Instructions to Physicians and Other Suppliers: How to Submit Claims

30.5 - Instructions to Physicians and Other Suppliers: How to Submit Claims to A/B MACs (Part B) and DME MACs When There Are One or More Primary Payers (Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23) A. When Medicare is the Secondary Payer Following One Primary Payer There are situations where one primary payer pays on a Medicare Part B claim and Medicare may make a secondary payment on the claim. Physicians and other suppliers must comply with the Section titled “Coordination of Benefits,” found in the 837 version Professional Implementation Guide (IG) regarding the submission of Medicare beneficiary MSP claims Physicians and other suppliers must follow the section that discusses the provider-to-payer-to-provider methodology of submitting electronic claims. Physicians and other suppliers must use the appropriate loops and segments to identify the other payer paid amount, allowed amount, and the obligated to accept payment in full amount on the 837 as identified below: Primary Payer Paid Amount: For line level services, physicians and other suppliers must indicate the primary payer paid amount for that service line in loop ID 2430 SVD02 of the 837. For claim level information, physicians and other suppliers must indicate the other payer paid amount for that claim in loop ID 2320 AMT02 AMT01=D of the 837. Primary Payer Allowed Amount: For line level services, physicians and other suppliers must indicate the primary payer allowed amount by identifying the adjustment amount in the CAS segment using the CO 45 for that service line of the 837. For claim level information, physicians and other suppliers must indicate the primary payer allowed amount by identifying the adjustment amount in the CAS segment using the CO 45 for the 837 claim. Obligated to Accept as Payment in Full Amount (OTAF): The OTAF amount for Part A and Part B claims is identified in the CAS segment as group code CO (usually associated with Claim Adjustment Reason Code 45) with the associated dollar adjustment amount. The OTAF amount must be greater than zero if there is an OTAF amount, or if OTAF applies. B. When Medicare is the Secondary Payer Following Multiple Primary Payers There may be situations where more than one primary insurer to Medicare makes payment on a claim; for example, a group health plan makes a primary payment for a service and, subsequently, another group health plan also makes a primary payment for the same service. Claims with multiple primary payers cannot be sent electronically to Medicare. A hardcopy claim must be submitted on Form CMS-1500. Physicians and other suppliers must attach the other payers’ EOB, or remittance advice, to the claim when sending it to Medicare for processing. C. Submission of MSP Claims with Multiple Primary Payers Where There is More Than One Insurance Type Code for Part B Claims When A/B MACs (Part B) and DME MACs receive claims with more than one insurance type code, the A/B MACs (Part B) and DME MACs must send the shared system and CWF the insurance type code associated with the highest other payer total claim payment amount. For example, a Medicare beneficiary sustains injury in a car accident. Five services were performed on the beneficiary. Since the services performed were related to the accident, the no-fault insurer (referred to as insurance type code 14) makes a $500.00 payment on each line of the claim totaling $2,500.00. The beneficiary also has coverage through the spouse’s group health plan. The spouse’s plan (referred to as insurance type code 12) makes a $400.00 payment on each line of the claim totaling $2000.00. The A/B MACs (Part B) and DME MACs must send insurance type code 14 (not insurance type code 12) to the shared system and CWF. D. Amounts A/B MACs (Part B) and DME MACs and Part B Shared Systems must send MSPPAY on electronic and paper claims with one or more Primary Payers There are situations with MSP Part B claims when the 1) the primary payer allowed amount(s) are greater than the billed amount; 2) the primary paid amount(s) are greater than the primary payer contractual amounts (a.k.a. the obligated to accept as payment in full (OTAF) amounts); and 3) the primary paid amount(s) are in excess of the primary allowed amount. When MSP claims of these types are received and processed it causes the outbound remittance advice (RA) to be out of balance. To prevent this from occurring the following actions must be taken: When the other insurer paid amount, or combined paid amount exceeds the physician or other supplier billed amount, the shared systems shall send the billed amount in place of the primary payer’s paid amount to MSPPAY and CWF. When the primary payer allowed amount exceeds the physician or other supplier’s billed amount, the shared systems shall send the billed amount in place of the primary payer allowed amount to MSPPAY. When the primary paid amount is greater than the primary allowed amount, and less than billed charges, the shared systems shall send the primary payer paid amount instead of the primary allowed amount to MSPPAY. When the primary payer paid amount exceeds the primary payer contractual amount, the shared system shall send the primary payer contractual amount instead of the primary payer paid amount to MSPPAY. The remittance advice must show the billed amount, the Medicare payment amount, and the “impact amounts” from the primary payer(s) on which the Medicare payment is based, and all Medicare adjustments. The impact amount, as found in section 2.2.13 of the 835 Implementation Guide, is defined as the amount on which Medicare’s payment is based. This amount will depend on the payment methodology followed in the above business requirements. Shared Systems shall no longer use reason code 35 on the outbound remittance advice unless the life time benefit has been reached is the reason the claim is being adjusted. Shared systems instead shall use Group Code “CO” with Reason Code “45” on the outbound remittance advice when the OTAF amount minus the other payer’s payment is the lowest of the three MSP calculations and is used to identify Medicare’s Secondary payment. NOTE: In regards to the outbound 837, when the primary payment is equal to or exceeds the billed amount, and Medicare’s payment is equal to zero, the outbound 837 shall show Medicare’s zero payment in the 2320 AMT segment. The shared systems shall identify in the CAS segment of the outbound 837 the amount that exceeds the billed amount and the reason why Medicare is making a zero payment by using group code and claims adjustment reason code CO 94 (processed in excess of charges), with an accompanied negative dollar amount, and OA 23 (payment adjusted because charges have been paid by another payer) with an accompanied negative dollar amount. E. - When A/B MACs (Part B) and DME MACs receive a hard copy Part B claim with multiple primary payer amounts A/B MACs (Part B) and DME MACs must take into consideration instructions found in section 30.5.D above when sending the correct amounts to MSPPAY for payment calculation. Primary Payer Paid Amounts: For line level service claims, the A/B MACs (Part B) and DME MACs must add all primary payer paid amounts for that service line and send the total line level payment amount to MSPPAY. If only claim level information is sent to Medicare, the A/B MACs (Part B) and DME MACs add all other payer paid amounts for that claim and sends the total claim payment amount to MSPPAY. Note: If the payment amount is greater than the billed amount, send the billed amount to MSPPAY instead of the other payer paid amount. Primary Payer Allowed Amount: For line level services, A/B MACs (Part B) and DME MACs use one of the two fields as follows: • Either the higher of the allowed amount for that service line, or • The total of the other payer paid amounts, whichever is higher, and send it to MSPPAY. If only claim level information is sent to Medicare, A/B MACs (Part B) and DME MACs use one of the two fields as follows: • Take the total claim level allowed amount, or • The total of the paid amount, if less than the billed amount, whichever is higher, and send it to MSPPAY. Obligated to Accept as Payment in Full Amount (OTAF): For line level services, the carrier takes the lowest OTAF amount for that service line, which must be greater than zero, and sends that amount to MSPPAY. If only claim level information is sent to Medicare, the A/B MACs (Part B) and DME MACs take the lowest claim level OTAF amount, which must be greater than zero, and send it to MSPPAY. (NOTE: If submitted charges are lower than the OTAF amount, then send the lowest Medicare covered charge for that service line to MSPPAY. Claim Example: Below is an example of a hard copy Part B MSP claim, with more than one primary payer, sent to A/B MACs (Part B) and DME MACs. All services are Medicare covered services. Payer 1 Submitted Covered Charges Other Payer Allowed Amount (Medicare Part B only) OTAF Other Payer Paid Amount Line 1 $60.00 $60.00 $50.00 $40.00 Line 2 $40.00 $30.00 $30.00 $30.00 Total $100.00 $90.00 $80.00 $70.00 The A/B MACs (Part B) and DME MACs must send the following line level other payer amounts to MSPPAY based on the instructions cited above. Based on the example above, since Payer 2 had no OTAF amount on service line 2 and Payer 1 had an OTAF amount greater than zero on service line 2, Payer 1's OTAF of $30.00 is used and sent to MSPPAY. Since the combined payment amount is higher than the primary payer OTAF amount for Line 1 and line 2, the OTAF amounts are sent to MSPPAY in place of the paid amounts.