to send that information to the BCRC and request that they set one up. Refer to Set Up a Beneficiary's MSP Record.
Step 4: If a Matching MSP Record is on CWF, Submit the MSP Claim
You can submit MSP claims via:
- 837I claim
- FISS DDE
- Hardcopy format if you have an approved ASCA waiver. For hardcopy claim submissions, you must properly code the MSP claim on a hardcopy UB-04/CMS-1450 claim form, attach any supporting documentation including the primary payer’s remittance advice and EOB statement and submit it to the applicable National Government Services Medicare Claims Department. You can find the applicable address on our website under Contact Us.
If Medicare is the tertiary payer, refer to Prepare and Submit a Medicare Tertiary Claim.
As long as there was a matching MSP record on CWF prior to your claim submission, and there is no other reason not to process the claim, we will process your MSP claim.
Step 5: If a Matching MSP Record is not on CWF, Submit the MSP Claim and Wait for Medicare to Contact the BCRC with the New MSP Information You Reported on the Claim
If there is no matching MSP record in CWF, the submission of your MSP claim notifies us of the new MSP information and allows us to send that information to the BCRC and request that they set one up. Refer to Set Up a Beneficiary’s MSP Record.
You can submit MSP claims via:
- 837I claim
- FISS DDE
- Hardcopy format if you have an approved ASCA waiver. For hardcopy claim submissions, you must properly code the MSP claim on a hardcopy UB-04/CMS-1450 claim form, attach any supporting documentation including the primary payer’s remittance advice and EOB statement and submit it to the applicable National Government Services Medicare Claims Department. You can find the applicable address on our website under Contact Us.
If Medicare is the tertiary payer, refer to Prepare and Submit a Medicare Tertiary Claim.
As long as there was a matching MSP record on CWF prior to your claim submission, and there is no other reason not to process the claim, we will process your MSP claim.
Step 6: Return Your MSP Claim After the New MSP Record is on the CWF
Medicare’s Processing of MSP Claims
- Claim accepted: If MSP claims are submitted in accordance with the above instructions and do not encounter any other editing, they will proceed to the payment floor.
- Claim RTP: If MSP claims fail to meet Medicare’s usual claim submission requirements (technical, medical, and frequency of billing) and/or fail to meet the requirements for MSP billing, they will not be accepted and you must correct the claims which you may do in the FISS DDE per CMS CR 8486 effective 1/1/16.
Related Content
- ASCA Requirements for Paper Claim Submissions
- CMS Change Request 6426: Instructions on utilizing 837 Institutional CAS segments for Medicare Secondary Payer (MSP) Part A Claims
- CMS Change Request 8486: Instructions on Using the Claim Adjustment Segment (CAS) for Medicare Secondary Payer (MSP) Part A CMS-1450 Paper Claims, Direct Data Entry (DDE), and 837 Institutional Claims Transactions
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Completing and Processing the Form CMS-1450 Data Set, Section 75
- CMS IOM Publication 100-05, Medicare Secondary Payer Manual,
- Identify the Proper Order of Payers for a Beneficiary’s Services
- Prepare and Submit a Medicare Tertiary Claim
- Set Up a Beneficiary's MSP Record
- Fiscal Intermediary Standard System/Direct Data Entry Provider Online Guide
Revised 10/26/2023
Helpful Resources
Helpful Resources
Note: Providers should not call the BCRC to request they set up new or make corrections to existing MSP records. In addition to reporting such information on Medicare claims, when applicable providers may refer beneficiaries and other entities to the BCRC
BCRC Contact
1-855-798-2627
TTY/TDD: 1-855-797-2627
FAX: 405-869-3307