Last Modified: 12/31/2017 Location: FL, PR, USVI Business: Part A
MSP and conditional payment request claim filing guidelines
Prior to the implementation of change requests (CRs) 6426 and 7355, occurrence code (OC) 24 was the key element when requesting a conditional payment from Medicare to allow the intermediary to review the denial comments in the remarks field. Currently, physicians, providers, or other suppliers have been advised to include CAS segment related group codes when submitting X12N 837 institutional MSP claims to indicate the primary insurer’s denial.
When a physician, provider, or other supplier bills Medicare for secondary benefits, the primary payment amounts are reported according to the direction in the internet-only manual (IOM) 100-05, chapter 3, section 40.1.1 and 40.1.2. If the primary insurer denies the claim for primary benefits, the provider submits a bill to Medicare for conditional payment when conditions outlined in IOM 100-05, chapter 3, section 40.3 and CR 7355 is met. In these instances, OC 24 and date of denial are utilized along with the appropriate claim adjustment reason code (CARC) if applicable.
Conditional payment claim requests require several claim processing elements for 837 institutional claims format as shown in the IOM 100-05, chapter 5, section 40.6 and 40.6.1. These elements consist of the following:
• Appropriate OC needed for non-group health plan (NGHP) such as 01, 02, 03 or 04 (2300 HI)
• OC 24 and date of denial (2300 HI)
• MSP value code with the zeroed paid amount (2300 HI)
• CAS segment which indicates the provider attempted to bill primary insurer and received a denial (2320 Loop)
• Remarks/comments explaining why the primary insurer did not pay the claim
It has been identified when reason code 31409 is received, the claim is billed as Medicare primary and OC 24 and date are present; however, the MSP value code is not present. This billing is incorrect based on the IOM direction for conditional payment claim requests. Claims billed as Medicare primary with OC 24 present will be returned to the provider (RTP) to ensure proper conditional payment criteria is applied.
However, when services are not related to no-fault (auto), liability, worker’s compensation or the NGHP did not pay during the promptly pay period, the exact reason in the remarks field will be required. This verbiage should state the following: “Services are not related to (insert MSP type)” or “No response from promptly pay period billing received”.
Note: If there is a primary group health plan (GHP), the physician, provider, or other supplier should send the claim to the GHP first before Medicare can consider conditional payment.
For a list of CARCs, please refer to Washington Publishing Company (WPC) website http://www.wpc-edi.com/reference/ .
For more information about correctly filing OC 24, MSP and conditional payment claims, please refer to these resources:
• Internet only manual publication 100-05, Medicare Secondary Payer (MSP) manual chapter 3 and chapter 5 external_pdf.gif
Please advise your billing personnel the importance of billing these types of claims correctly.
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