Last Modified: 10/22/2022
Location: FL, PR, USVI
Business: Part B
In order to bill MSP claims electronically, there are several critical pieces of information that are necessary to ensure your claims are processed and adjudicate correctly.
MSP claims require:
• Medicare indicated as the secondary payer
• Insurance type indication (explains why Medicare is secondary)
• Coordination of benefits (COB) payer paid amount
• COB adjustment amount(s), claim adjudication date
• Service line data, line adjudication information, and any line adjustment(s)
The information below is intended to provide you and your software IT staff with a reference point to provide the necessary MSP information for electronic claim filing in the ASC X12 5010 format.
In the ASC X12 5010 format indication of payer priority is identified in the SBR segment. The format allows for primary, secondary, and tertiary payers to be reported. The payer priority is identified by the value provided in the 2000B and the 2320 SBR01. Currently, Medicare does not accept electronically filed claims when there is more than one payer primary to Medicare. Claims that involve more than one primary payer to Medicare must be submitted on the 1500 paper claim form, with all appropriate attachments.
When billing Medicare as the secondary payer, the destination payer loop, 2000B SBR01 should contain ‘S’ for secondary and the primary payer loop, 2320 SBR01 should contain a ‘P’ for primary.
The example below represents the syntax of the 2000B SBR segment when reporting information about the destination payer (Medicare).
SBR01=‘S’ indicates secondary payer
SBR02=‘18’ indicates self as the subscriber relationship code. The insurer is always the subscriber for Medicare
SBR05=‘12’ indicates Medicare secondary working aged beneficiary or spouse with employer group health plan. Select the appropriate Insurance Type code for the situation.
SBR09=‘MB’ indicating Medicare part B
The example below represents the syntax of the 2320 SBR segment when reporting information about the primary payer.
SBR01=‘P’ indicating primary payer
SBR02=Individual relationship code‘18’ indicates self
SBR03=’XR12345’, insured group/policy number
SBR09=‘CI’ indicate Commercial insurance. Claim filing indicator must not be equal to ‘MA’ or ‘MB’ in the 2320 SBR 09
When submitting an electronic claim to Medicare on which Medicare is not the primary payer, the prior payer paid amount is required to be present in the 2320 AMT segment of the primary payer. If the prior payer adjudicated the claim, but did not make payment on the claim, it is acceptable to show “0” (zero) as the amount paid.
The claim adjudication date is used to identify when the claim was adjudicated or paid by the primary payer and is required on MSP claims. Claim level information in the 2330B DTP segment should only appear if line level information is not available and could not be provided at the service line level (2430 loop).
Line adjudication information should be provided if the claim was adjudicated by the payer in 2330B NM1 and the service line has payment and/or adjustments applied to it. This information should be reported at the service level but may be reported at the claim level if line level information is unavailable. Note, if the service line adjudication segment, 2430 SVD, is used, the service line adjudication date segment, 2430 DTP, is required.
Below is an example of the 2430 SVD segment provided for syntax representation. The 2430 SVD segment contains line adjudication information.
SVD01=actual other payer identifier code
SVD02=actual service line paid amount
SVD03-1=‘HC’ indicates service line HCPCS/procedure code
SVD03-2= the procedure code
SVD05=number of paid units
Line adjustments should be provided if the primary payer made line level adjustments that caused the amount paid to differ from the amount originally charged. This information should be reported at the service level but may be reported at the claim level if line level information is unavailable.
Below is an example of the 2430 CAS segment provided for syntax representation. The 2430 CAS segment contains the service line adjustment information. This information should come from the primary payer’s remittance advice.
CAS01=‘CO’ indicates contractual obligation. The appropriate claim adjustment group code should be used.
CAS02=‘45” indicates that the charges exceed the fee schedule/maximum allowable or contracted/legislated fee arrangement. The appropriate claim adjustment reason code should be used.
CAS03=’10’ actual monetary adjustment amount. This is the difference between the billed amount (2400 SV102) and the primary insurance paid amount (2430 SVD02).
• 2000B SBR05 must be present on an MSP claim and should contain the appropriate Insurance Type Code, which defines the type of insurance plan that is primary to Medicare
• 2320 SBR03 is the insured group or policy number. The contents of this field should not be equal to the 2330A NM109, insured identification number.
• If an insured group (or policy) number is provided in 2320 SBR03, the insured group name, 2320 SBR04 cannot be present. The converse is also true; if 2320 SBR04 is present then 2320 SBR03 cannot be given.
• 2320 SBR09 (primary payer claim filing indicator) cannot contain ‘MB’, Medicare Part B.
• The equations for the balancing routines are as follows:
• Claim payer paid amount [2320 AMT02 (AMT01=D)] = line level paid amounts [(all) 2430 SVD02] – claim level adjustment [2320 CAS monetary amounts (CAS03, 06, 09, 12, 15 and 18)].
• Line charge amount [2400 SV102 ]= payer paid amount [2430 SVD02 ]+ line level adjustments [2430 CAS monetary amounts (CAS03, 06, 09, 12, 15 and 18)].
• The value in 2430 SVD01 (Other Payer Primary Identifier) should be the same value as in 2330B NM109 or else the amount in SVD02 won’t be used in the balancing equation.
• The same adjustment can’t be reported in both the claim level CAS and the service level CAS or else the claim won’t balance.
For additional information, please contact Medicare EDI at 888-670-0940.
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