Payment Calculation for Physician/Supplier Claims (MSPPAYB

50.1.7 - Payment Calculation for Physician/Supplier Claims (MSPPAYB Module) (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) The MSPPAYB module performs the necessary payment calculation for physician/supplier claims. A. Data Elements to send to MSPPAYB MSPPAY must send the following data elements to MSPPAYB: NO. Field Name Definition/Use Source/Value 1 TEST SWITCH Indicator to turn on function within the MSP software display sending and returning data. Used to identify payment problems. "T" = display send/return data Space = do not display data. 2 THRU DATE Ending service date of the period included on the claim (CCYYMMDD) Supplied by A/B MAC (Part B) system from the claim. THRU DATE CC Value = "19" or "20" NO. Field Name Definition/Use Source/Value THRU DATE YY Value = "00" thru "99" THRU DATE MM Value = "01" thru "12" THRU DATE DD Value = "01" thru "31" 3 RECORD ID Identifies the claim type. Part B = "HMBC" 4 CLMNO Health Insurance Claim Number (HICN) Supplied by A/B MAC (Part B) system from the claim 5 DOC CNTL NUM Assigned document control number. Assigned and supplied by A/B MAC (Part B) system. 6 FULLY PAID CLAIM IND Indicator that reflects claim is fully paid by the third party payer. Supplied by A/B MAC (Part B) system. Values: Y = Fully Paid Space = Not Fully Paid 7 NUM OF OTHER PAYERS The number of other payers who are primary to Medicare. Supplied by A/B MAC (Part B) system Values = "01" thru "10" 8 THIRD PARTY PAYER TABLE MSP code(s) and MSP amount comprise third party data Supplied by A/B MAC (Part B) system. May occur up to 10 times. MSP CODE Code(s) identifying the other payer: 12 = EGHP (Working Aged) 13 = ESRD (End Stage Renal Disease) 14 = AUTO (Automobile/No- Fault) 15 = WORK (Workers" Compensation) 16 = FEDS (Federal) 41 = BL (Black Lung) 42 = VA (Veterans) 43 = DSAB (Disability) 47 = LIAB (Liability) Based on information obtained from the claim or from third party-payer information submitted with the claim, i.e., explanation of benefits. MSP AMOUNT Amount(s) paid by the other payer. Third party payer explanation of benefits 9 TOTAL ACTUAL CHARGES Total charges billed by the physician/supplier. Total Charges billed on the professional claim. 10 OBLIGATED TO ACCEPT Amount the provider agrees to accept as payment in full when this amount is less than the charges but higher than the payment received from the primary payer. Third party payer explanation of benefits NO. Field Name Definition/Use Source/Value 11 OTHER PAYER ALLOWED AMT. Covered charges allowed by the third party payer. Third party payer explanation of benefits 12 MEDICARE REASONABLE CHG & FEE SCHEDULE The Medicare reimbursement amount excluding applicable deductible and coinsurance. Computed and supplied by A/B MAC (Part B) system. 13 FILLER Nine Value Spaces 14 BLOOD DEDUCTION Dollar amount of blood deductible charged by Medicare. Zero for Medicare Part B 15 CASH DEDUCTION Dollar amount of deductible charged by Medicare. Supplied by A/B MAC (Part B) system. 16 FILLER Sixty-eight value spaces 17 TOTAL COIN AMT The total coinsurance amount chargeable to the beneficiary. Computed and supplied by A/B MAC (Part B) system. 18 FILLER Six value spaces 19 Assignment Indicator An indicator that identifies if the claim is assigned or unassigned. From the claim. 20 FILLER Twenty-eight value spaces 21 MED PRIMARY PAYMENT The Medicare reimbursement amount less applicable deductible and coinsurance. Computed and supplied by A/B MAC (Part B) system. 22 PROVIDER PAYMENT AMT The Medicare reimbursement amount to be paid to the provider. Computed and supplied by A/B MAC (Part B) system. 23 PATIENT PAYMENT AMT The Medicare reimbursement amount to be paid to the patient. Computed and supplied by A/B MAC (Part B) system. 24 G-R-H PERCENT (GRAMM- RUDMANN- HOLLINGS) The applicable percent reduction required by the Gramm-Rudmann-Hollings Act. Supplied by A/B MAC (Part B) system. 25 CHARGES NSDC (CHARGES NOT SUBJECT TO DEDUCTIBLE AND COINSURANCE) Charge amount not subject to deductible and coinsurance, i.e., reimbursed at 100%. Compute and supplied by A/B MAC (Part B) system. 26 CHARGES SD (CHARGES SUBJECT TO DEDUCTIBLE) Charge amount subject to the deductible. Computed and supplied by A/B MAC (Part B) system. NO. Field Name Definition/Use Source/Value 27 PSYCH CHARGES Allowed psychiatric charges. Computed and supplied by A/B MAC (Part B) system. 28 PAR INDICATOR Supplied by A/B MAC (Part B) system "P" = Par Provider "N" = No-Par Provider 29 LIMITED FEE NON-PAR Computed and supplied by A/B MAC (Part B) system 30 LIMITED CHARGES UNASSIGNED Computed and supplied by A/B MAC (Part B) system 31 RESERVED FOR CMS Space reserved for future enhancements. One hundred seventy nine value spaces. 32 RESERVED FOR USER Space reserved for user as necessary. One hundred ninety value spaces. B. MSPPAYB Returning Data Elements MSPPAYB will return the following data elements to MSPPAY. Refer to section A above for field definitions not reflected below. NO. Field Name Definition/Use Source/Value 1 RETURN CODE Numeric code indicating the results from processing the secondary payment computation and savings. Identifies a fully or partially paid bill as well as invalid sending data. Determined by MSPPAYB Valid values "3000" thru "3999" (See §40.1.3 above; also refer to the technical documentation released with the software.) Unless otherwise specified MSPPAY is the source of all the following, possibly modified by MSPPAY. No Field Name Definition/Use 2 BLOOD DEDUCTION TO CWF Amount of blood deductible to report to CWF. 3 CASH DEDUCTION TO CWF Dollar amount of deductible to report to the CWF 4 FILLER Seventy-seven value spaces 5 TOTAL COIN AMT TO CWF The total coinsurance amount to report to the CWF. 6 FILLER Nine value spaces 7 MED SECONDARY PAYMENT Medicare's secondary payment computed by the MSP software. 8 PROVIDER PAYMENT AMT No Field Name Definition/Use 9 PATIENT PAYMENT AMT 10 BLOOD DEDUCTION TO CHG The amount of blood deductible the beneficiary may be charged by the provider. 11 CASH DEDUCTION TO CHG The dollar amount of deductible the beneficiary may be charged by the provider. 12 TOTAL COIN AMT TO CHG The total coinsurance amount chargeable to the beneficiary. 13 FILLER Three value spaces 14 G-R-H (GRAMM-RUDMANN- HOLLINGS) SAVINGS REDUCTION The amount of the MSP savings reduced for Gramm-Rudmann-Hollings. 15 GROSS MEDICARE PAYMENT The amount Medicare pays as primary excluding deductibles and coinsurance. 16 FILLER Nine value spaces. 17 SAVINGS MSP GHP Amount saved by Medicare when an GHP has made a payment for a working aged beneficiary (MSP Code 12). 18 SAVINGS MSP ESRD Amount saved by Medicare when an EGHP has made a payment for an ESRD beneficiary (MSP Code 13). 19 SAVINGS MSP AUTO Amount saved by Medicare when another insurer has made payment in an automobile/no-fault situation (MSP Code 14). 20 SAVINGS MSP WORK Amount saved by Medicare when workers' compensation payment has been made (MSP Code 15). 21 SAVINGS MSP FEDS Amount saved by Medicare when PHS or other Federal agency made payment (MSP Code 16). 22 SAVINGS MSP BL Amount saved by Medicare when Black Lung payment has been made by the Department of Labor (MSP Code 41). 23 SAVINGS MSP VA Amount saved by Medicare when payment has been made by the Department of Veteran's Affairs (MSP Code 42). 24 SAVINGS MSP DSAB Amount saved by Medicare when an LGHP has made a payment for a disabled beneficiary (MSP Code 43). 25 SAVINGS MSP LIAB Amount saved by Medicare when payment has been made by a liability insurer (MSP Code 47). 26 SAVINGS TOTAL Total savings to the Medicare program when Medicare is the secondary payer a primary payer(s) has made some payment. No Field Name Definition/Use Includes all MSP codes 12 - 16, 41 - 43, and 47. 27 SAVINGS NON-EGHP Total savings to the Medicare program for all non-EGHP payments for a Medicare beneficiary. Includes MSP codes 14, 15, 16, 41, and 47. (This field is only returned for claims with service "thru-dates" prior to 11/13/89.) 28 SAVINGS EGHP Total savings to the Medicare program for all EGHP payments for a Medicare beneficiary. Includes MSP codes 12, 13, and 42. (This field is only returned for claims with service "thru-dates" prior to 11/13/89.) 29 MSP COMPUTATION 1 The result of: the total actual charge by the physician/supplier, or the limiting charge (if the claim is unassigned), or an amount the physician/supplier is obligated to accept as payment in full if that is less than the charges) minus the amount paid by the primary payer for covered services. 30 MSP COMPUTATION 2 The result of the gross amount payable by Medicare minus applicable deductible and coinsurance amounts. 31 MSP COMPUTATION 3 The result of the higher of the primary payer's allowed or the Medicare allowed minus the amount paid by the primary payer. The Medicare allowed and the primary payer's allowed are determined without regard to the Medicare or primary plan's deductible or coinsurance, respectively. 32 FILLER Nine value spaces 33 RESERVED FOR CMS Space reserved for future enhancements. (200 value spaces) 34 RESERVED FOR USER Space Reserved for User as Necessary. (153 value spaces)