MSP Electronic Billing Instructions
The Centers for Medicare and Medicaid Services (CMS) now requires all
claims, including MSP claims, to be filed electronically,
with few exceptions. Please reference CMS
Change Request 3440 
and
the Administration Simplification Compliance Act (ASCA) of 2001. An exception
to this rule is when there is more than one payer responsible for payment
before Medicare considers the charges. These claims may still be submitted
hardcopy. Complete information about submitting electronic MSP claims
is included in the "4010A1 Professional Implementation Guide 837".
The implementation guide is available at http://www.wpc-edi.com/content/views/533/377/.
If another insurance company pays primary benefits, secondary Medicare
benefits may be payable to supplement the amount paid by the primary
insurer. Medicare secondary benefits may be payable if all of the following
situations apply:
- The primary insurer's payment is less than the provider's charges for Medicare covered services;
- The primary insurer's payment is less than the maximum amount payable by Medicare; and,
- The provider does not accept and is not obligated to accept the primary insurer's primary payment as payment in full.
The following commonly used terms and field explanations will serve as a guide for submitting proper electronic MSP claims.
Commonly Used Terms:
OTAF
The Obligated To Accept as Payment in Full Amount (OTAF) is the amount
the provider agreed to accept as payment in full for a service rendered
under the provisions of the primary payer's contract. When a primary
payer allows less than the billed amount and the provider is contractually
obligated to accept that amount as payment in full then the allowed amount
is the OTAF amount. Terms often seen on primary insurer Explanation of
Benefits to indicate OTAF include but are not limited to: Contractual
Adjustment, Network Discount, Provider Discount, Contract Write-off,
Capitation Amount, PPO Discount, PPO Savings.
Contractual
Contractual Obligation is the difference between billed amount and Obligation
primary allowed amount that cannot be billed to the beneficiary.
Patient Responsibility
Beneficiary responsibility is the amount that can be billed to the (PR) beneficiary,
normally the difference between primary allowed amount and the primary
paid amount. This amount can be equal to zero.
Approved Amount
Approved Amount is the amount of money approved by the primary payer.
The allowed equals the amount for the service line that was approved
by the payer.
Line Adjustments
Line adjustments are required if the primary payer made line level adjustments
that caused the amount paid to be different from the amount originally
charged. 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 Adjudication
Line Adjudication segment is used to report the date the claim was adjudicated
by the primary payer and is required on all MSP claims.
CAS Segment
CAS Segment is used to report the adjustment reason codes and amounts
as needed.
Adjustment Reason
Adjustment Reason is used to report the adjustment on each service line
such as co-insurance, deductible, contractual adjustment, etc. Example: The
provider submits an MSP claim with the following:
$60 Billed Amount
$20 Network Discount
$40 Primary Allowed Amount
$10 Copayment Amount
$30 Primary Paid Amount
The $20 difference between the allowed and the billed amount will be
a Contract Obligation (CO) adjustment. The $40 the primary allowed will
also be the Obligated To Accept as Payment in Full (OTAF) amount. The
$10 difference between the primary paid and the primary allowed will
be a Patient Responsibility (PR) adjustment. The primary payment will
be $30
The Claim Adjustment Reason codes are located on the Washington Publishing
Company web site http://www.wpc-edi.com.
Instructions for Electronic Billing of MSP Claims:
Claim Level Primary Payer Paid Amount
For claim level information, physicians and suppliers must indicate the
other payer paid amount for the claim in loop 2320 AMT01 = D (qualifier)
and AMT02 the monetary amount. NOTE: All line level payments
when added together must equal the total amount paid on the claim.
Claim Level Primary Payer Allowed Amount
For claim level information, physicians and suppliers must indicate the
other payer allowed amount for the claim in loop 2320 AMT01 = B6 (qualifier)
and AMT02 the allowed amount. NOTE: All line level allowed
amounts must equal the total allowed amount on the claim when added
together.
Claim Level Obligated to Accept as Payment in Full Amount (OTAF)
For claim level information, physicians and suppliers must indicate the
OTAF amount in loop 2300 CN101 = 9 and CN102 = the OTAF amount. This
amount must be greater than zero if there is an OTAF amount. NOTE:
All line level OTAF amounts must equal the total OTAF amount on the
claim when added together.
Line Level Primary Payer Paid
For line level information, physicians and suppliers must indicate the
other payer paid amount for that particular service in loop 2430 SVD02.
Line Level Primary Payer Approved
For line level information, physicians and suppliers must indicate the
other payer approved amount for that particular service in loop 2400
AMT01 = AAE (qualifier) and AMT02 the monetary amount.
Line Level Obligated to Accept as Payment in Full Amount (OTAF)
For line level information, physicians and suppliers must indicate the
OTAF amount for that service line in loop 2400 CN101 = 9 and CN102
is the OTAF amount. This amount must be greater than zero if there
is an OTAF amount.
Loops and Segments Table
The following are instructions for the segments and elements that are required when submitting MSP information electronically. Please note that some segments and elements are situational but may become required when used.
Loop 2000B - Subscriber Information
| Usage | Element | Value | Comment |
|---|---|---|---|
Required |
SBR01 | P=Primary S =Secondary T=Tertiary Use to indicate 'payer of last resort' |
Code identifying the insurance carrier's level of responsibility for payment of a claim. (To identify whether Medicare is primary, secondary or tertiary) For Medicare Secondary Payer (MSP) claims being sent to Medicare Part B the code would be "S". |
Situational |
SBR02 | 18 |
Specifies the relationship to the person insured. |
Situational |
SBR03 | Policy or group number |
|
Situational |
SBR04 | The name of group plan |
|
Situational |
SBR05 | 12 = Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 = Medicare Secondary End-Stage Disease Beneficiary in the 12 month coordination period with an employer's group health plan 14 = Medicare Secondary, No-fault Insurance including Auto is Primary 15= Medicare Secondary Worker's Compensation 16 = Medicare Secondary Public Health Services (PHS) or Other Federal Agency 41 = Medicare Secondary Black Lung 42 = Medicare Secondary Veteran's Administration 43 = Medicare Secondary Disabled Beneficiary Under Age 65 with Large group Health Plan (LGHP) 47 = Medicare Secondary, Other Liability Insurance is Primary |
Code to identify the type of insurance policy within a specific insurance program. (Required when SBR01 = S) |
Situational |
SBR09 | 09 = Selfpay10 = Central Certification 11 = Other Non-Federal Programs 12 = Preferred Provider Organization (PPO) 13 = Point of Service (POS) 14 = Exclusive Provider Organization (EPO) 15 = Indemnity Insurance 16 = Health Maintenance Organization (HMO) Medicare Risk AM = Automobile Medical BL = Blue Cross/Blue Shield CH = Champus CI = Commercial Insurance Co. DS= Disability HM= Health Maintenance Organization LI = Liability LM = Liability Medical MB = Medicare Part B MC = Medicaid OF = Other Federal Program TV = Title V VA = Veteran Administration Plan WC = Workers' Compensation Health Claim ZZ = Mutually Defined |
Code to identify the type of claim |
Loop 2300 - Claim Information
Contract Information
| Situational | CN101 | 01 = Diagnosis Related Group (DRG) 02 = Per Diem 03 = Variable Per Diem 04 = Flat 05 = Capitated 06 = Percent 09 = Other |
Code to identify a contract type |
|---|---|---|---|
Situational |
CN102 |
The amount of the contract agreement (Obligated to Accept as Payment in Full Amount). |
Loop 2320 - Other Subscriber Information
Required if other payers are known to potentially be involved in paying on this claim.
| Usage | Element | Value | Comment |
|---|---|---|---|
Required |
SBR01 | P=Primary S =Secondary T=Tertiary Use to indicate 'payer of last resort' |
Code identifying the insurance carrier's level of responsibility for payment of a claim. If claim is being sent to Medicare Part B the code would be "P" to identify primary information. |
Required |
SBR02 | 01 = Spouse 04 = Grandfather or Grandmother 05 = Grandson or Granddaughter 07 = Nephew or Niece 10 = Foster Child 15 = Ward 17 = Stepson or Stepdaughter 18 = Self 19 = Child 20 = Employee 21=Unknown22 = Handicapped Dependent 23 = Sponsored Dependent 24 = Dependent of a Minor Dependent 29 = Significant Other 32 = Mother 33 = Father 36 = Emancipated Minor 39= Organ Donor 40 = Cadaver Donor 41 = Injured Plaintiff 43 = Child Where Insured has No Financial Responsibility 53 = Life Partner G8 = Other Relationship |
Specifies the relationship to the insured |
Situational |
SBR03 | Policy or group number |
|
Situational |
SBR04 | Name of plan |
|
Required |
SBR05 | AP = Auto Insurance Policy C1 = Commercial CP = Medicare Conditionally Primary GP = Group Policy HM = Health Maintenance Organization (HM0) IP = Individual Policy LD = Long Term Policy LT = Litigation MB = Medicare Part B MC = Medicaid MI = Medigap Part B MP = Medicare Primary OT = Other PP = Personal Payment (Cash - No Insurance) SP = Supplemental Policy |
Code to identify the type of insurance policy within a specific insurance program. |
Required |
SBR09 | 09 = Selfpay 10 = Central Certification 11 = Other Non-Federal Programs 12 = Preferred Provider Organization (PPO) 13 = Point of Service (POS) 14 = Exclusive Provider Organization (EPO) 15 = Indemnity Insurance 16 = Health Maintenance Organization (HMO) Medicare Risk AM = Automobile Medical BL = Blue Cross/Blue Shield CH = Champus CI=Commercial Insurance Co DS= Disability HM = Health Maintenance Organization LI = Liability LM = Liability Medical MB= Medicare part B MC = Medicaid OF = Other Federal Program TV= Title V VA=Veteran Administration Plan Refers To Veterans Affairs Plan WC = Workers' Compensation Health Claim ZZ = Mutually Defined Unknown |
Code to identify the type of claim |
Loop 2320 - Other Subscriber Information
Coordination of Benefits (COB) Payer Paid Amount and Allowed Amount
| Required | AMT01 | D | Code to identify the primary paid amount |
|---|---|---|---|
Required |
AMT02 | Total amount paid by the primary payer |
|
Required |
AMT01 | B6 | Code to identify the primary allowed amount |
Required |
AMT02 | Total amount allowed by the primary payer |
Subscriber Demographic Information
| Required | DMG01 | D8 | Code indicating the format of the date |
|---|---|---|---|
Required |
DMG02 | Date of birth (CCYYMMDD) |
|
Required |
DMG03 | F = Female M = Male U= Unknown |
Code indicating the sex of the individual |
Other Insurance Coverage Information
| Required | OI03 | N = No Y = Yes |
A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. |
|---|---|---|---|
Situational |
OI04 | B = Signed signature authorization form or forms for both HCFA-1500 Claim Form block 12 and block 13 are on file C = Signed CMS Claim Form on file M = Signed signature authorization form for CMS Claim Form block 13 on file P = Signature generated by provider because the beneficiary was not physically present for services S = Signed signature authorization form for CMS Claim Form block 12 on file |
Indicates how the beneficiary or subscriber authorization signature was obtained and how it is being retained by the provider. |
Required |
OI06 | A = Appropriate Release of Information on File at Health Care Service Provider or at Utilization Review Organization I= Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statues M = The Provider has Limited or Restricted Ability to Release Data Related to a Claim N= No, Provider is Not Allowed to Release Data O = On file at Payer or at Plan Sponsor Y = Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim |
Code indicating if the provider has on file a signed statement by the beneficiary authorizing the release of medical data to other organizations. |
Loop 2330A Other Subscriber Name and Address
| Usage | Element | Value | Comment |
|---|---|---|---|
Required |
NM101 |
IL | Code identifying the insured or subscriber |
Required |
NM102 |
1 = Person 2 = Nonperson Entity |
Code qualifying the type of entity |
Required |
NM103 |
Last Name or Organization Name |
|
Situational |
NM104 |
Subscriber first name |
|
Situational |
NM105 |
Subscriber middle |
|
Situational |
NM107 |
Subscriber generation (suffix) |
|
Required |
NM108 |
MI = Member Identification Number to convey the following terms: Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc. |
Code to indicate Member ID |
Required |
NM109 |
Identification Number |
|
Required |
N301 |
Address Information (address 1) |
|
Situational |
N302 |
Address Information (address 2) required if second address exists |
|
Situational |
N401 |
City Name Required when information is available |
|
Situational |
N402 |
State or Province Code Required when information is available |
|
Situational |
N403 |
Postal Code Required when information is available |
|
Situational |
N404 |
Country Code Required if the address is out of the U.S. |
Loop 2330B - Other Payer Name
| Usage | Element | Value | Comment |
|---|---|---|---|
Required |
NM101 |
PR = Payer | Code to identify an organizational entity or other payer. |
Required |
NM102 |
2= Nonperson Entity |
Code to identify type of entity |
Required |
NM103 |
Name Last or Organization Name |
|
Required |
NM108 |
PI = Payer Identification
XV = Health Care Financing Administration National Plan ID |
Code to identify Payer or organization |
Required |
NM109 |
Payer Identification Code |
Loop 2400 - Service Line
Contract Information
| Required | CN101 | 01 = Diagnosis Related Group (DRG) 02 = Per Diem 03 = Variable Per Diem 04 = Flat 05 = Capitated 06 = Percent 09 = Other |
Code to identify the contract type |
|---|---|---|---|
Situational |
CN102 |
The amount of the contract agreement (Obligated to Accept as Payment in Full Amount). |
Approved Amount
| Usage | Seg/El | Value | Comment |
|---|---|---|---|
Required |
AMT01 |
AAE | Code to identify the amount approved by the primary payer. |
Required |
AMT02 |
Code to identify the primary payer approved amount for each service line. |
Loop 2430 - Line Adjudication Information
| Usage | Seg/El | Value | Comment |
|---|---|---|---|
Required |
SVD01 |
Payer Identification Code |
|
Required |
SVD02 |
The amount paid by the primary payer for each service line. Zero "0" is an acceptable value for this element. |
|
Required |
SVD03-1 |
HC = Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
IV=Home Infusion EDI Coalition (HIEC) Product/Service Code ZZ = Mutually Defined |
Code to identify the type of medical procedure. |
Required |
SVD03-2 |
Procedure Code |
|
Situational |
SVD03-3 |
Procedure Code Modifier Procedure Modifier 1 |
|
Situational |
SVD03-4 |
Procedure Code Modifier Procedure Modifier 2 |
|
Situational |
SVD03-5 |
Procedure Code Modifier Procedure Modifier 3 |
|
Situational |
SVD03-6 |
Procedure Code Modifier Procedure Modifier 4 |
|
Required |
SVD05 |
Paid units of service |
|
Situational |
SVD06 |
Assigned Number (used only for bundling of service lines). |
Line Adjustment
| Usage | Seg/El | Value | Comment |
|---|---|---|---|
Required |
CAS01 | CO = Contractual Obligations CR = Correction and Reversals OA = Other Adjustments PI = Payer Initiated Reductions PR = Patient Responsibility |
Code to identify the general category of payment adjustment. |
Required |
CAS02 | Claim Adjustment Reason codes are located on the Washington Publishing Company web site at http://www.wpc-edi.com |
|
Required |
CAS03 | Monetary Amount Use this amount for the adjustment amount |
|
Situational |
CAS04 |
Quantity Use as needed to show payer adjustment |
|
Situational |
CAS05 |
Claim Adjustment Reason Code Use as needed to show payer adjustment |
|
Situational |
CAS06 |
Monetary Amount Use as needed to show payer adjustment |
|
Situational |
CAS07 |
Quantity Use as needed to show payer adjustment |
|
Situational |
CAS08 |
Claim Adjustment Reason Code Use as needed to show payer adjustment |
|
Situational |
CAS09 |
Monetary Amount Use as needed to show payer adjustment |
|
Situational |
CAS10 |
Quantity Use as needed to show payer adjustment |
|
Situational |
CAS11 |
Claim Adjustment Reason Code Use as needed to show payer adjustment |
|
Situational |
CAS12 |
Monetary Amount Use as needed to show payer adjustment |
|
Situational |
CAS13 |
Quantity Use as needed to show payer adjustment |
|
Situational |
CAS14 |
Claim Adjustment Reason Code Use as needed to show payer adjustment |
|
Situational |
CAS15 |
Monetary Amount Use as needed to show payer adjustment |
|
Situational |
CAS16 |
Quantity Use as needed to show payer adjustment |
|
Situational |
CAS17 |
Claim Adjustment Reason Code Use as needed to show payer adjustment |
|
Situational |
CAS18 |
Monetary Amount Use as needed to show payer adjustment |
|
Situational |
CAS19 |
Quantity Use as needed to show payer adjustment |
Line Adjudication Date
| Usage | Seg/El | Value | Comment |
|---|---|---|---|
Required |
DTP01 |
573 |
Date/Time Qualifier |
Required |
DTP02 |
D8 | Date Expressed in Format CCYYMMDD |
Required |
DTP03 |
Date Time Period |
