Last Modified: 11/3/2017 Location: FL, PR, USVI Business: Part A
Electronic filing of Medicare Part A secondary payer claims (MSP) in the 5010 format
Note: These instructions are not for conditional payments. If you are billing a conditional payment claim, with a 24 occurrence code, please review “Conditional payment requests for MSP claims”.
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
• Coordination of benefits (COB) payer paid amount
• COB adjustment amount(s), claim adjudication date (check 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.
Identifying Medicare as the secondary payer 2000B SBR / 2320 SBR
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 based on 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 UB04 paper claim form, will 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). This loop must always contain Medicare as the payer.
Loop 2000B SBR*S*18********MA
SBR01=‘S’ indicates Medicare as secondary payer
SBR02=‘18’ indicates self as the subscriber relationship code. The insurer is always the subscriber for Medicare.
SBR09=‘MA’ indicating Medicare part A
The example below represents the syntax of the 2320 SBR segment when reporting information about the primary payer.
Loop 2320 SBR*P*18*XR12345*******CI
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.
Claim level reporting for COB
When billing Medicare secondary payer (MSP) claims, it is important to use the correct value codes (VC) based on the type of MSP claim. https://medicare.fcso.com/MSP/210298.asp
Loop 2300 HI*BE*12**0
HI01-1=BE indicates code list qualifier code
HI01-2=12 indicate value code (12 is working aged)
HI01-5=0 indicates value code amount
The 2320 AMT segment is required if the claim has been adjudicated by the primary payer in this loop. It is acceptable to show “0” (zero) as an amount paid.
Loop 2320* AMT*D*XX = payer paid amount
When billing MSP the other payer information should be identified in Loop 2330B.
Loop 2330B NM1* other payer name, payer identification (PI), and other payer identifier
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 2330 DTP should only appear if line level information is not available and could not be provided at the service line level (2430 loop).
Loop 2330B DTP*XXXXXXXX = claim adjudication/EOB date
Service line level reporting for COB
Line adjudication information
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. 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.
Loop 2430 SVD*00813*65*HC> 90805**1~
SVD01=actual other payer identifier code
SVD02=actual service line paid amount
SVD03-1=‘HC’ is the product service qualifier
SVD03-2= indicates service line HCPCS/procedure code
SVD03-3 thru SVD03-6= indicates service line modifiers
SVD04= indicates service line revenue code
SVD05=number of paid units
Line adjustment information
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/EOB.
Loop 2430 CAS*CO*45*10~
CAS01=‘CO’ Indicates contractual obligation. This is the general category of payment adjustment.
CAS02=‘45” Claim adjustment reason code (CARC)
CAS03=’10’ actual adjustment amount. This is the difference between the billed amount (Loop 2400 SV203) and the primary insurance paid amount (Loop 2430 SVD02).
CAS01=‘PR’ Indicates contractual obligation or patient responsibility. This is the general category of payment adjustment
CAS02=‘1” Claim adjustment reason code (CARC)
CAS03=’7.93’ actual adjustment amount. This is the difference between the billed amount (Loop 2400 SV203) and the primary insurance paid amount (Loop 2430 SVD02).
Line adjudication date
The line adjudication date should be provided if the claim was adjudicated by the primary payer. This information should be reported at the service level but may be reported at the claim level if no line level payment or adjustments are reported.
Loop 2430 DTP*573*D8*20160115~
DTP01=573 indicates date claim paid
DTP02=D8 indicates date format
DTP03=CCYYMMDD indicate the adjudication/payment date
• 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 ‘MA’, Medicare Part A.
• The equations for the balancing routines are as follows:
• Claim charge amount [2300 CLM02] = payer paid amount [2320 AMT02=D]. [+ all payer adjustment amounts CAS 2320 and 2430]Line charge amount [2400 SV203] = payer paid amount [2430 SVD02] + line level adjustments [2430 CAS03, 06, 09, 12, 15 and 18]
• The value in 2430 SVD01 should be the same value as in 2330B NM109 (payer ID) or the amount in SVD02 won’t be used in the equation.
• The same adjustment can’t be reported in both the claim level CAS and the service level CAS or the claim won’t balance.
For additional information, please contact Medicare EDI at 888-670-0940 option 1.
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