Completing the Form CMS-1500 in MSP Situations by Physicians and Other

60 - Completing the Form CMS-1500 in MSP Situations by Physicians and Other Suppliers of Services (Rev. 11874, Issued: 02-23-23; Effective: 03-24-23; Implementation: 03-24-23) Instructions for completing the Form CMS-1500 can be found in Pub 100-4, Chapter 26, "Completing and Processing Form CMS-1500 Data Set," of the Medicare Claims Processing Manual. Specific data elements used to report MSP information are listed below. In addition, each claim must have an EOB or remittance advice from the primary payer attached that identifies the amount allowed, paid, or denied by the primary payer. Item Data Element Name Instruction to Physician or Other Supplier Item 4 Insured's Name If the patient has insurance primary to Medicare, either through the patient's or the spouse's employment or any other source, the biller lists the name of the insured here. When the insured and the patient are the same, the biller enters the word SAME. If Medicare is primary this item is left blank. Item 7 Insured Address The insured's address and telephone number. When the address is the same as the patients, the biller uses the word SAME. It completes this item only when items 4 and 11 are completed. Item 8 Patient Status The patient's marital status and whether employed or a student. Item 9 Other Insured Name; The last name, first name, and middle initial of the enrollee in a Medigap policy if it is different from that shown in item 2. Otherwise, the biller uses the word SAME. If no Medigap benefits are assigned, the biller leaves this item Item Data Element Name Instruction to Physician or Other Supplier blank. This field may be used in the future for supplemental insurance plans. Participating physicians and other suppliers taking assignment under a MEDIGAP policy complete this item. Other supplemental claims are not listed here because they are forwarded automatically to the private insurer if the private insurer contracts with the carrier to send Medicare claim information electronically. If there is no such contract, the beneficiary must file his/her own supplemental claim. 9a Other Insured's Policy or Group Number Item 9a. The policy and/or group number of the Medigap insured preceded by: MEDIGAP, MG, or MGAP. 9b Other Insured's Date of Birth Item 9b. The Medigap insured's 8-digit birth date (MMDDCCYY) and sex. 9c Employer's Name or School Name; Item 9c. Blank if a Medigap PayerID is in item 9d. Otherwise, the claims processing address of the Medigap insurer. 9d Insurance Plan Name or Program Name Item 9d. The 9-digit PAYERID number of the Medigap insurer. If no PAYERID number exists, then the Medigap insurance program or plan name is shown. Item 10a Is Patient's Condition Related to Employment? Items 10a thru 10c. "YES" or "NO" must be checked to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in item 24. The State postal code must be shown. Any item checked "YES" indicates there may be other insurance primary to Medicare. Primary insurance information must then be shown in item 11. Item 10b Is Patient's Condition Related to Auto Accident? Item 10c Is Patient's Condition Related to Other Accident? Item 11 Insured's Policy Group or FECA Number If there is insurance primary to Medicare, the biller enters the insured's policy or group number. Item 11a Insured's Date of Birth Insured's 8-digit birth and sex if different from item 3 Item Data Element Name Instruction to Physician or Other Supplier Item 11b Employer's Name or School Name The name of the insured's employer is shown here. If there is a change in the insured's insurance status, e.g., retired, this contains a retirement date preceded by the word “RETIRED”. Item 11c Insurance Plan or Program Name The 9-digit PAYERID number of the primary insurer. If no PAYERID number exists, the complete primary payer's program or plan name. If the primary payer's EOB does not contain the claim processing address, this contains the primary payer's claims processing address as shown on the EOB.