Populating MSP Insurance Type Code on Electronic Claims
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Populating MSP Insurance Type Code on Electronic Claims
When you identify beneficiaries that have Medicare as the secondary payer, you are required to submit electronic claims with the appropriate MSP insurance type code.
MSP Insurance Type Codes identify the reason for other coverage and shall be indicated on the ANSI 5010A1 within the 2000B and 2320 SBR05 loop/segment. When 2000B SBR01 equals “T” or “S,” the MSP insurance type code must equal one of the following values: 12, 13, 14, 15, 16, 41, 42, 43 or 47.
Beneficiaries insurance is classified in different MSP insurance type codes and categories such as:
- Group Health Plan (GHP): types of coverage are based on current or past employment
- Non-group Health Plan (NGHP): typically types of coverage that are a result of an accident or injury
The most common used MSP insurance type codes fall under GHP 12, 43 and 13.
GHP
| MSP Type Code | MSP Category |
|---|---|
| 12 | Working Aged – Beneficiaries age 65 or older who are insured through their own or their spouse’s current employment. The beneficiary must be aged 65 or older. There must be at least 20 or more employees. |
| 13 | End Stage Renal Disease – This coverage is for beneficiaries enrolled with Medicare solely due to renal failure and are insured their own, or through a family member’s current or former employment. Medicare is secondary payer for the first 30 months. There is no age restriction on this type of coverage. The beneficiary may be under or over age 65. |
| 43 | Disability – This coverage is for beneficiaries who are under age 65 and disabled. Insurance is based on their own current employment or through the current employment of a family member. There must be 100 or more employees. |
NGHP
| MSP Type Code | MSP Category |
|---|---|
| 14 | Automobile/no-fault – No-Fault insurance that pays for medical expenses for injuries sustained from a motor vehicle accident. This coverage is not based on employment. |
| 15 | Workers’ Compensation – This is insurance that employers are required to provide employees that become ill or injured on the job. |
| 47 | Liability – Insurance (including a self-insured plan) that provides payment based on the policyholder’s alleged legal liability for injury, illness or damage to property. Some examples of this coverage could be product liability, malpractice, and homeowner’s coverage. |
NGS encourages J6 and JK providers and suppliers to use the CMS Model MSP Questionnaire available in CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Section 20.2.1 to screen for other payers that are primary to Medicare. Use of the CMS questionnaire will help you in determining the applicable MSP insurance type code.
Related Content
- CMS IOM Publication 100-05, Medicare Secondary Payer Manual,
- CMS Medicare Secondary Payer web page
- Medicare Secondary Payer for Provider, Physician, and Other Supplier Billing Staff
Reviewed 10/25/2023