Medicare Secondary Payer (MSP)

Correct or Adjust a Claim Due to an MSP-Related Issue

Table of Contents

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Background

To correct claims not finalized (i.e., RTP claims), you can use the FISS DDE and return them (PF9 key) to us.

To correct or change finalized (processed or rejected) claims, you must submit claim adjustments with TOB XX7. There is one exception which is when the claim is an MSP or conditional claim, and it was rejected due to errors related to the coding you reported from the primary payer’s RA such as the CAGCs, CARCs or amounts. In this case, you must resubmit new corrected MSP claims. This is indicated in the reason code narrative.

Claim Types Defined:

  • MSP = Claims submitted to/processed by Medicare as secondary (primary payer paid in part or in full)
  • Conditional = Claims submitted to/processed by Medicare conditionally because the primary payer did not pay for a valid reason or did not pay promptly (within 120 days for accidents only)
  • Medicare primary = Claims submitted to/processed by Medicare as primary
  • Cost avoided = Claims submitted to Medicare as primary but rejected due to an open MSP record (FISS rejection reason code is commonly in the 34XXX range).

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Step 1: Identify the Fiscal Intermediary Shared System Direct Data Entry Status Location of the Claim and the Reason(s) for the Claim Correction or Change

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Status Location TB9997 (Returned to Provider Claims)

  • MSP and conditional claims are RTP and in S/L TB9997 if they do not meet Medicare requirements. They have reason code(s) explaining the error(s). To correct these claims, follow the reason code narratives, and return them (PF9 key). Do not adjust RTP claims since they are not finalized.

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Status Location PB9997 (Processed Claims)

  • MSP and conditional claims are processed and in S/L PB9997 if they meet Medicare requirements. To correct or to change these claims for any reason, adjust them.
  • Medicare primary claims are processed and in S/L PB9997 if they meet Medicare requirements and did not reject (cost avoid) due to open MSP records. To correct or to change these claims to MSP or conditional claims, adjust them.

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Status Location RB9997 (Rejected Claims)

  • MSP and conditional claims are rejected and in S/L RB9997 if they have errors related to the CAGCs, CARCs or amounts. To correct these claims, resubmit them with no errors.
  • Medicare primary claims are rejected and in S/L RB9997 if they reject (cost-avoid) due to open MSP records. To correct or to change these claims to MSP, conditional or back to primary claims, adjust them.

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Step 2: Prepare a Claim Adjustment Involving an MSP Situation

You may need to make the following adjustments (TOB XX7) to processed or rejected claims:

  • Change processed MSP or conditional claims for any reason
  • Change processed Medicare primary claims to make Medicare secondary
  • Change Medicare primary claims that rejected for MSP (cost avoided) to make Medicare secondary
  • Change Medicare primary claims that rejected for MSP (cost avoided) back to Medicare primary
  • Note: Never cancel (TOB XX8) claims for any of the above reasons; always submit claim adjustments

Timely filing of MSP-related claim adjustments: Per Medicare regulations, you have one year from a claim’s date of service to submit claims or adjustments. When MSP is involved, there are two exceptions:

  1. If you submitted an MSP claim to us, but the primary payer later retracts their payment from you, then you may adjust that MSP claim within one year of the date on which we had processed it (our RA date)
  2. If you submitted a Medicare primary claim to us, but a primary payer later pays you, then you may adjust that primary claim beyond our one-year timely filing. However, you must adjust it within 60 days of the date you received the primary payer’s payment.

Options for preparing claim adjustments (TOB XX7):

  • 837I claim
  • FISS DDE claim entry
  • Hardcopy claim (UB-04/CMS-1450 claim form)

Claim adjustment coding: Report TOB XX7 and:

  • DCN of original claim (claim you are adjusting)
  • CC, which is also known as a claim change reason code
  • D7 = Change to make Medicare secondary
  • D8 = Change to make Medicare primary
  • D9 = Other change (use when you submitted the original claim as Medicare primary, it rejected due to an open MSP record, and you are adjusting the rejected claim to change it back to a Medicare primary claim)
  • Corrections and/or changes you want to make
  • FISS claim adjustment reason code if you are preparing your claim adjustment in FISS DDE. A list of these codes is in the FISS DDE Inquiry menu (01) Adjustment Reason Code file (16)

Refer to the two charts below for assistance in preparing MSP-related claim adjustments.

  1. Preparing MSP-Related Claim Adjustments: Provides the claim’s current type, the claim type you want to change to, an example, the CC you must report on the adjustment and comment codes that provide additional instructions. Do not report the comment code(s) on claim adjustments.
  2. Comment Code Definitions: Defines comment codes in the Preparing MSP-Related Adjustments chart.

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Preparing MSP-Related Claim Adjustments (TOB XX7) Chart

Current Claim Type Change to Claim Type Example Use CC Follow Comment Codes
Medicare primary MSP After billing us as primary, you billed a primary payer and received payment D7 1, 8 (if primary payer is liability VC 47) and 10
Medicare primary Conditional After billing us as primary, you billed a primary payer, but they did not pay for a valid reason or within 120 days (accidents only) D9 2
MSP MSP After billing as MSP, you identified a needed change in claim coding (i.e., MSP VC amount) D9 3 and 10
MSP Conditional After billing as MSP, you received a retraction from primary payer (they cited a valid reason other than Medicare is primary) D9 2 and 9
MSP Medicare primary After billing as MSP, you received a retraction from primary payer (they cited reason as Medicare is primary) D8 4 and 9
MSP rejected MSP After billing as primary (claim rejected for MSP), you billed a primary payer and received payment D7 1 and 11
MSP rejected Conditional After billing as primary (claim rejected for MSP), you billed a primary payer, but they did not pay for a valid reason or within 120 days (accidents only) D9 2 and 11
MSP rejected Medicare primary After billing us as primary (claim rejected for MSP), you verified we are primary D9 4, 5, 6, 7 and 11
Conditional MSP After billing us conditionally, you received payment from a primary payer D7 1, 8 (if primary payer is liability VC 47) and 10
Conditional Conditional After billing us conditionally, you identified a needed change in claim coding (i.e., MSP VC) D9 3
Conditional Medicare primary After billing us conditionally, you determined we are primary D9 4

 

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Comment Code Definitions Chart (Additional Instructions for Claim Adjustments)

Code Definition (Instructions)
1 Report MSP claim coding. See Prepare and Submit an MSP Claim.
2 Report conditional claim coding. See Prepare and Submit an MSP Conditional Claim.
3 Report MSP claim coding or conditional claim coding. Include remarks in the remarks field to explain the adjustment reason. See Prepare and Submit an MSP Claim or Prepare and Submit an MSP Conditional Claim
4 When you determine Medicare is primary to a GHP and a GHP MSP record (VC 12, 13, or 43) requires correction, see Correct a Beneficiary's MSP Record.  When you submit the adjustment, see Prevent an MSP Rejection on a Medicare Primary Claim for codes you can use to indicate the reason we are primary.
5 If the claim is rejected for MSP due to an open accident MSP record (VCs 14, 15, 41, or 47), but you determined the claim is not an accident (i.e., no trauma diagnosis codes) and not related to the MSP record, report this in remarks. For example, remarks = “Services not related to <insert VC of accident MSP record type> MSP record.” Do not report occurrence code (OC) 05.
6 If the claim is rejected for MSP due to an open accident MSP record (VCs 14, 15, 41, or 47), and you determined the claim is an accident (i.e., trauma diagnosis codes) but there is no primary payer and it is not related to the MSP record, report this in remarks. For example, remarks = “Services not related to <insert VC of accident MSP record type> MSP record.” Report OC 05 and the date of the current accident.
7 If comment code 5 or 6 applies, see Correct a Beneficiary's MSP Record and Prevent an MSP Rejection on a Medicare Primary Claim.
8 If the primary payer is liability (MSP VC 47), see the CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 2, Section 40.2E for instructions since you accepted our conditional payment and should have withdrawn your claim/lien against the liability/beneficiary’s liability insurance settlement.
9 When you submitted an MSP claim, but the primary payer later retracts payment from you, you may adjust the MSP claim within one year of its processed (our RA) date.
10 You must repay us within 60 days from the date you received payment from a payer primary to Medicare.
11 If submitting the adjustment via FISS DDE, change noncovered days/charges back to covered (as originally billed). Delete the noncovered charge lines and rekey each as covered (Place a ‘D’ on claim line, hit <HOME> key, then hit <ENTER> key).

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Step 3: Submit a Claim Adjustment Involving an MSP Situation

Options for submitting claim adjustments (TOB XX7):

  1. 837I claim
  2. FISS DDE
  3. Hardcopy claim (UB-04/CMS-1450 claim form). Properly code the claim adjustment on a UB-04/CMS-1450 claim form, attach supporting documentation (including primary payer’s RA) and submit it to the applicable National Government Services Medicare Claims Department. You can find the applicable address on our website under Contact Us.  You do not need to request and be approved for an ASCA waiver.

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Related Content

Revised 11/13/2024

Helpful Resources

MSP Questionnaire Example

Helpful Resources

BCRC Contact Information

Note: Providers should not contact the BCRC to set up new MSP records. Instead, report MSP coding on your MSP and conditional claims. Providers should not contact the BCRC to correct MSP records to make Medicare primary. Instead, report coding on your primary claims to indicate why Medicare is primary. If there is no applicable coding, you may refer beneficiaries and other entities to the BCRC.

BCRC Contact

  • 1-855-798-2627
  • TTY/TDD: 1-855-797-2627
  • FAX: 1-405-869-3307