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Medicare Secondary Payer FAQs

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  1. How do providers bill for MSP Conditional Payments?
  2. If there is an open Worker's Compensation screen on CWF, does it need to be closed if not Worker's Compensation related?
  3. When can Conditional Primary Medicare Benefits be Paid?
  4. What if the Insurance name on the claim does not match Common Working File?
  5. How do I proceed with a claim that has been rejected with an MSP reason code in the 34000 range?
  6. How do you use Value Code 44 when billing MSP claims?
  7. How do I bill a claim to Medicare that has been denied by the primary insurance?
  8. What required "claim change condition code" do I use when adjusting a denied claim to make Medicare the primary payer?
  9. Can MSP adjustments be submitted electronically?
  10. Who do I contact if the beneficiary's admission questionnaire does not match the information on Common Working File (CWF)?
  11. Updating an Employer Group Health Plan (EGHP) or Large Group Health Plan (LGHP) record
  12. Updating a liability, no-fault, or worker's compensation record
  13. Updating a Datamatch record
  14. If we have never sent claims electronically, how do we get set up to do so?
  15. Is dialing through a modem the only way to send an electronic file?
  16. Is there a free software program available to create our claims, or would we have to purchase one?
  17. Can the PC-Ace program be used to transmit claims electronically?
  18. If we already create electronic claim files using a vendor software, do we have to use the PC-Ace software for our MSP claims?
  19. Can the PC-Ace software be used to correct claims that are in a Return to Provider (RTP) location?
  20. If we use a clearinghouse to submit our Medicare primary claims electronically, can they also submit our MSP claims?
  21. Where do I bill Black Lung?
  1. How do providers bill for MSP Conditional Payments?

    The following conditions must be present if requesting a conditional payment:

    • MSP value code must be present with a zero (0.00) dollar amount listed
    • Occurrence code 01, 02, 03, 04, or 24 must be present
    • First Payer Identification code must be reported as a C
    • Insurer name must be present and match CWF
    • Remarks must be present with a valid reason for requesting conditional payment

    ***If adjusting a claim for a conditional payment, a D9 condition code must be used. The D9 is only to be used when it is an adjustment for a conditional payment. The conditional payment is given when the primary insurance (GHP or a Liability insurance) denies the claim in whole or when the liability insurance has not responded to the provider and it has been over 120 days since the date of the claim. All other situations should either be a D7-adjustment to make Medicare Secondary (MSP value code and amount of the primary payment is more than $0.00) or D8-adjustment to make Medicare primary (CWF is closed).

    ***If remarks are not valid, the claim will be returned to the provider.

    ***If requesting a conditional payment due to the 120 day rule, a 24 occurrence code cannot be used because insurance has not denied the claim. The requester must use the appropriate accident/injury occurrence code 01, 02, 03, or 04.

    Example of valid reason for requesting a conditional payment:

    1. GHP denies a properly filed claim in whole.
    2. The claim is 120 days past the date of accident and a conditional payment is being requested.

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  3. If there is an open Worker's Compensation screen on CWF, does it need to be closed if not Worker's Compensation related?

    No, just put your claim information on the first line in remarks "Not Workers Compensation" and the MSP department will work these claims. If the claim is worked incorrectly, refer to MSP to have claim adjusted.

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  5. When can Conditional Primary Medicare Benefits be paid?

    • The beneficiary, provider, physician, or supplier has filed a proper claim with a Group Health Plan in the case of services for which payment under Workers Comp, or liability, or no-fault insurance can reasonably be expected, and the contractor determines that the Group Health Plan insurer will not pay promptly (within 120 days of receipt of the claim) for any reason except when the Group Health Plan claims that its benefits are secondary to Medicare; or
    • The beneficiary or provider, physician, or supplier that has accepted assignment filed a proper claim with a Group Health Plan or Large Group Health Plan denied the claim in whole or in part; or
    • Because of physical or mental incapacity of the beneficiary, the physician, the supplier or beneficiary failed to file a proper claim with the Group Health Plan.

    When such conditional Medicare payments are made, they are made on condition that both the insurer and beneficiary will reimburse the program to the extent that payment is subsequently made by the Group Health Plan.

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  7. What if the Insurance name on the claim does not match Common Working File?

    As the provider, you are responsible for checking the MSP screen on CWF to ensure the information is accurate before you submit your claim to Medicare. If the information is correct, you may proceed with submitting your claim. If the screen is incorrect, you must contact the Benefits Coordination and Recovery Center (BCRC) at (855) 798-2627 to update the CWF. Once the screen has been updated you may submit your claim. However, if you do not have access to CWF you may contact the MSP Department at (866) 518-3284 and we will check CWF for you.

    For Internal Revenue Service (IRS)/Social Security Administration (SSA)/Datamatch you or the employer must send a letter (on the employer's letterhead) to the BCRC at the following address:

    Benefits Coordination and Recovery Center
    P.O. Box 138832
    Oklahoma City, OK 73113
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  9. How do I proceed with a claim that has been rejected with an MSP reason code in the 34000 range?

    When a claim has been rejected with a reason code in the 34000 range, you must either bill the other insurance company or contact the Coordination of Benefit Contractor (COB) Benefits Coordination and Recovery Center (BCRC) to update the MSP record on Common Working File (CWF). If you receive a payment or a denial from the other insurance company, you can request an adjustment be made on the original claim. You can also request an adjustment to the original claim after the BCRC has corrected the MSP record on CWF. Please do not request a cancel on the original claim. Only an adjustment should be completed on a rejected MSP claim.

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  11. How do you use Value Code 44 when billing MSP claims?

    A value code 44 is used when a primary payer pays less than actual charges and less than the amount a provider is contractually obligated to accept as payment in full from an insurance company. A 44 code should only be used for claims where there is a contractual agreement with an insurance company. The value code 44 is used with the amount the provider was obligated to accept. Use the appropriate value code (12, 13, or 43) with the amount actually received from the insurance company.

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  13. How do I bill a claim to Medicare that has been denied by the primary insurance?

    If the primary insurance denied the claim use an Occurrence Code 24 with the date the primary insurance denied the claim, use the appropriate value code with a $0.00 dollar amount. The primary payer code should be a "C with the primary insurance name and the secondary line should show a payer code "Z and Medicare. Include in remarks the reason the primary insurance denied the claim (i.e., insurance denied services not covered).

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  15. What required "claim change condition code" do I use when adjusting a denied claim to make Medicare the secondary payer?

    You must use a condition code D7 along with the appropriate adjustment reason code (i.e., BL (Black Lung), DB (Disability), LI (Liability), WC, (Workers Compensation), etc.

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  17. Can MSP adjustments be submitted electronically?

    With the exception of (DDE) Direct Data Entry, MSP adjustments can be submitted electronically or hardcopy, but for faster processing of your adjustments we encourage you to submit them electronically.

    You are responsible for checking the MSP screen on Common Working File (CWF) to ensure the information is accurate. If the information is correct, you may proceed with requesting your adjustment. If the screen is incorrect, you must call the Benefits Coordination and Recovery Center (BCRC) at (855) 798-2627 to update the CWF.

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  19. Who do I contact if the beneficiary's admission questionnaire does not match the information on Common Working File (CWF)?

    If you have a situation where the MSP information does not match CWF the Benefits Coordination and Recovery Center (BCRC) must be contacted at (855) 798-2627. Submit a claim once CWF has been updated.

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  21. Updating an Employer Group Health Plan (EGHP) or Large Group Health Plan (LGHP) record

    If your provider number is on file with the Benefits Coordination and Recovery Center (BCRC) you may update a regular group record. You must be able to provide the insurance name, address, policy number, and the termination date. If you are trying to change the name and number of the insurance (i.e., "Prudential to "Anthem ) you must provide correct insurance name, address, policy number, and telephone number. BCRC will request information about the patient such as the patient's name, address, date of birth, possible effective dates to Medicare, etc. You should already have this information according to their records and the MSP admission questionnaire.

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  23. Updating a liability, no-fault, or worker's compensation record

    If your provider number is on file with the Benefits Coordination and Recovery Center (BCRC) and you want to update a liability, no fault or worker's comp record you will need to contact the lead contractor assigned by the BCRC. The BCRC should be able to give the provider the name and number of the contractor who can update this record. CMS has assigned certain states (where the patient currently lives) to each Medicare office that initiates for subrogation. This will happen when a patient is involved in a slip/fall, auto accident, malpractice, or worker's comp injury.

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  25. Updating a Datamatch record

    If you call Benefits Coordination and Recovery Center (BCRC) and your provider number is in the system and you want to update a group record, you may be told that the record is a Datamatch record. In this situation BCRC will instruct you to call the patient and have the patient's employer fax information to their office that contains a termination date or any information that is needed to update this record, so a claim can be processed correctly.

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  27. If we have never sent claims electronically, how do we get set up to do so?

    The first step a provider would need to do in order to send claims electronically is to register for a WPS Medicare Submitter ID. This Submitter ID is used within the electronic file to identify who is sending the file. You can register for a Submitter ID on our website. If you currently receive your remittance advices electronically, registration is not necessary. Fax an Electronic Data Interchange (EDI) form to WPS Medicare at (402) 995-0606.

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  29. Is dialing through a modem the only way to send an electronic file?

    No. Your connectivity options are:

    • Bulletin Board System (BBS)
    • Use of connectivity vendor: IVANs or Vision Share.
    • Clearinghouses or billing service
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  31. Is there a free software program available to create our claims, or would we have to purchase one?

    We do offer free billing software called PC-Ace Pro 32. The software and a user's guide can be downloaded from the WPS EDI website.

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  33. Can the PC-Ace program be used to transmit claims electronically?

    No. The PC-Ace program can only be used to create the electronic claim file. It cannot send the file for you.

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  35. If we already create electronic claim files using a vendor software, do we have to use the PC-Ace software for our MSP claims?

    No. If you are already using vendor software to create your claims electronically, you can use that software for your MSP claims unless they are not set up to create MSP claims.

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  37. Can the PC-Ace software be used to correct claims that are in a Return to Provider (RTP) location?

    No. In order to correct claims in the RTP location, you will have to contact the MSP area at (866) 518-3284, and they will make the corrections for you.

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  39. If we use a clearinghouse to submit our Medicare primary claims electronically, can they also submit our MSP claims?

    Yes. If you use a clearinghouse to submit Medicare primary claims, the clearinghouse can also be used to submit MSP claims.

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  41. Where do I bill Black Lung?

    If you are aware that a Medicare beneficiary may be entitled to have the services reimbursed by the Department of Labor (DOL) under the Federal Black Lung Program, bill DOL for only Black Lung related claims and submit a no-payment bill (IOM Publication 100-05, Chapter 5, Section 30.4) to your intermediary.

    The address for sending bills to DOL is:

    U.S. Department of Labor
    Federal Black Lung Program
    PO Box 8302
    London, KY 40742-8302

    Please be sure to include the claim number on every page you mail or fax to OWCP.

    If your medical providers' bills or your own reimbursement requests are denied under your state award, send the bill or the reimbursement request and original receipts, along with a copy of the denial letter, to:

    FEDERAL BLACK LUNG PROGRAM
    P.O. BOX 828
    LANHAM-SEABROOK, MD 20703-0828

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Page Last Updated: Monday, 29-Sep-2014 13:59:17 CDT