Correct or Reopen a Claim Due to an MSP-Related Issue

Table of Contents

• Correct or Reopen a Claim Due to an MSP-Related Issue
• Identify the Finalized Status of the Claim and Take the Appropriate Action Depending on the Type of Denial/Correction That Needs to be Made
  • Step 1
  • Claim Denied as Unprocessable or Returned (Message MA-130 on your provider remittance statement). You cannot reopen a claim that rejected as unprocessable or MA130.
• Claim Denied for Working Age, Disability, ESRD
  • Step 2
  • Claim Denied for Auto/No-Fault, Liability, Workers’ Compensation, Workers’ Compensation Set Aside, and Medicare Should be Primary
  • MSP Claim Paid Incorrectly
  • Received Payment from Medicare and Another Payer as Primary
• Related Content

[Return to Top]

Correct or Reopen a Claim Due to an MSP-Related Issue

Depending on the error, you can correct or reopen an MSP claim that has been submitted to Medicare for processing. If the claim is still in process, you will need to wait until it finalizes before any additional action can be taken.

[Return to Top]

Identify the Finalized Status of the Claim and Take the Appropriate Action Depending on the Type of Denial/Correction That Needs to be Made

Step 1

Review your remittance advice to determine the finalized status of the claim. If you do not understand the denial or none of the situations in Step 2 apply, please call the Provider Contact Center for assistance. Ensure that you have all the information required in order to obtain information/assistance from a representative.

[Return to Top]

Claim Denied as Unprocessable or Returned (Message MA-130 on your provider remittance statement). You cannot reopen a claim that rejected as unprocessable or MA130.

Determine what information is missing from the original claim submission and resubmit a correct claim. Refer to Prepare and Submit an MSP for additional information.

[Return to Top]

Claim Denied for Working Age, Disability, ESRD

Step 2

• If the MSP eligibility file is showing Medicare is secondary, submit the claim secondary, refer to Electronic Data Interchange Medicare Secondary Payer ANSI Specifications for 837P
• If the MSP eligibility file is showing Medicare primary, submit the claim primary.
• If the claim denied as MSP and Medicare is now primary, submit a clerical error reopening.
• If the claim denied as MSP, the CWF shows MSP, but the beneficiary states they (self/spouse) retired, submit claim with statement that beneficiary is retired and give the retirement date in loop 2300/2400 NTE segment.
• Medicare timely filing is one calendar year from the date of service.

[Return to Top]

Claim Denied for Auto/No-Fault, Liability, Workers’ Compensation, Workers’ Compensation Set Aside, and Medicare Should be Primary

• If the condition is related to auto/no-fault, liability, or workers’ compensation but the insurer is not paying the claim, you may submit a conditional claim to Medicare. Refer to CMS’ MLN® Booklet: Medicare Secondary Payer and CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 1 General MSP Overview.
  • These payments are referred to as conditional payments because the money must be repaid to Medicare when a settlement, judgement, award, or other payment is secured.
• If the claim denied auto/no-fault, liability, or workers’ compensation and is not related to auto/no-fault, liability, or workers’ compensation, submit an appeal.
  • The appeal (redetermination) must be submitted within 120 days from the claim determination. 

[Return to Top]

MSP Claim Paid Incorrectly

• Refer to MSP Post-Pay Overpayments.

[Return to Top]

Received Payment from Medicare and Another Payer as Primary

• First, determine which payer is the proper primary payer.
  • Review Model Admission Questions to Ask Medicare Beneficiaries.
• If Medicare is the proper secondary payer but paid as primary, then Medicare must be refunded.
  • You will need to refund the difference between the amount Medicare actually paid and the amount Medicare should have paid (if any).
  • The MSP regulations at 42 CFR 489.20 require that you repay Medicare within 60 days from the date you receive a payment from another payer (primary to Medicare) for the same service for which Medicare paid.
  • For proper MSP refunds, use the MSP Post-Pay Overpayments form and attach a copy of the primary explanation of benefits. We will create the full claim adjustment and let you know what the overpayment will be via the Medicare remittance advice.
• If Medicare sent you a demand letter, follow the instructions within the demand letter.

Please note: if you are on automatic recoupments for all and future, no action is necessary for repayment.

[Return to Top]

Related Content

• 42 CFR 489.20
• Resources > Claims and Appeals > Telephone Reopenings
• CMS IOM Publication 100-05, Medicare Secondary Payer Manual,
  • Chapter 2, MSP Provisions, Section 40.2
  • Chapter 3, MSP Provider, Physician, and Other Supplier Billing Requirements, Sections 10.4 and 10.5
• Correct a Beneficiary's MSP Record
• Provider Contact Center

Revised 10/26/2023