Prepare and Submit a Medicare Secondary Payer Claim

Step 1: Determine If You Must Submit an MSP Claim

Before you can submit an MSP claim, you must submit the claim to the payer(s) you identified as the primary payer(s). Refer to Identify the Proper Order of Payers for a Beneficiary’s Services.

Once you submit a claim to and receive payment from the primary payer(s), use the guidelines below to determine if you must submit an MSP claim. MSP claims are subject to the one-year timely filing regulation so follow up with the primary payer(s) often.

If the primary payer made a partial payment, you must submit an MSP claim.
a. Partial payment - primary payer paid more than zero but less than full payment on the claim. They paid less than Medicare-covered charges or less than the amount you agreed to accept, per a contract or an obligation under law, as full payment of Medicare-covered charges.
If the primary payer made a full payment, follow the instructions in numbers 1 or 2 below if you are not an HH+H provider or follow the instruction in number 3 below if you are an HH+H provider:
a. Full payment - Primary payer paid Medicare-covered charges or an amount you agreed to accept, per a contract or an obligation under law, as full payment of Medicare-covered charges.

If the claim is for inpatient services, you must submit an MSP claim.
If the claim is for outpatient services, you must submit an MSP claim IF the beneficiary has not met the annual Medicare Part B deductible. You may, but are not required to, submit an MSP claim if the beneficiary has already met the annual Part B deductible
HH+H providers must submit MSP claims in all situations whether the beneficiary has or has not met their annual Medicare Part B deductible.

Note: There may be more than one payer primary to Medicare. The type of claim you submit to us depends on how the primary payers handled your claim.

If both payers paid on the claim, submit a Medicare tertiary claim reporting both payers before Medicare and their payment information.
If one payer paid on the claim but the other did not for a valid reason or within the 120-day promptly period for accidents (review Prepare and Submit an MSP Conditional Claim), submit an MSP claim reporting only the payer that paid before Medicare and their payment information. Do not report the payer or the payment information for the payer that did not pay.

[Return to Top]

Step 2: Prepare an MSP Claim

To prepare the MSP claim, follow these guidelines:

Report a covered TOB, not a noncovered TOB such as 110, 130, 210, etc.
Complete the claim as usual as if Medicare were primary except report the primary payer(s) before Medicare and Medicare second (or third, if applicable).
Report any claim coding as usual including services/charges for Medicare-covered services. Do not just balance bill for charges remaining after the primary payer’s payment.
If submitting an inpatient MSP claim, report the covered and noncovered days/charges as usual. Do not report days/charges paid by the primary payer as noncovered.
Follow Medicare’s technical (for example, timely filing) and medical (for example, clinical and/or assessment) requirements since these apply to all Medicare claims, including MSP claims.
- Hospice providers: Submit the NOE as usual with Medicare as primary regardless of the payer order. Report the MSP information on the claim(s).
- Home health providers: Submit the NOA RAP showing Medicare as primary regardless of the payer order. Report the applicable MSP information on your claim(s).
Follow Medicare’s usual billing (for example, frequency of billing guidelines for your provider type). If you are required to submit claims to us from admission to discharge, every 30 days or every 60 days (or at another billing frequency), this remains true even when Medicare is not the primary payer. If another payer was primary for a portion of the claim’s billing period, submit the entire claim to us as an MSP claim. Do not split your claim during your frequency of billing period if we become primary or secondary payer during that period.
Report applicable MSP billing codes from the MSP Billing Code Table below.
Report any adjustment(s) the primary payer(s) made by including the CAGC(s), CARC(s) and amount(s) from the primary payer’s RA.

CAGC(s):

Required when the primary payer adjusts your billed charges
Identifies the general category of those payment adjustments
Options:
- CO (Contractual Obligations)
- OA (Other Adjustments)
- PI (Payer Initiated Reductions)
- PR (Patient Responsibility)

CARC(s):

Required when the primary payer adjusts your billed charges
Explains why the primary payer paid differently than it was billed
Options:
- Refer to primary payer’s RA which shows the CARC(s) for each CAGC. If their RA does not provide CARCs and/or CARC definitions, refer to the external code list.

If using FISS DDE to enter the MSP or Medicare tertiary claim:

In addition to the guidelines above, follow the Claim Entry instructions in the Fiscal Intermediary Standard System/Direct Data Entry Provider Online Guide.
Enter all required claim coding (non-MSP and MSP) on the appliable claim pages.
Go to claim page 03 (MAP1713) and press the F11/PF11 key to get to the additional pages (MAP1719). Enter the CAGCs, CARCs and amounts from the primary payer(s) RAs for up to two primary payers.
Enter this information for primary payer 1 (up to 20 entries), if applicable.
Enter this information for primary payer 2 (up to 20 entries), if applicable.
MAP1719 fields:
- Paid date: Enter paid date from primary payer’s RA
- Paid amount: Enter paid amount from primary payer’s RA. This amount must equal the MSP VC amount reported on the claim and must equal the charges minus the total of all amounts with CARC.
- GRP: Enter CAGC(s)
- CARC: Enter CARC(s)
- AMT: Enter the dollar amount associated with each CAGC and CARC pair

[Return to Top]

MSP Billing Code Table

Code	UB-04 (CMS-1450) Claim Form	Field on 837I Claim	Page/MAP in FISS DDE Claim Entry	Instruction - Report following code(s) as applicable
Condition Code	FL 18–28	2300.HI (BG)	Page 01 (MAP1711)	CC 02 = Condition is employment-related Requires OC 04 and VC 15 or VC 41 CC 06 = ESRD beneficiary is in first 30 months of eligibility or entitlement covered by an EGHP Requires MSP VC 13 CC 77 = Primary payer paid in full. They paid full charges or an amount you are accepting, per a contract or obligation under law, as full payment toward the Medicare covered charges. No MSP payment due. Note: Do not report CC77 when you receive less than full payment from the primary payer toward Medicare-covered charges.
Occurrence Code and Date	FL 31–34	2300.HI (BH)	Page 01 (MAP1711)	OC 01 and date of accident or injury = primary payer is medical-payment coverage Requires VC 14 OC 02 and date of accident or injury = primary payer is No-Fault/No-Fault Set Aside Requires VC 14 OC 03 and date of accident or injury = primary payer is Liability insurance/Liability Set Aside Requires VC 47 OC 04 and date of accident or injury = primary payer is Workers Compensation/WC Set Aside Requires CC 02 and VC 15 OC 33 and first day of MSP ESRD coordination period for ESRD beneficiaries covered by an EGHP Requires CC 06 and VC 13
Value Code & Amount	FL 39–41	2300.HI (BE)	Page 01 (MAP1711)	MSP VC that represents MSP Provision and dollar amount primary payer paid toward Medicare covered charges on claim. Note: If primary payer’s payment was reduced because of failure to file a proper claim (unless failure was due to beneficiary’s mental or physical incapacity), report amount you would have received had you filed a proper claim with them. MSP VC options: VC 12 Working Aged Beneficiary (65 or older and enrolled in Part A) or spouse with EGHP, employer size 20 or more employees (Primary Payer code A) VC 13 ESRD Beneficiary (any age) with EGHP in MSP/ESRD 30-month coordination period (Primary Payer code B) Requires CC 06 and OC 33 VC 14 No Fault Includes automobile and other types such as: personal injury protection (PIP) and medical-payment coverage. (Primary Payer Code D or T) Requires OC 01 or OC 02 VC 15 WC Includes WC Set Aside (Primary Payer Code E or W) Requires CC 02 or OC 04 VC 16 PHS or other federal agency (Primary Payer Code F) VC 41 Federal Black Lung program (Primary Payer Code H) Requires OC 02 or OC 04 VC 43 Disabled Beneficiary (under 65 and enrolled in Part A) or family member employed with LGHP – 100 or more employees (Primary Payer Code G) VC 47 = Any liability insurance (primary payer code L) Requires OC 03 VC 44 and amount: When applicable, report VC 44 and dollar amount in addition to MSP VC and amount. Report VC 44 and amount you are obligated to accept as full (OTAF) payment from the primary payer due to a contractual arrangement or obligation under law (expected amount) when that amount is less than the claim’s Medicare covered charges but higher than the amount you received from the primary payer. An MSP payment may be due. (Never report CC 77 with VC 44 on the same claim). VC 44 example: Medicare covered charges = $5,000 OTAF amount = $4,000 Primary payer paid = $3,000 Submit $5,000 MSP claim and report appropriate MSP VC = $3,000 and VC 44 = $4,000
Primary Payer Code (Code ID)	N/A	N/A	Page 03 (MAP1713)	For first three payers (payers marked A, B and C), report this code for Payer A and Payer B (for MSP claims) or Payers A, B and C (for Medicare Tertiary claims). Use payer code Z for Medicare. A = Refer to VC 12 above B = Refer to VC 13 above D = Refer to VC 14 above E = Refer to VC 15 above F = Refer to VC 16 above H = Refer to VC 41 above G = Refer to VC 43 above L = Refer to VC 47 above S = Refer to VC 47 above T = Refer to VC 14 above W = Refer to VC 15 above
Primary Insurer name	FL 50A, B, C	2320.SBR04	Page 03 (MAP1713)	Full, actual (not vague) name of primary insurer(s). Report Medicare on line 50B (Medicare secondary) or on line 50C (Medicare tertiary). Note: If using FISS DDE, “Medicare” populates for lines where you reported Primary Payer Code (Payer Code ID) Z.
Insured’s Name	FL 58 A, B, C	2330A.NM104	Page 05 (MAP1715)	Insured’s name for each payer.
Patient’s Relationship to Insured	FL 59A, B, C	2320.SBR02	Page 05 (MAP1715)	Beneficiary’s relationship to insured for each payer. 01 = spouse 18 = self 19 = child 20 = employee 21 = unknown 39 = organ donor 40 = cadaver 53 = life partner G8 = other relationship
Insured’s Unique ID	FL 60A, B, C	2330A.NM109	Page 05 (MAP1715)	Insured’s ID for each payer (beneficiary’s MBI on Medicare line).
Insurance Group Name	FL 61A, B, C	2320.SBR04	Page 05 (MAP1715)	Name of primary insurance group for each primary payer.
Insurance Group Number	FL 62A, B, C	2320.SBR03	Page 05 (MAP1715)	Primary insurance group number for each primary payer.
Employer Name	FL 65 A, B, C	N/A	N/A	For UB-04/CMS-1450 claim form only, report name of employer that provides health care coverage.
Primary Insurer’s Address	Use FL 80 (Remarks)	2300.NTE	Page 06 (MAP1716)	Insurer’s full address.

[Return to Top]

Step 3: Check for Matching MSP Record in the CWF

For an MSP claim to process without intervention, there must be a matching MSP record for the beneficiary in the CWF. Before you submit an MSP claim, check for such a record in the CWF using the provider self-service tools listed under Step 1 in the Identify the Proper Order of Payers for a Beneficiary's Services. A matching MSP record is one with the same MSP information you will report on your MSP claim.

If there is no matching MSP record in the CWF:

Ask the beneficiary (or other party) to contact the Benefits Coordination & Recovery Center (BCRC) to inform them of any new MSP information and to request they set up an MSP record before you submit your claim. Providers should not contact the BCRC to set up MSP records. Continue to check for the MSP record in the CWF and when it appears, move to Step 4.

Move directly to Step 4. Upon receipt of your claim, we will set up a matching MSP record for the beneficiary in the CWF or request that the BCRC set one up, depending on the circumstances.

[Return to Top]

Step 4: Submit the MSP Claim

Submit the MSP claim, whether there is or is not a matching MSP record in the CWF. Submit the claim via:

837I claim
FISS DDE
Hardcopy format if you have an approved ASCA waiver.
- Note: You must properly code the MSP claim on a hardcopy UB-04/CMS-1450 claim form, attach any supporting documentation including the primary payer’s remittance advice and EOB statement and submit it to the applicable National Government Services Medicare Claims Department. You can find the applicable address on our website under Contact Us.

[Return to Top]

Step 5: Keep Checking for the MSP Claim to Process

You can check the status of your MSP claims via FISS DDE.

If there is a matching MSP record in the CWF when you submit your MSP claim, we can process it. If there is not a matching MSP record in the CWF when you submit your claim, then submitting your claim notifies us of the MSP situation. If there is enough information on the claim to set up an MSP record (with a validity indicator of “I”) in the CWF, we will do so. If there is not enough information on the claim to set up an MSP record, we will not be able to do so. But we may still be able to send the MSP information from the claim to the BCRC via an electronic transaction to ask them to set up an MSP record in the CWF. Refer to Set Up a Beneficiary's MSP Record.

Regardless of how the MSP record is established in the CWF, the BCRC investigates the record. If the BCRC confirms the MSP information we added is accurate, they validate the MSP record in the CWF to change the validity indicator from “I” to “Y.” If we were not able to add an MSP record to the CWF and they, instead, set up an MSP record at our request, and then we can process your MSP claim. If the BCRC could not validate an MSP situation exists and/or confirm the MSP information we sent them is accurate, they may not be able to set up an MSP record for the beneficiary in the CWF. Should this occur, we will RTP your claim to advise you of this situation. Follow the claim’s reason code(s) instructions. For details on how we send the MSP information on your claims to the CWF and/or to the BCRC as well as how we process your MSP claims, review CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 6.

[Return to Top]

Step 6: Return or Resubmit a Corrected Claim

If you submit an MSP claim per the above instructions and it does not encounter additional editing, it will proceed to the payment floor.

If you submit an MSP claim that does not meet our claim coding and submission requirements, it will be returned to the provider or rejected, depending on the circumstances. IF this occurs, you must:

Correct the claim in FISS DDE and return it to us
or
Submit a new corrected claim based on the reason code narrative.

[Return to Top]

Prepare and Submit a Medicare Secondary Payer Claim

Table of Contents

Step 1: Determine If You Must Submit an MSP Claim

Step 2: Prepare an MSP Claim

MSP Billing Code Table

Step 3: Check for Matching MSP Record in the CWF

Step 4: Submit the MSP Claim

Step 5: Keep Checking for the MSP Claim to Process

Step 6: Return or Resubmit a Corrected Claim

Related Content