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PC-ACE Quick Reference Guide: Medicare Secondary Payer

The following are Medicare A (Institutional) instructions for entering line item and claim information into PC-ACE when Medicare is the secondary payer.

Situations where Medicare is the secondary payer must be submitted electronically in the following manner:

  1. Bill the primary insurance and receive an explanation of benefits before you can electronically bill Medicare as the secondary payer.
  2. The primary payer must be in PC-ACE in the Payer Information database.

The following patient information is sample data only which is used in the examples below:

Sample Data Used:
Field Example data
Primary Insurance Health Source (01041)
Primary Insurance Address 1234 No Road
Miami, FL 33012
Commercial Insurance, Group Name Walmart, Group Number - 55555
Relationship Self (18)
Insured ID - 654654654
Patient name Mary B Jones
Patient address 532 Riverside Ave
Floor 5
Jacksonville, FL 32202
Patient account # MSP Part A
Sex Female
Birth Date 01/01/1935
Employ Status 9 (Widowed, employment not known, and not a student)
Signature is on file Y
Release of information date 05/05/2001
Secondary Insurance Medicare FL (09101)
Medicare HIC number 654654654A

Payer Information Screen

The Payer Information Screen is located under the Reference File Maintenance menu. The Payer Information must be set up before any Patient information is entered. 

Image of Payer Information Screen

Field Description
Payer ID Payers National Identification number.
LOB Line of Business must be COM.
Receiver ID Leave blank if not already on file.
ISA08 Override Leave blank.
Full Description Name of payer
Address & Contact Information All fields are optional.
Flags:
Source Payment source code for this payer. Use "CI" (Commercial Insurance) Ensure Primary Payer is on PC-ACE Pro32 Payer file as a Commercial.
Media Specifies the payer receives claims electronically. Use "E" (Electronic)
Usage Indicates whether the payer record is restricted. Use "U" (Institutional)

Patient Information Screen

The Patient Information Screen/database is located under the Reference File Maintenance menu and must be set up with the primary payer reflected and Medicare as the secondary insurance payer. Note: Any changes to the patient insurance must be updated, here, in the Patient Information Screen (i.e.: Medicare becomes primary, change in insurance company, etc.).

Image of Patient Information Screen

General Information tab – information such as the patient's name, address, birth date, any various status flags. This example does not contain information on the patient’s legal representative; therefore no information is entered on the Extended Info tab.

Image of Patient Information screen showing highlighting the general information tab.

Primary Insured (Inst) tab – provides the primary payer ID and name, primary insured, and employer information of the primary insured.

Image of the Patient Information screen highlighting the primay insured tab.

Secondary Insured (Inst) tab – provides the secondary payer ID and name, secondary insured, and employer information of the secondary insured.

Entering an Institutional Claim 

After completing the Payer Information and Patient Information screens, now it’s time to enter the claim information.

Sample Data Used:
Line # Rev Code CPT w/Modifier Date Billed Amount
1. 420 97140 GP 8/20/08 $30.00
2. 420 97112  GP 8/21/08 $35.00
3. 420 97112 GP 8/22/08 $35.00
4. 420 97140 GP 8/22/08 $30.00
Sample Data from Primary Payer payment information:
Line # Billed Amount (what you charged) Primary Paid Amount (amount other insurance Paid) Difference between Billed amount and Primary Paid amount
1. $30.00 $20.00 $10.00
2. $35.00 $20.00 $15.00
3. $35.00 $20.00 $15.00
4. $30.00 $20.00 $10.00
TOTAL $80.00

Image of the Patient Info and Codes tab.

Patient Info and Codes tab – From the “Institutional Claim Form” screen, select the "Patient Info & Codes" tab. Enter the appropriate billing information to include the MSP value code and amount.

Note: The complete listing of value codes are found on the CMS website in the CMS Internet-Only Manual (IOM) 100-05, Medicare Secondary Payer Manual, Chapter 3 (228 KB)

Image of the Billing Line Items tab.

Billing Line Items tab – Enter the required information for line. Then select the “MSP/COB (Line xx)” tab. (Example: If you are on service line 1, it will read MSP/COB [Line 1]. Tab line number will change with each service line you enter.) 

Image of the Diagnosis / Procedure tab.

Diagnosis/Procedure tab – Enter a “Y” in the “COB?” field to activate the MSP/COB and COB Info tabs.

Claim Level MSP Reporting

  • Note: The other insurance remittance determines if MSP information is reported by the Claim Level or by the Line Level.

    When selecting “Y” on the “COB?” field, a new tab will appear under the “Extended Payer” tab. This tab is called “COB Info Primary” and “COB Info Secondary”.

    On this new tab under the “COB/MIA/MOA Amounts” column the provider must list the qualifier “D” and the amount paid by the other payer

    Under the “Claims Level Adjustment (CAS)” column the provider must:

    Account for the difference between the Total Charges (billed amount) on the “Line Items Detail” sub tab of the “Billing Line Items” tab and “D” with the appropriate codes that are provided in your remittance advice from the primary payer.

    The following is an example – Providers must use the information contained in their primary payer remit to determine the codes and amounts in the CAS column.

    This claim example was submitted to Blue Cross. The claim total was $500. Blue Cross paid $100. The patient had a deductible of $50 and $350 was sent back to the provider with as contractual adjustments listed under code CO 45 in the remit.

    • Under the “COB/MIA/MOA Amounts” enter a "D" qualifier and an amount of $100 to show what Blue Cross paid the provider for this claim.
  • This leaves $400 that the provider must account for under the “CAS” heading. This information MUST be found on the remittance advice from the other payer.
    • In this case the provider lists a contractual obligation with code 45 (CO 45) of $350 and a patient deductible (PR 1) of $50.
    • The remittance date must be listed in the bottom left hand corner in the “Claim Adjudication Date” field.

Image of the COB Info (Primary) tab.

Related Content

Electronic MSP Specifications for Inbound Claims

National Government Services electronic specification information regarding submitting MSP claims can be found on our website.

Preparing MSP claims

National Government Services instructions on how to prepare a MSP claim from a billing standpoint can be found on our website.

MSP and Conditional Billing Code Chart

National Government Services MSP and Conditional Billing Code Chart can be found on our website. 

PC-ACE Quick Reference Guide: Medicare Secondary Payer
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