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Prevent an MSP Rejection on a Medicare Primary Claim

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Prevent an MSP Rejection on a Medicare Primary Claim

  • Fact: If you submit a Medicare primary claim when there is a MSP record for the beneficiary on CWF, you may receive a claim rejection. These “cost-avoided” claim rejections related to open MSP records receive FISS rejection reason codes in the 34### range.
  • Fact: To prevent most of these claim rejections, you can report on your Medicare primary explanatory billing codes and we can submit the information to the BCRC to request they correct the beneficiary’s MSP record on the CWF.

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Step 1: Identify the MSP Record for the Beneficiary on the CWF That Needs Correction

You can check to determine if there is an MSP record for the beneficiary on the CWF using the provider self-service tools listed under Step 2 of Identify the Proper Order of Payers for a Beneficiary's Services.

Reasons Medicare may be the primary payer for a beneficiary’s services, rather than the insurer in the MSP record on the CWF, include but are not limited to:

  • Neither the beneficiary nor spouse is employed
  • Beneficiary and/or spouse are employed but the beneficiary is not enrolled in an EGHP
  • Disabled beneficiary and/or spouse/family member is employed but the beneficiary is not enrolled in a Large Group Health Plan (LGHP)
  • Beneficiary is retired
  • Beneficiary’s spouse is retired
  • Beneficiary’s family member retired
  • EGHP/LGHP terminated for reasons other than retirement
  • Beneficiary’s and/or spouse’s EGHP is secondary to Medicare. The beneficiary and/or spouse are employed and there is an EGHP that covers beneficiary, but either the EGHP is a single employer plan and employer has fewer than 20 full-and/or part-time employees OR the EGHP is a multi- or multiple-employer plan that elects to pay secondary to Medicare for employees and spouses aged 65 and older for those participating employers who have fewer than 20 employees.
  • Disabled beneficiary and/or family member’s LGHP is secondary to Medicare. The beneficiary and/or family member are employed and there is a LGHP that covers the beneficiary but either the LGHP is a single employer plan and the employer has fewer than 100 full- and/or part-time employees OR the LGHP is a multi-or multiple employer plan and all employers participating in the plan have fewer than 100 full- and/or part-time employees.
  • Non-GHP benefits exhausted
  • Non-GHP case settled
  • Services are not related to the accident for which there is an MSP record on the CWF

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Step 2: Prepare a Medicare Primary Claim for the Beneficiary’s Services

Prepare the Medicare primary claim as you usually would.

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Step 3: Report Explanatory Billing Codes on Your Medicare Primary Claim to Indicate the Reason Medicare is the Primary Payer for the Beneficiary’s Services and Submit

Before you submit your Medicare primary claim, report on that claim the specific reason Medicare is the primary payer for the beneficiary’s services. To do so, refer to the Explanatory Billing Codes below. These codes include condition codes 09, 10, 11, 28, 29 and occurrence codes 18, 19, 25 as well as certain Remarks. Upon receipt of the information, if appropriate, we can send the information to the BCRC.

There are many reasons you may have determined Medicare is the primary payer for the beneficiary’s services. If there is no claim coding available to indicate the specific reason Medicare is the primary payer for the beneficiary’s services, do not contact the BCRC. Providers may refer beneficiaries and other entities to the BCRC.

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Step 4: Wait for Medicare to Contact the BCRC with the Corrected Information From Your Medicare Primary Claim

Continue to check for the MSP record to be corrected. Use the provider self-service tools listed under Step 2 of Identify the Proper Order of Payers for a Beneficiary's Services.

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Step 5: Check the Status of Your Medicare Primary Claim.

Explanatory Billing Codes to Report on Claims to Indicate the Reason Medicare is the Primary Payer for the Beneciary's Services

The CMS expects you to report explanatory uniform billing codes on claims to let Medicare know the reason Medicare is the primary payer for the beneficiary’s services. This is true regardless of whether or not there is an MSP record that could cause the claim to be rejected. You can find references to support this in the CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Sections 20.1 and 20.2.1 and Chapter 5, Sections 70.3 and 70.3.1.1.

You must report the following uniform billing codes on Medicare claims, when applicable.

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Condition Codes

UB-04 FLs 18–28 or 2300.HI (BG) of the 837I Claim

Code Description
09 Neither the beneficiary nor spouse is employed.
10 Beneficiary and/or spouse are employed but no EGHP. You may report this code when beneficiary is age 65 or over, or when beneficiary has ESRD but not for a disabled beneficiary under age 65 (use CC 11 instead).

Note: Report, when applicable, for age 65 or over beneficiary or for ESRD beneficiary but for not for disabled beneficiary (use CC 11 instead).
11 Disabled beneficiary and/or family member is employed but no LGHP.
28 Beneficiary’s and/or spouse’s EGHP is secondary to Medicare.

Beneficiary and/or spouse are employed and there is an EGHP that covers beneficiary, but either:
  1. EGHP is a single employer plan and employer has fewer than 20 full- and/or part-time employees
or
  1. EGHP is a multi- or multiple-employer plan that elects to pay secondary to Medicare for employees and spouses aged 65 and older for those participating employers who have fewer than 20 employees.
29 Disabled beneficiary and/or family member’s LGHP is secondary to Medicare. Beneficiary and/or family member(s) are employed and there is a LGHP that covers beneficiary but either:
  1. LGHP is a single employer plan and employer has fewer than 100 full- and/or part-time employees
or
  1. LGHP is a multi-or multiple employer plan and all employers participating in plan have fewer than 100 full- and/or part-time employees.

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Occurrence Codes and Dates

UB-04 FLs 31–34 or 2300.HI (BH) of the 837I Claim

Code Description
05 Date of accident/injury for which there is no primary payer.
The claim is for an accident (typically a trauma diagnosis) but there is NO no-fault, medical payment, Workers’ Compensation, liability or other third-party coverage.

Notes:
  • If there is no open MSP record for this accident or for a prior accident and there is no other primary payer, no additional claim coding is necessary.
  • If there is an open MSP record for this accident, develop further with the beneficiary to validate their prior responses to the MSP questionnaire. Medicare may not be primary for this claim.
  • If there is an open MSP record for a prior accident, verify whether or not the current claim is related to that prior accident. If the current claim is related, develop further with the beneficiary to validate their prior responses to the MSP questionnaire. Medicare may not be primary for this claim. If the current claim is not related, also report remarks to indicate this (see Remarks below).
18 Date of retirement (beneficiary)
19 Date of retirement (spouse)
25 Date coverage no longer available (accident)
Date on which coverage, including Workers’ Compensation benefits or no-fault coverage, is no longer available to beneficiary.

Do not report OC 25 on MSP or conditional claims.


Note: You will not need to report an OC 24 and date of insurance denial/rejection on a Medicare primary claim. OC 24 is used on conditional claims when the primary payer has not made payment for a valid/acceptable reason.

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Remarks

UB-04 FL 80 or 2300.NTE of the 837I Claim

Statement Description
Claim is not related to open accident MSP record (name which record or records such as MSP VC 14 for no-fault or medical-payment, MSP VC 15 for Workers’ Compensation, or MSP VC 47 for liability) in Medicare’s records Report these remarks when the information obtained from the beneficiary or their representative, indicates that although the beneficiary was involved in a prior accident, the services on this claim are not related and Medicare is primary. You must be able to support the remarks if necessary.

National Government Services Medicare cannot accept remarks using phrases, such as:

“unrelated”
“not an accident”
“not part of an accident” or
improper spelling of the phrase “not related”

We RTP or reject claims with unacceptable phrases in remarks.

If this claim is also for a current accident (trauma diagnosis) for which you determined there is no primary payer, also report OC 05 and the date of the current accident on the claim.


In many cases, using the codes/remarks listed in the above chart(s) prevent claims from being rejected for MSP. However, if you submit the primary claim prior to when the BCRC corrects the MSP record, your claim may reject for MSP. If this happens, you must adjust it to resolve it; do not resubmit the claim as it will be rejected as a duplicate claim. Refer to Correct or Adjust a Claim Due to an MSP-Related Issue.

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Revised 10/26/2023