Summary of MSP Data Elements for the Form CMS-1450 (UB-04)

50 - Summary of MSP Data Elements for the Form CMS-1450 (UB-04) (Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23) The following table identifies the data elements that are submitted on bills to communicate the status of the primary payer and payment where Medicare is the secondary payer. See Medicare Claims Processing Manual 100-04, Chapter 25, "Completing and Processing the Form CMS -1450 Data Set," for a crosswalk to the electronic data elements or segment names. Data Element Value for MSP MSP Situation Condition Code 02-Employment Related Workers' Compensation and Black Lung 05-Lien has been filed WC, No-fault, Liability, 06-ESRD Patient within coordination period and covered by GHP End Stage Renal Disease and covered by a GHP 08-Beneficiary would not furnish information concerning other insurance coverage All MSP situations 09-Neither patient nor spouse is employed Working Aged, Disability, or ESRD 11-Disabled Beneficiary but no GHP exists Disability Data Element Value for MSP MSP Situation 28-Patient and/or Spouse's GHP is Secondary to Medicare Working Aged 29-Disabled Beneficiary and/or Family Member's GHP is Secondary to Medicare Disability 77-Provider Accepts Payment by a Primary Payer as Payment in Full All MSP Situations D7-Claim Change Reason Code for Adjustment Requests to Make Medicare the Secondary Payer All MSP Situations D8-Claim Change Reason Code for Adjustment Requests to Make Medicare the Primary Payer All MSP Situations Occurrence Code and Date 01-Auto Accident No-Fault or Liability 02-No-fault Insurance including Auto accident/Other No-Fault 03-Accident/Tort Liability Liability 04-Accident/Employment Related WC or BL 05-Other Accident Liability 18-Date of Retirement Working Aged, Disability, or ESRD 19-Date of Retirement Spouse Working Aged, Disability, or ESRD 24-Date Insurance Denied All MSP Situations 25-Date Benefits Terminated by Primary Payer All MSP Situations 33-First day of the Medicare coordination period for ESRD beneficiaries covered by GHP ESRD A1-Birth date -Insured A Working Aged, Disability, or ESRD A2-Effective Date-Insured A Policy Working Aged, Disability, or ESRD Data Element Value for MSP MSP Situation A3- Benefits Exhausted for Payer A Working Aged, Disability, or ESRD B1-Birth date -Insured B Working Aged, Disability, or ESRD B2-Effective Date-Insured B Policy Working Aged, Disability, or ESRD B3- Benefits Exhausted for Payer B Working Aged, Disability, or ESRD C1-Birth date -Insured C Working Aged, Disability, or ESRD C2-Effective Date-Insured C Policy Working Aged, Disability, or ESRD C3- Benefits Exhausted for Payer C Working Aged, Disability, or ESRD Value Codes and Amounts 12- Working Aged Beneficiary/Spouse Group Health Plan Working Aged 13-ESRD Beneficiary in a Medicare Coordination Period with an Employer Health Plan ESRD 14-No-fault, including auto/other. No-Fault 15-Workers' Compensation Six zeros in the amount field indicates a request for a conditional Medicare payment. WC 16-PHS, Other Federal Agency Other Federal Agency, VA 41-Black Lung Six zeros in the amount field indicates a request for a conditional Medicare payment. Black Lung 42-Veterans Affairs VA 43-Disabled Beneficiary Under Age 65 with GHP Disability 44-Amount Provider Agreed to Accept from Primary Payer as Payment in Full All MSP Provisions 47- Any Liability Insurance Liability Provisions Insured's Name Data Element Value for MSP MSP Situation For Primary Payer Information All MSP Provisions Patient's Relationship to Insured 01-Patient is Insured All MSP Provisions 02-Spouse All MSP Provisions 03- Natural Child/Insured has Financial Responsibility Disability, ESRD 08- Employee Working Aged, ESRD, Disability 15-Injured Plaintiff Liability Certificate/Social Security Number/Medicare beneficiary identifier The involved claim number for the primary coverage is shown All MSP Provisions Insurance Group Number Identification number All MSP Provisions Employment Status Code 1-Employed Full Time Working Aged, ESRD, Disability 2-Employed Part-Time Working Aged, ESRD, Disability 3-Not Employed Working Aged, ESRD, Disability 4-Self-employed Working Aged, ESRD, Disability 5-Retired Working Aged, ESRD, Disability Employer Name WC, Working Aged, ESRD, Disability Employer Location WC, Working Aged, ESRD, Disability Payer ID Data Element Value for MSP MSP Situation All MSP Provisions