How To File Medicare Part B
MSP Claims Electronically

MSP Electronic Claim Filing Requirements
Effective October 1, 2005

Healthcare providers must submit their Medicare Secondary Payer (MSP) claims electronically unless they meet one of the following exceptions:

  1. Providers with fewer than 10 full-time equivalent employees
  2. Dentists
  3. Participants in a Medicare demonstration project when paper claim filing is required by that demonstration project due to the inability of the applicable implementation guide adopted under HIPAA to report data essential for the demonstration
  4. Providers that conduct mass immunizations, such as flu injections, that may be permitted to submit paper roster bills
  5. Providers that submit claims when more than one other payer is responsible for payment prior to Medicare payment (This applies when Medicare is at least the tertiary payer)
  6. Providers that only furnish services outside of the United States
  7. Providers experiencing a disruption in electricity and communication connection that is outside of their control
  8. Providers that can establish an "unusual circumstance" exists that precludes submission of claims electronically

Effective October 1, 2005, electronic MSP claims must comply with all 12X 837 Version 4010A1 implementation guide requirements, and include standard claim adjustment reason codes to describe adjustments that a primary payer made during adjudication. It is the provider’s responsibility to convert local adjustment reason codes or messages into appropriate standard CAS codes, along with other loops, segments, and data elements that apply prior to transmission. A list of all American National Standards Institute (ANSI) reason codes are available online at http://www.wpc-edi.com/.

Appropriate MSP information should be reported in the following Loops:

LOOP 2000B (Subscriber information)
  SBR01 = Secondary Payer Responsibility (S)
    SBR05 = Insurance Type Code
      12 = working aged
      13 = End State Renal Disease (ESRD)
      14 = No Fault
      15 = Workers Compensation
      16 = PHS or Federal Agency
      41 = Black Lung
      42 = Veterans Administration
      43 = Disabled
      47 = Liability
    SBR09 = Medicare Part B Claim Filing (MB)
LOOP 2300
  Segment AMT02 = the amount paid, which is equivalent to item 29 on a CMS-1500 claim form. (If you put something here payment will be sent to the beneficiary)
LOOP 2320 – (This is the header field for MSP information)
  Segment SBR01 = Primary Payer Responsibility (P)
  Segment SBR02 = Self Relationship (18) (Only required if patient relationship is self)
  Segment SBR03 = Insured Group or Policy Number
  Segment SBR04 = Insured Group Name
  Segment SBR05 = Other Insurance
  Segment SBR09 = Claim Filing Indicator Code
  Segment DMG02 = Subscribers Date of Birth
  Segment DMG03 = Male or Female

IMPORTANT NOTE: Reporting payment information in LOOP 2320 is optional. However, if you choose to report Coordination of Benefits (COB) payment information in this LOOP (2320), you must include all of the following segments:

AMT01 = COB Allowed or Approved Amount
AMT02 = Monetary Amount
AMT01 = COB Payer Paid Amount
AMT02 = Monetary Amount

LOOP 2330A – (Subscriber information)
  Segment NM101 = Insured or Subscriber (IL)
  Segment NM102 = Person (1)
  Segment NM 103 = Last/Organization Name
  Segment NM104 = First Name
  Segment NM105 = Middle Name (Middle initial)
  Segment NM 108 = Member Identification Number (MI)
  Segment NM109 = Identifier (Policy Number)
  Segment N301 = Address Line (Subscriber’s address)
  Segment N401 = City Name (Subscriber’s city)
  Segment N402 = State Name (Subscriber’s state)
  Segment N403 = Zip Code
   
LOOP 2330B – (Other payer information)
  Segment NM101 = Payer (PR)
  Segment NM102 = Non-Person Entity (2)
  Segment NM103 = Last/Organization Name (Name of primary insurer)
  Segment NM108 = Payer Identification (PI)
  Segment NM109 = Identifier (Medigap Inkey code) (If no Medigap Inkey code, we recommend including the insurer’s address in this field)
   
LOOP 2400 – (Service line)
  Segment AMT01 = COB Approved Amount (AAE)
  Segment AMT02 = Monetary Amount (What the primary allowed for the service billed)
  Segment CN101 = Other Contract (09) (Obligated to accept indicator)
  Segment CN102 = Contract Amount (The amount that you are obligated to accept)
   
LOOP 2430 – (Line adjudication information)
  Segment SVD01 = Other Payer Primary Identifier (This number should match NM109 in Loop id 2330B Identifying Other Payer) 
  Segment SVD02 = Service Line Paid Amount (What the primary paid for this service reported in LOOP 2400)
CAS Segments are where the reason codes of the primary insurers will explain how they processed the claim.
  No Contractual Obligation
    CAS01 = Patient Responsibility Adjustment (PR)
    CAS02 = Reason Code (ANSI)
    CAS03 = Adjustment Amount
  Contractual Obligation
    CAS01 = Contractual Obligation Adjustment (CO)
    CAS02 = Reason Code (ANSI)
    CAS03 = Adjustment Amount
    CAS01 = Patient Responsibility Adjustment (PR)
    CAS02 = Reason Code (ANSI)
    CAS03 = Adjustment Amount

A list of all ANSI (American National Standards Institute) reason codes can be found in the ANSI Reason Code Guidebook Section of our web site or at: http://www.wpc-edi.com/.

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