Quick reference chart for billing Medicare secondary payer (MSP) claims
After the processing of the claim by the primary insurer, the claim should be submitted to Medicare for consideration of secondary benefits. The following chart provides guidance on the MSP data elements to report on your MSP claim.
An MSP claim may be submitted:
- Electronically via 837I claim:
- Using a billing service or clearinghouse, directly through a Secure File Transfer Protocol (SFTP) connection (PC-ACE), or SPOT portal 's batch claim submission
- Using a billing service or clearinghouse, directly through a Secure File Transfer Protocol (SFTP) connection (PC-ACE), or SPOT portal 's batch claim submission
- Through Fiscal Intermediary Standard System (FISS)/direct data entry (DDE)
- Hardcopy CMS-1450 (UB-04) claim form:
- Only if you qualify for a waiver/exception under the Administrative Simplification Compliance Act (ASCA)
- Include primary payer’s remittance advice (RA) or explanation of benefits (EOB) statement
- Only if you qualify for a waiver/exception under the Administrative Simplification Compliance Act (ASCA)
| Code/Data element | UB-04 form locator (FL) | Electronic field | FISS/DDE |
|---|---|---|---|
|
Condition codes * 02 Condition is employment-related 06 end stage renal disease (ESRD) patient in first 30 months of entitlement 08 beneficiary refused to provide information concerning other insurance coverage 77 full payment received from primary payer |
FL 18-28 |
2300 HI (BG) |
Page 01 |
|
Occurrence codes and dates* 01 and date of accident (DOA) if medical-payment plan is primary 02 and DOA if no-fault is primary 03 and DOA if liability is primary 04 and DOA if WC is primary 05 and date of other accident- date 33 and date ESRD coordination period began |
FL 31-34 |
2300 HI (BH) |
Page 01 |
|
Value codes and payment 12 Working aged 13 ESRD 14 Auto/No-fault 15 Worker’s Compensation 41 Black Lung 43 Disability 44 Obligated to accept (OTAF) 47 Liability |
FL 39-41 |
2300 HI (BE) |
Page 01 |
|
Payer code ID A Working aged B ESRD D Auto/No-fault E Worker’s Compensation G Disability H Black Lung L Liability |
N/A |
N/A |
Page 03 |
|
Primary insurer name |
FL 50A |
2330B NM1 |
Page 03 |
|
Paid date |
N/A |
2330B DTP03 or 2430 DTP03 |
Page 03 CAS Segment |
|
Paid amount |
N/A |
2320 AMT02 D (full claim) 2430 SVD02 (line level) |
Page 03 CAS Segment |
|
Group code (GRP) CO contractual obligations CR corrections and reversals OA other adjustments PI payer initiated reductions PR patient responsibility |
N/A |
2320 CAS01 or 2430 CAS01 (one or the other but not both) |
Page 03 CAS Segment |
|
CARC code (See X12 External Code Lists for complete list) * 1 deductible 2 coinsurance amount 3 copayment amount 27 expenses incurred after coverage terminated 45 charge exceeds fee schedule/maximum allowable or contracted/legislative fee arrangement 96 noncovered charge(s) 119 benefit maximum has been reached |
N/A |
2320 CAS02 or 2430 CAS02 (one or the other but not both) |
Page 03 CAS Segment |
|
Amount |
N/A |
2320 CAS03 |
Page 03 CAS Segment |
|
Insured's name |
FL 58A |
2330A NM104 |
Page 05 |
|
Patient relationship* 01 Spouse 18 Self 19 Child 21 Unknown 53 Life partner G8 Other relationship |
FL 59A |
2320 SBR02 |
Page 05 |
|
Insured's unique ID |
FL 60A |
2330A NM109 |
Page 05 |
|
Insurance group name |
FL 61A |
2320 SBR04 |
Page 05 |
|
Insurance group number |
FL 62A |
2320 SBR03 |
Page 05 |
|
Insurance address |
Use Remarks FL80 |
Use Remarks 2300 NTE |
Page 06 |
|
Employer name |
FL 65A |
N/A |
N/A |
|
Remarks |
FL 80 |
2300NTE |
Page 06 |
* Not an all-inclusive list
References
- Electronic filing of Medicare Part A secondary payer claims (MSP) in the 5010 format
- CMS IOM Pub. 100-05, Medicare Secondary Payer (MSP) Manual, Chapter 3
- National Uniform Billing Committee (NUBC)
- X12 External Code Lists