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

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