April 1, 2010, Home Health & Hospice Medicare A Newsline - CGS

Clarification on Submitting Medicare Secondary Payer (MSP) Claims andAdjustments and Reason Code 31265Beginning October 1, 2009, Medicare regulations changed the way providers submit MSP claims andadjustments to Medicare in certain MSP situations. Based on questions we have received, it appears thatthere is still some confusion about when and how to submit MSP claims and adjustments.To think of this in simple terms, if the primary insurer made a payment or there is a possibility that theprimary insurer will make a payment, the claim cannot be submitted direct data entry (DDE) via the FiscalIntermediary Standard System (FISS). If the primary insurer will never make a payment (services areunrelated or primary insurer denied payment), the claim can be submitted DDE via FISS. Below is a tableto assist you with determining how an MSP claim can be submitted based on the MSP situation.MSP SituationServices are unrelated to No-fault (value code 14),Liability (value code 47) or Workers’Compensation (value code 15) recordPrimary insurance denied paymentPrimary insurance made payment. BillingMedicare secondaryPrimary insurance liable, but not paid promptly(within 120 days of when claim submitted toprimary insurer)Primary insurance liable. All charges applied todeductibleDDE viaFISSYesYesElectronically(837 format)NoNoPaper (UB-04)YesSee “Note”YesSee “Note”No Yes YesNoNoNoNoYesSee “Note”YesSee “Note”Primary insurance is Federal Black Lung Program No No YesNote: If your facility does not have a waiver to allow the submission of paper claims, you must submitthe claim DDE via FISS showing Medicare as the primary payer. The claim will reject. When theclaim appears in R B9997 (this may take up to 75 days), a hardcopy adjustment can then be submittedwith the appropriate MSP information.It is important to understand if the claim is required to be submitted electronically or on paper due to theMSP situation and the claim is returned to the provider (RTP) (status/location T B9997), the claim cannotbe corrected out of RTP – a new claim must be submitted using these same regulations. In addition,when submitting the new claim, take extra care to ensure that all necessary corrections have been madebefore submitting it.If an MSP claim or adjustment, that should have been submitted electronically (837 format), is submitted orcorrected (RTP) via FISS DDE, the claim will RTP with reason code 31265. This reason code narrativestates “MSP claims and adjustment cannot be entered via direct data entry (DDE) using FISS, or correctedout of your RTP file. If you need to correct a claim that is in RTP (status/location T B9997), you mustsubmit a new claim/adjustment electronically (using the 837 format) or on paper.” In addition the narrativereminds providers that “all errors, including those for which the claim RTP’d are corrected beforesubmitting the new claim.”Home Health & Hospice April 1, 2010 35Medicare A Newsline Vol. 17, No. 7