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Part A Electronic Medicare Secondary and Tertiary Payer Specifications for ANSI Inbound Claims

The following information is intended to provide you and your software vendor with a reference for electronically billing MSP and MTP claims. Use this information to assist in reporting the appropriate MSP and MTP information in the ANSI format.

This document is designed to give examples and describe the required fields in relation to the ASC X12 Technical Report Type 3 (TR3) for 837I, Institutional Health Care Claims.

Specifications for 837I

Use the information below to assist you and your software vendor report the appropriate MSP information in the correct ANSI fields.

This document lists the required fields in relation to the Accredited Standards Committee (ASC) X12N Technical Report Type 3 (TR3).

Required MSP Data

In order to bill MSP and MTP claims electronically for Medicare Part A, home health and hospice, and federally qualified health centers; there are some critical pieces of information that are necessary to ensure claims are processed and adjudicate correctly. MSP and MTP claims require:

• indication of Medicare as the secondary or tertiary payer;
• value codes;
• condition codes;
• occurrence codes;
• claims adjustments (situational); and
• claim details from primary payer and/or secondary payer.

Indication of Medicare as the Secondary or Tertiary Payer

SBR Segment

All MSP or MTP claims are created around the assumption that Medicare is the secondary or tertiary payer (e.g., the beneficiary has other insurance(s) that pays the health care claim prior to Medicare). The basic principle behind filing a MSP or MTP claim to Medicare is to report all payment information the primary payer (for MSP claims) or the primary and secondary payers (for MTP) provided and indicate that Medicare is the secondary or tertiary payer. The ANSI X12 TR3 indicates primary, secondary, and tertiary payers by using the SBR01 segments in the 2000B and 2320 Loops. The SBR segment is used to record information specific to the primary insured and the insurance carrier for that insured. Use the SBR01 segment in the 2000B loop to report what type of claim is being submitted representing Medicare. The values for SBR01 are:

• P = Primary
• S = Secondary
• T = Tertiary

2320/SBR

Report the name of the primary and/if secondary insurance company information in the SBR01 element in loop 2320 with the value of “P” for Primary and/if “S” for Secondary insurance.

Note: Medicare will always be listed in the 2000B loop.

Value/Condition/Occurrence Codes

HI Segments

To prevent delays in claim processing, all available coding options should be used. This includes value, condition and occurrence codes when appropriate. These codes are contained in the 2300 loop HI segments, identified by individual qualifiers. Multiple HI segments are used in the 2300 loop.

Note: If you are obligated to accept, or voluntarily accept an amount OTAF from the primary payer (i.e., your contractual obligation), you must identify this amount as Value Code 44 in the 2300 HI Value Information. This amount is also known as the obligated to accept as OTAF. Details of the MSP OR MTP payment provisions may be found in the CMS Medicare Secondary Payer Manual and in the Federal Regulations at 42 CFR 411.32 and 411.33.

NTE Segment ‒ 2300 Billing Note Segment

The billing note segment in the 2300 loop should be used to give additional information on a particular claim. For MSP OR MTP claims, it is used to report the primary or secondary payer’s address.

This field is limited to 80 characters only.

A link to conditional billing instructions, as well as to our “MSP OR MTP and Conditional Claim Billing Code Chart” which explains all ten codes, has been provided below under “References”.

Claim Adjustments

CAS Segments

Adjustments made by the primary payer are reported in the CAS segment. Providers must take the CAS segment adjustments (as found on the EOB) and report these adjustments when sending the claim to Medicare for secondary and/or tertiary payment.

Claim Level—2320 CAS Segment

The CAS segment in the 2320 loop must be used to report prior payers claim level adjustments that caused the amount paid to differ from the amount originally charged. This segment reports information returned on the previous payers’ EOB.

For conditional payments, the CAS must contain the total billed amount.

Line Level—2430 CAS Segment—Line Adjustment Information

Line adjustment information is reported in the CAS segment, including the claim adjustment group code, claim adjustment reason code and the monetary adjustment amounts. Line adjustments should be provided if the primary and/or secondary payers made line level adjustments that cause the amount paid to differ from the amount originally charged.

Adjustment Group Codes

Amounts from Primary Payer

AMT Segments

Payer Paid Amount

This segment is required in the 2320 loop if the primary payer has adjudicated the claim. It is acceptable to show “0” (zero) as an amount paid. For conditional claims, prior payer paid amount is ‘0’

Balancing

The monetary amount in CLM02 should equal the sum of all 2320 (claim) & all 2430 (line) CAS and AMT01 = D segments.

For conditional claims, total submitted charges are the total billed amount.

The general balancing calculation is:

Claim Adjudication Date – Claim Level

The ANSI X12 indicates the Claim Adjudication date by using a DTP segment in loop 2330B. The DTP01 element will contain qualifier “573,” Date Claim Paid, to indicate the type of date that follows. DTP02 will contain qualifier “D8” to indicate the format of the date. The DTP03 element will contain the claim adjudication date. The Claim Adjudication Date is required on all MSP claims and is used to report the date a claim was adjudicated or paid by the primary payer.

The example below displays the adjudication date.

2330B/DTP

Segment Syntax: DTP*573*D8*20041116~

Service Line Information

Approved Amount

The approved amount, also known as the allowed amount, is the amount of money approved by the primary payer. The approved amount equals the amount for the service line that was approved by the payer. If the primary insurance does not show the approved amount, enter the billed amount in this element.

Line Adjudication Information

Use the line adjudication information to report the original services billed to the primary payer. This information is required if the claim has been previously adjudicated by the payer identified in the 2330B loop and the service line has adjustments applied. The Line Adjudication Information is present on most MSP claims.

2430/SVD Implementation Guide Specifics:

Report line adjudication information in the SVD segment including the specific service line items billed to the primary payer (procedure code, amount paid for the service, units billed, etc.)

Syntax of Segment:
SVD*00820*20*HC>98940**1~

Note: the information found in the SVD01 (00820) must match the payer ID for the primary payer (2330 NM109).

2430/CAS Implementation Guide Specifics:

Line adjustment information is reported in the CAS segment, including the claim adjustment group code, claim adjustment reason code and the monetary adjustment amounts (See IG for complete list of codes)

Syntax of Segment:
CAS*CO*42*5~
CAS*PR*2*20~

2430/DTP Implementation Guide Specifics:

Use the Line Adjudication Date segment to report the date the claim was adjudicated/paid by the primary payer. Line Adjudication Date is reported in a DTP segment and is required.

Syntax of Segment:
DTP*573*D8*20041116~

If you are experiencing trouble with these fields, providers using EMC software, contact your EMC software vendor with any questions regarding the electronic submission of MSP OR MTP conditional claims/adjustments.

Providers using PC-ACE, contact the NGS EDI Help Desk: 877-273-4334.

Information regarding billing guidelines for MSP or MTP claims, conditional MSP or MTP claims and MSP or MTP adjustments; please refer to the Medicare Secondary Payer section under Claims of our website.

Revised 9/29/2018