J11 Part A Medicare Secondary Payer (MSP ... - Palmetto GBA

The Medicare SecondaryPayer (MSP) ProgramWebinarPresented by Palmetto GBA1DisclaimerThis presentation was current at the time it was published or uploaded onto thePalmetto GBA Web site. Medicare policy changes frequently so links to the sourcedocuments have been provided within the document for your reference.This presentation was prepared as a tool to assist providers and is not intended to grantrights or impose obligations. Although every reasonable effort has been made to assurethe accuracy of the information within these pages, the ultimate responsibility for thecorrect submission of claims and response to any remittance advice lies with theprovider of services.The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staffmake no representation, warranty, or guarantee that this compilation of Medicareinformation is error-free and will bear no responsibility or liability for the results orconsequences of the use of this guide.This publication is a general summary that explains certain aspects of the MedicareProgram, but is not a legal document. The official Medicare Program provisions arecontained in the relevant laws, regulations, and rulings.March 20112History of the MedicareProgram Medicare law was enacted in 1965. Under the original law, Medicare was theprimary payer for all services except thosecovered by Workers’ Compensation (WC). In 1980, Congress enacted the first series ofMedicare Secondary Payer (MSP) provisions.March 201131

Government ProgramsGovernment programs, such as researchgrants, have the primary responsibility forservices directly related to the particularfederal program.March 201110Department of VeteransAffairs (VA)Veterans who have benefits available underthe VA have the option of choosing Medicareor the VA as the primary payerNo payment may be made under Medicare forservices authorized by the VAMarch 201111Department of VeteransAffairs (VA)March 2011VA agrees to pay a provider for a specific service• Usually based on a service-connected condition• Provider bills the VA first• If the VA does not pay 100% of the charges, Medicarecan be billed secondary• If the VA denies the services, the provider should submitthe claim to Medicare primary• No conditional payment claim is neededIf the beneficiary chooses Medicare as primary, noclaim can be submitted to the VA124

Worker’s Compensation(WC)Medicare beneficiaries who work and areinjured on the job are eligible for WC benefitsunder federal law.Medicare is secondary to WC benefits whenservices rendered are related to the injury,illness, or disease sustained on the job.March 201113No-Fault or LiabilityInsuranceNo-fault/liability insurance is designed forindividuals who have had a non-work relatedaccident.Medicare is secondary in cases where thebeneficiary receives Medicare coveredservices as a result of the accident.March 201114No-FaultNo-fault insurance pays for medical expenses relatedto an injury resulting from an accident, regardless ofwho is at fault.Types of no-fault insurance include:• Automobile Insurance (Auto Medical or Med-Pay) Pays for all or part of the medical expenses for injuries sustainedin the use of, or occupancy of, an automobile regardless of whowas at fault• Homeowners’ Insurance• Commercial Insurance PlansMarch 2011155

LiabilityAny source which provides payment based on legalliability for injuries, illnesses or damages toproperty.Liability includes, but is not limited to:• Auto Liability• Uninsured/ Underinsured Motorist• Homeowner’s Liability• Product Liability• Malpractice Insurance• Wrongful DeathMarch 201116DisabilityMarch 2011Medicare is secondary if an individual meetsall of the following criteria:• Entitled to Medicare on the basis of a disability (otherthan End Stage Renal Disease).• Has Large Group Health Plan (LGHP) coverage eitherthrough his/her active employment or that of a familymember.• The LGHP is offered by an employer of 100 or moreemployees.The disability provision is designed for individualswho are under age 65 and entitled to Medicare.17Working AgedMedicare is secondary if an individual meetsall of the following criteria:• Age 65 or older and entitled to MedicarePart A• Employed or has a spouse that is activelyemployed and is covered by an EmployerGroup Health Plan (EGHP) EGHP is offered by an employer of 20 ormore employeesMarch 2011186

End-Stage Renal Disease(ESRD)The ESRD provision is designed for individuals of any agewho are entitled to Medicare because of kidney failure andwho:• Receive dialysis on a regular basis, OR• Receive a kidney transplant.Medicare entitlement for ESRD begins with the month abeneficiary:• Completes a 3 month waiting period after beginning dialysis, OR• Is admitted as a hospital inpatient for procedures in preparation for orin anticipation of a kidney transplant (if transplant takes place withinthe following 2 months), OR• Enrolls in a self-dialysis training program.March 201119End-Stage Renal Disease(ESRD)Medicare is the secondary payer if anindividual meets all of the following criteria:• Within a 30-month coordination period, theindividual was entitled to Medicare based onESRD on or after March 1, 1996.• Covered under an EGHP regardless of thenumber of employees, and through theemployment of the individual (full-time, parttime,or retired) or any family member.March 201120End-Stage Renal Disease(ESRD)30-Month Coordination Period• Effective March 1, 1996• During the coordination period, Medicare is secondary (tothe GHP) for a period of 30 months after the beneficiary’sMedicare entitlement begins.• Coordination period begins with the earlier of: The first month of eligibility for Medicare Part A, or The first month of entitlement• For beneficiaries that didn’t apply for entitlement, the dateentitlement would have begun if a timely application had been filed• MSP provision applies to all Medicare covered items andservices, not just the treatment of ESRD.March 2011217

End-Stage Renal Disease(ESRD)Example:• Beneficiary diagnosed with ESRD and begins dialysis on1/1/2009 Medicare entitlement begins 4/1/2009(Remember: Entitlement begins once a 3 month waiting period afterbeginning dialysis is completed) Medicare is secondary beginning 4/1/2009(Remember: Medicare is secondary for 30 months after entitlement begins)• Beneficiary enrolls in Self-Dialysis Training on 1/15/2009 Therefore, Medicare entitlement begins 1/1/2009(Remember: Entitlement begins at the beginning of the month a beneficiaryenrolls in Self-Dialysis Training)March 201122End-Stage Renal Disease(ESRD)Medicare coverage ends:• 12 months after the month the individual nolonger requires maintenance dialysis; or• 36 months after a successful kidney transplant.March 201123Special ESRD SituationsMarch 2011Dual Entitlement: Beneficiary is entitled toMedicare based on ESRD and also on the basis ofage or disability at the same time.• ESRD law applies regardless of the age of the Medicarebeneficiary.When a beneficiary becomes entitled on the basis ofage or disability after being entitled based on ESRD,the coordination period continues for the remainderof the 30 months.As long as dual eligibility/entitlement exists, theESRD MSP provision applies exclusively.248

Special ESRD SituationsBeneficiaries entitled to Medicare based on WorkingAged or Disability before being diagnosed withESRD are not subject to the coordination period ifMedicare was already primary.• Medicare remains the primary payer.If Medicare is secondary at the time the beneficiaryis diagnosed with ESRD, a 30-month coordinationperiod begins at the time the ESRD entitlementbegins.• Once the coordination period has ended, Medicarebecomes and remains primary for the duration of thebeneficiary’s entitlement.March 201125MSP Value CodesValue codes are used to identify the different typesof MSP categories• Working Aged: 12• Disability: 43• ESRD: 13• No-Fault: 14• Liability: 47• Workers’ Compensation: 15• Black Lung: 41• Government Programs: 16• Veterans’ Affairs: 42March 201126Identifying Other PrimaryPayer Sources279

Medicare Policies/ProceduresGeneral Admission ProceduresIdentifying Other Primary Payers During TheAdmissions ProceduresTypes of Medicare Questions to Ask aBeneficiaryPolicy for Provider Records Retention ofMSP InformationMarch 201128Provider MSP ResponsibilitiesMarch 2011A provider that bills Medicare for servicesrendered to Medicare beneficiaries mustdetermine the primary payer for thoseservices.• Ask Medicare beneficiaries, or theirrepresentatives, questions concerning thebeneficiary’s MSP status.Upon admission, complete the MSPQuestionnaire (MSPQ).29MSP Questionnaire (MSPQ)Providers are required to complete a MSPQuestionnaire for each service provided for aMedicare-entitled patient.• One Claim = One QuestionnaireThere are some exceptions for non-patient andrepetitive services.Required to identify all other primary payersunder federal law.March 20113010

MSP Questionnaire (MSPQ)Part I: Relates to Black Lung, GovernmentPrograms and Workers’ CompensationPart II: Relates to Liability and No-Fault PlansPart III: Covers Why the Beneficiary is Entitled toMedicarePart IV: Addresses Working Aged BeneficiariesPart V: Requests Additional Information forDisabled IndividualsPart VI: Pertains to Individuals Entitled to MedicareBased on ESRDMarch 201131Should I complete the MSPQ?If beneficiary is a Medicare Advantage (MA)member• Do not complete the MSPQIf beneficiary is not a MA member• Initial visit: Complete the MSPQ• Recommended that MSPQ is reviewed at leastevery 90 days and updated as necessaryMarch 201132Should I complete the MSPQ?Hospital Lab Services• If beneficiary is present, complete the MSPQ.• If beneficiary is not present, do not complete the MSPQ.Reference Labs• There is a “relaxed” policy for reference labs.• MSPQs that are no older than sixty (60) calendar daysfrom the date of service may be used to bill Medicare.• Remember to keep an audit trail.March 20113311

Should I complete the MSPQ?Recurring Outpatient Services• MSPQ can be completed once every 90 days forrecurring outpatient services.• The beneficiary must be receiving identicalservices and treatments on an outpatient basismore than once during the same monthly billingcycle.March 201134Why Comply with MSPProvisions?Compliance is the law!• Required by Medicare regulations• Required by provider’s Medicare Conditions ofParticipation (COP) contractFailure to Comply• Loses money for your facility• Subjects your facility to audits• Could cause your facility to lose its providercontract with MedicareMarch 201135Top 10 Errors Found in MSPAuditsMarch 2011Providers should comply with MSP provisions toensure that they avoid the top 10 provider errorsfound during MSP audits.1. MSP Questionnaires are not completed correctly andaccurately.2. MSP Questionnaires are not fully completed.3. Claims are filed to Medicare prior to checking CWF.4. MSP Questionnaires are not compliant with MSPregulations.5. Retirement date policy has not been implemented.3612

Top 10 Errors Found in MSPAudits6. Claims filed to Medicare incorrectly.7. Providers are not submitting no payment claimsto Medicare.8. Coordination of Benefits Contractor is not beingcontacted to update CWF.9. Occurrence codes, condition codes and valuecodes are not consistently entered on the UB-04.10. Improper use of value code 44.March 201137Eligibility ReviewOnline data may be viewed during theadmission or billing process• Data must be viewed prior to submitting a claimto Medicare• Online questions may be found in: CMS Publication 100-05, Medicare Secondary PayerManual, Chapter 3, Section 20.2.1 MSP Lookup Tool on www.PalmettoGBA/J11Aunder Self-Service Tools• Questions should be asked in sequenceMarch 201138Direct Data Entry (DDE)Access to EligibilityMarch 2011Providers may access certain MSP data in theCommon Working File (CWF) in DDE:• MSP effective/termination date• Subscriber name/policy number• Patient relationship• MSP type• Insurer type• Insurer information• Employer/employee information• Remarks code3913

Interactive Voice Response(IVR) Access to Eligibility Call (877) 567-9249:• Say or Press 2 for Eligibility• Enter NPI• Enter PTAN• Enter TIN• Enter Medicare Number• Enter Date of Birth• Enter 6 Letters of Patient’s Last Name• Enter First Letter of Patient’s First NameMarch 201140Online Provider Services(OPS) Access to EligibilityProviders may also access certain MSP datain the Online Provider Services (OPS):• MSP effective/termination date• Subscriber name/policy number• Patient relationship• MSP type• Insurer type• Insurer informationMarch 201141Policy for Provider RecordsRetention of MSP InformationProviders must document and maintain MSPinformation for Medicare beneficiaries.Information must be retained for 10 years.March 20114214

Coordination of BenefitsContractor (COBC)43Coordination of BenefitsContractor (COBC) Overview The COBC became effective as of January 8,2001. Handles the initial development of MSPrecords for all Medicare contractors. Is responsible for updating and maintainingall MSP records in the Common Working File(CWF).March 201144Why was the COBC Started?What are It’s Responsibilities?CMS believes that one contractor doing all initialinvestigation will be more efficient.Provide better customer service to beneficiaries,attorneys, employers, insurers, providers, andsuppliers.Will develop MSP investigations and reduce theamount of duplicates.Ensure accuracy and integrity of the MSPinformation contained in Common Working File(CWF).March 20114515

Who is the COB Contractor?Group Health, Inc (GHI)Medicare- Coordination of BenefitsMSP Claims Investigation ProjectPost Office Box 33847Detroit, MI 48232Telephone Number: 1-800-999-1118March 201146Reporting to the COBCThe following information must be reporteddirectly to COBC:1. Beneficiary and/or spousal change in employment2. Reporting of an accident, illness, or injury3. Federal Program coverage change4. Any other insurance coverage5. General questions relating to primary/ secondarycoverage and MSP letters/questionnairesMarch 201147March 2011Responsibilities of the MedicareAdministrative Contractor(MAC)The MAC will be responsible for:• Answering questions regarding Medicare claim orservice denials and adjustments• Answering questions concerning how to bill forpayment• Processing claims for primary and secondarypayment• Accepting the return of inappropriate Medicarepayment4816

MSP Billing Tips andProcedures49MSP Claim Submission Change Request (CR) 6426 Effective October 5, 2009, MSP claims andMSP adjustments can no longer be entereddirectly into the Fiscal Intermediary SharedSystem (FISS) via Direct Data Entry (DDE).March 201150MSP Claim SubmissionProviders have the following options to submit MSPclaims to Palmetto GBA:• DDE submitters may submit MSP claims electronicallyusing the PC-ACE Pro32 Software.• Providers may submit claims via vendor softwareprograms.• May submit MSP claims and adjustments on a hardcopyUB-04 (CMS-1450). Only if you meet the small provider exception or oneof the other exceptions outlined in the MedicareClaims Processing Manual (Publication 100-04).March 20115117

Submitting through PC-ACEPro32Downloaded for free from the Palmetto GBA Web site.• www.PalmettoGBA.com/J11A• Choose EDI > Software and ManualsIs a Windows-based claims processing system for electronichealth care claims submission in the HIPAA-compliantformat.MSP information entered via FISS DDE on a Medicare claimor adjustment on or after 10/05/2009 will Return to theProvider (RTP).• Press the F1 key from any claim page for an explanation of the reasoncode applied to the claim.March 201152Submitting through PC-ACEPro32March 2011When PC-ACE Pro32 is used to bill an MSPclaim, the information is entered in severaldifferent fields.• The LOB (Line of Business) field should containMCA (Medicare A) when filing the claim toMedicare as an MSP claim.• Enter the appropriate codes in the ConditionCodes, Occurrence Codes, and Value Codessections.53Sample PC ACE Pro32 PatientInfo & CodesMarch 20115418

March 2011CAS Segment – Claim LevelAdjustmentThe CAS segment is used to report prior payers claim level adjustments thatcaused the amount paid to differ from the amount originally charged. Thissegment is used if the payer in this loop has reported claim level adjustmentinformation on the primary payer’s remittance advice. This line can be repeated ifthere are multiple adjustment groups.CAS for Claim Level Adjustment Information:CAS01 = indicates Claim Adjustment Group Code CAS01 valid values:• CO = indicating Contractual Obligations• CR = indicating Corrections and Reversals• OA = indicating Other Adjustments• PI = indicating Payer Initiated Reductions• PR = indicating Patient ResponsibilityCAS02 = indicates Claim Adjustment Reason CodeCAS03 = indicates Monetary Adjustment AmountCAS04 = indicates Service Line Adjusted UnitsCAS05 = indicates Claim Adjustment Reason CodeCAS06 = indicates Monetary Adjustment AmountCAS07 = indicates Service Line Adjusted Units55Payer Paid AmountThis is required if the primary payer has adjudicated theclaim. Note: It is acceptable to show “0” (zero) as an amountpaid.AMT segment for COB Payer Paid Amount:• AMT01 = ‘C4’ indicating Prior Payment - Actual• AMT02 = Monetary Amount• AMT01 = ‘T3’ indicating Total Submitted Charges• AMT02 = Monetary Amount• DTP = indicates the Date Claim PaidThis monetary amount should match the claim total amountin the CLM 02. If you are doing claim level reporting, theTotal Primary Payer Paid amount (AMT*C4) plus theadjustment amounts in the claim CAS segments must equalthe Total Submitted Charge (AMT*T3).March 201156Sample PC ACE Pro32 COBInfo (Primary)March 20115719

Service Line Level ReportingLine adjudication information is provided if theservice line has adjustments applied by the primarypayer. This information is reported at the servicelevel but may be reported at the claim level if linelevel information is unavailable.Line Adjudication Information:• SVD01 = indicates Other Payer Identifier Code• SVD02 = indicates Service Line Paid Amount• SVD03 = indicates Service Line Procedure Code• SVD05 = indicates Service Line Quantity/Units ofServiceMarch 201158March 2011CAS Segment - Line LevelAdjustmentCAS segment for Line Adjustment Information:• CAS01 = indicates Claim Adjustment Group Code• CAS01 valid values:• CO = indicating Contractual Obligations• CR = indicating Corrections and Reversals• OA = indicating Other Adjustments• PI = indicating Payer Initiated Reductions• PR = indicating Patient Responsibility• CAS02 = indicates Claim Adjustment Reason Code 42• CAS03 = indicates Monetary Adjustment Amount• CAS04 = indicates Service Line Adjusted Units• CAS05 = indicates Claim Adjustment Reason Code• CAS06 = indicates Monetary Adjustment Amount• CAS07 = indicates Service Line Adjusted Units• DTP = indicates the Date Claim Paid59Sample PC ACE Pro32 MSPBilling Line ItemsMarch 20116020

Submitting Claims via VendorSoftware ProgramsTo ensure proper calculation, providers must submit CASsegments on MSP claims and adjustments.CAS segment related group codes, claim adjustment reasoncodes and associated adjustment amounts must be includedon the American National Standard Institute (ANSI) ASCX12N 837 4010-A1 MSP claim sent to Medicare.CAS segments are not utilized in the DDE environment.• The provider must take the CAS segment adjustments, as found onthe remittance advice and report these adjustments on the 837unchanged when sending the claim to Medicare for secondarypayment.Providers who are unable to submit MSP claims andadjustments via the 837 should contact their software vendor.March 201161March 2011Submitting MSP ClaimsHardcopyProviders may submit MSP claims and adjustments on ahardcopy/paper CMS-1450 (UB-04) claim form if:• They meet the small provider exception, or• They meet a qualified exception outlined in Publication 100-04,Medicare Claims Processing ManualMedicare requires mandatory electronic submission of claims• Publication 100-04, Medicare Claims Processing Manual, Chapter 24,Section 90Qualified hardcopy submitters may submit MSP claims andadjustments on a hardcopy/paper CMS-1450 (UB-04) to:Palmetto GBAClaims DepartmentMail Code: AG-600P.O. Box 100238Columbia, SC 29202-323862Condition Code 08 Condition Code (CC) 08• Use when a beneficiary will not provide other insuranceinformation.• Condition Code 08 flags the COBC for development ofthe other insurance information.• Do not include accident Occurrence Codes or ValueCodes with Condition Code 08.• Enter all available information in Remarks, including therefusal to cooperate.• Submit claim as Medicare primary.March 20116321

Billing Procedures for No-Fault and LiabilityMarch 2011Determine if services are the result of an accident.Bill all no-fault and liability insurers first.If liability is involved, obtain information andattempt to collect for 120 days.After 120 day period, you may request a conditionalpayment.Withdraw any claim you have with the liabilityinsurer.Bill Medicare showing any accident-related primarypayments using Value Codes 14 or 47, asappropriate.64Requesting a ConditionalPaymentA provider may file for conditional payment fromMedicare for services for which another payer isresponsible.If payment has not been made or cannot be expectedto be made promptly by the other payer, Medicaremay make conditional payment.Conditional payments are subject to repayment whenthe primary plan makes payment.March 201165Requesting a ConditionalPaymentTwo scenarios under which a provider mayfile for conditional payment:• No payment received from Group Health Plan(GHP)• No prompt payment received from liabilityinsurance Prompt means that payment is not received within 120daysMarch 20116622

Requesting a ConditionalPayment Do not file for conditional payment:• For services provided under the Black LungProgram• Under no-fault, liability, and worker’scompensation when:March 2011Benefits exhaust• Provide term date or contact COBC to have MSPrecord closed• Place comments on the claim in RemarksThe claim is not related• Place comments on the claim in Remarks67Requesting a ConditionalPaymentMarch 2011In a Group Health Plan (GHP) situation:• One of the following applies: Primary benefits exhausted Services not covered under primary plan Services applied to deductible or coinsurance• Show value code (12, 13, or 43) with six zeroes(0000.00).• Include Occurrence Code 24 with date of primaryinsurer’s rejection notice.68In a liability situation:Requesting a ConditionalPayment• Request conditional payment when no prompt payment isreceived from liability insurance (120 days)• Show the MSP Value Code 14 or 47 with six zeroes(0000.00)• Report the date of the accident in Occurrence Code 01,02, or 04• Include Occurrence Code 24 or 25 (date benefits exhaustor 120 days elapsed).• In the Remarks section, provide any information you haverelated to the liability insurer.March 20116923

Requesting a ConditionalPaymentMarch 2011All situations:• Report the name of the primary insurer in Form Locator(FL) 50, along with payer code “C”. PC Ace Pro32 users do not have to enter Payer Code’s, these areautomatically filled based off of the value codes and CASinformation on the claim.• Indicate the name of the insured policyholder (FL 58) andMedicare beneficiary’s relationship to the insured (FL59).• State in Remarks “Requesting conditional paymentbecause …”.70Value Code 44 Billing• Providers report Value Code 44 to indicate theALLOWED amount they are obligated to acceptfrom the primary payer. Only report Value Code 44 if:• A balance is due from the patient and provider has acontractual agreement with the primary payer• The amount received is less than total charges, or• The amount received from the primary payer is less thanthe contracted amount. Do not report Value Code 44 if it is more than totalcharges.March 201171Value Code 44 Billing• Value Code 44• Represents the OTAF or total allowed amountfrom your EOB• Coinsurance or deductible due from the patient• Value Code 12, 13, 43• Submit the value code that represents your MSPtype followed by the actual amount of yourpaymentMarch 20117224

Billing Condition Code 77Indicates that the claim is paid in full by the primarypayer• Shows that provider is obligated to accept as payment infull (OTAF) (i.e. amount reimbursed by primary payer isthe total allowed amount)• Use if NOTHING is due from the patient and the providerhas a contractual agreement (i.e. you have a write offamount) with the primary payer• Provider is not seeking reimbursement from MedicareSubmit the Value Code that appropriately representsthe MSP type (e.g., 12, 13, 43) and the actual checkpayment amountMarch 201173Status/Location R B7516 Providers may receive reason code 30928• An adjustment is being processed against a recordin a post pay location. Claim needs to be in afinalized status before making an adjustment.Please wait and refile.Claims with this reason code are inStatus/Location (S/LOC) R B7516.March 201174Status/Location R B7516March 2011Publication 100-05, Medicare SecondaryPayer Manual, Chapter 5, Section 60.1.3.2.1,B• “Cost avoidance savings may not duplicatesavings reported as full or partial recoveries andmay not be shown where Medicare ultimatelymakes primary payment.”• “The CMS prefers cost avoidance savings onlyafter 75 days have elapsed.”7525

Status/Location R B7516Claims appearing on remits in S/LOC “R B7516” are notfinalized.• Must remain in R B7516 for 75 days to become final.• Adjusting claims before final (R B9997 or P B9997) receive the 30928reason code.Post-pay claim can be closed through the Action Request (AR)process if and when the term date of the MSP record is prior tothe dates of service of the claim.• COBC should be contacted to delete/term MSP record.• If Medicare is secondary, submit an adjustment. Claim must sit for 75days.• If adjusting to make Medicare primary, indicate in Remarks that servicesare not related to an open workers’ comp, liability, no-fault, or blacklung record. Have AR sent.March 201176Status/Location R B7516 Do not attempt to adjust claims until final oruntil CWF is updated. Request processing if CWF is updated prior toyour 75-day hold. If claim has been in R B7516 longer than 75days, contact the Provider Contact Center(PCC) to have an Action Request (AR)issued.March 201177CMS MSP Resources CMS MSP Web Site• http://www.cms.gov/MSPRGenInfo/ Coordination of Benefits (COB) Home Page on theCMS Web Site• http://www.cms.gov/COBGeneralInformation/01_overview.asp CMS MSP Manual (Publication 100-05)• http://www.cms.gov/Manuals/IOM/list.asp Change Request (CR) 6426• http://www.cms.gov/transmittals/downloads/R70MSP.pdfMarch 20117826

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Explanation of System Requirements for Certain Claim Adjustment ReasonCodes (CARCs)The Table below describes the actions taken by the Medicare claims processing system whencertain Claim Adjustment Reason Codes (CARCs) appear in the Claim Adjustment Segments(CAS) of the claim.CARCsExplanation1, 2, 3, or 66 When the primary payer payment is equal to zero on alllines of service, Medicare will make a primary payment.Occurrence Code 24 and date are not required on theclaim.1 and 66 When the primary payer makes a payment greater thanzero, Medicare secondary payment calculation will occurand payment (if any) will be made accordingly.Occurrence Code 24 and date are not required on theclaim.15, 17, 29, 58, 61, 95, 112, 117, 125, The dollar amounts reported will be added to the primary130, 150, 163, 164, 179, 181, 182, payer payment amount reported on the claim. The197, 210, 223, B4, B5, B7, B8, B10, amount of secondary payment, if any, will then beB16.calculated and made accordingly.4, 10, 11, 13, 14, 16, 19, 20, 21, 34,39, 54, 101, 110, 111, 114, 115, 128,129, 133, 136, 140, 146, 155, 158,165, 174, 175, 176, 177, 180, 188,189, 201, 206, 207, 208, A1, B15,B18, B2326, 27, 31, 32, 35, 49, 50, 51, 53, 55,56, 60, 96, 119, 149, 166, 167, 170,184, 200, 204, B1 (if aMedicare covered visit), B14, W15, 6, 7, 8, 9, 12, 18, 23, 24, 33, 38, 40,97, 107, 109, 116, 138, 148, 171, 172,178, 183, 185, 191, 193, 224, A7, B11,B12, B13.44, 45, 59, 90, 91, 94, 100, 102, 103,106, 118, 131, 147, 151, 152, 153,154, 160, 156, 157, 159, 173, 190,192, 194, 198, 202, 203, B9, B20, B22No Medicare payment will be made. The claim willautomatically be rejected.If the service is covered by Medicare and the primarypayer did not make a payment, Medicare will makeprimary payment.Note: for W1 Medicare shall pay conditionally when the“E” Workers’ Comp record is open on CWF andpayment will not be made within the promptly period.The claim may be suspended for manual review claimsto determine whether or not Medicare can payment. Theclaim will be processed in accordance with all applicableMSP and claims processing rules and procedures.When the service is covered and payable by Medicare,the system will: 1) make a secondary payment for agiven service, or group of services, and 2) utilize theprimary payer’s payment amount to determine what, ifany, payment can be made.225 No payment will be made. The claim will be denied andreturn to the provider.