Version 5010 Balancing for Incoming ASC X12 837 MSP

40.7.3.3 - Version 5010 Balancing for Incoming ASC X12 837 MSP Claims Where MSP Amounts Appear at the Claim Level and Not at the Service Detail Line (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) There may be situations where the primary payer may identify the CARCs at the line level, but may also include additional CARCs and adjustments at the header level. Although receiving such MSP claims is a rare occurrence it is possible that these types of claims may be sent on 5010 claim transactions or on hardcopy claims. The current Medicare Secondary Payer Payment Module (MSPPAY) calculates MSP claims payment for MSP claims received at the header level or at the detail level. Currently, when there is MSP information at the header level that is not identified at the detail the share system turns on the apportioning switch in MSPPAY to apportion the MSP claims to the detail lines. In situations where the claim level OTAF, primary payer allowed amount and/or primary payer paid amounts are not equal to the sum of the corresponding detail amounts, but the claim balances, this manual section instructs the Part B shared systems to use the claim level amounts to determine Medicare’s secondary payment. This involves determining the MSP amounts utilizing the CAS adjustments as instructed in previous MSP and MSP CARC change requests, and then send these amounts, along with the claim detail information, to MSPPAY so MSPPAY can apportion the MSP amounts to the detail. A/B MACs (Part B) may refer to the 5010 ASC X12 837professional claim implementation guide - Front matter, Balancing section, specifically 1.4.4.1 for additional reference as needed. To summarize this balancing, the claim level primary paid amount must equal the sum of the line level primary paid amounts less any claim level reductions. Submitted Charges Submitted Primary Payment Submitted CARCs Claim Level $200 $170 CO-xx $30 Line 1 $100 $100 Line 2 $100 $100 The above claim is considered in balance by version 837 balancing rules, however, the sum of the line level primary paid amounts does not equal the claim level primary paid amount.