Payment Calculation for Physician/Supplier Claims

50.1.8 - Payment Calculation for Physician/Supplier Claims (MSPPAYBL) (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) The sub-module performs the necessary payment calculation, on a by-line basis, for physician/supplier claims with service "thru-dates" on or after April 1, 1998. A. MSPPAYBL Sending Data Elements. MSPPAY must send the following data to MSPPAYBL: 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 FILLER 8 value spaces 3 RECORD ID Identification of Part B type claim being processed = "HMBL" 4 CLMNO Health Insurance Claim Number Supplied by the A/B MAC (Part B) system. 5 DOC CNTL NUM Assigned document control number Assigned and supplied by the A/B MAC (Part B) system 6 FILLER 1 value space 7 APPORTION SWITCH Determine whether to apportion the Other Payer's Allowed Amount and Payment Amount Supplied by the A/B MAC (Part B) system "N" = do not apportion Space = do apportion 8 TOTAL ACTUAL CHARGES Supplied by the A/B MAC (Part B) system 9 NUM OF OTHER PAYERS The number of other payers who are primary to Medicare Supplied by the A/B MAC (Part B) system. Valid value '01' thru '10' NOTE: THE FOLLOWING FIELDS WILL OCCUR 13 TIMES No. Field Name Definition/Use Source/Value 10 THIRD PARTY PAYER TABLE MSP code(s) and MSP amount comprise third party data. MSP Code - Code(s) identifying the other payer: 12 = GHP (Working Aged) 13 = ESRD (End Stage Renal disease) 14 = AUTO (Automobile/No-Fault) 15 = Work (Worker's Compensation) 16 = FEDS (Federal) 41 = BL (Black Lung) 42 = VA (Veterans) 43 = DSAB (Disability) 47 = Liab (Liability) Based on information obtained from the claim, third party information submitted with the claim, i.e., explanation of benefits or appropriate electronic data elements. Supplied by the A/B MAC (Part B) system. May occur up to 10 times. MSP AMOUNT Amount(s) paid by the other payer. 11 OTHER PAYER ALLOWED AMT Covered charges allowed by the third party payer. Third Party Payer explanation of benefits 12 NUMBER OF LINES Number of lines to compute MSP amounts. Supplied by the A/B MAC (Part B) system 13 RESERVED FOR CMS Space reserved for future enhancements. 124 value spaces 14 RESERVED FOR USER Space reserved for user as necessary. 100 value spaces 15 LINE NUMBER Line of service number. Supplied by the A/B MAC (Part B) system. Values "01" thru "13'' 16 DENIED INDICATOR Indicator that reflects whether Medicare or the other A/B MAC (Part B) denied the line of service. Supplied by the A/B MAC (Part B) system "D" = Line of service denied by the other A/B MAC (Part B) and/or Medicare. Space = Line of service accepted for payment by the other A/B MAC (Part B) and/or Medicare. 17 FILLER One value space 18 THRU DATE Ending service date of the period included on the claim (CCYYMMDD) THRU DATE CC THRU DATE YY THRU DATE MM Supplied by the A/B MAC (Part B) system from Field 24 of the Form CMS-1500 Value = "19" or "20" Value = "00" thru "99" Value = "01" thru "12" No. Field Name Definition/Use Source/Value THRU DATE DD Value = "01" thru "31" 19 RECORD ID Identifies the claim type. Part B = "HMBL" 20 CLMNO Health Insurance Claim Number (HICN) Supplied by the A/B MAC (Part B) system from Field 1a of the Form CMS-1500 21 DOC CNTL NUM Assigned document control number Assigned and supplied by the A/B MAC (Part B) system 22 FULLY PAID CLAIM IND Indicator that reflects claim is fully paid by the third party payer. Supplied by the A/B MAC (Part B) system "Y" = Fully paid by other payer Space = Not fully paid by other payer 23 NUM OF OTHER PAYERS The number of other payers who are primary to Medicare Supplied by the A/B MAC (Part B) system Valid value "01" thru "10" 24 THIRD PARTY PAYER TABLE MSP code(s) and MSP amount comprise third party data. Based on information obtained from the claim. Third party information submitted with the claim, i.e., explanation of benefits or appropriate electronic data elements. 25 MSP CODE Code(s) identifying the other payer: 12 = GHP (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) Supplied by the A/B MAC (Part B) system. May occur up to 10 times 26 MSP AMOUNT Amount(s) paid by the other payer. Third party payer explanation of benefits 27 TOTAL ACTUAL CHARGES Total charges billed by the physician/supplier. Form CMS-1500, Field 28 28 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 Third party payer explanation of benefits No. Field Name Definition/Use Source/Value payment received from the primary payer. 29 OTHER PAYER ALLOWED AMT Covered charges allowed by the third party payer. Third party payer explanation of benefits 30 MEDICARE REASONABLE CHG &FEE SCHEDULE The Medicare reimbursement amount excluding applicable deductible and coinsurance. Computed and supplied by the A/B MAC (Part B) system. 31 FILLER Nine value spaces 32 BLOOD DEDUCTION Dollar amount of blood deductible charged by Medicare. Zero for Medicare Part B 33 CASH DEDUCTION Dollar amount of deductible charged by Medicare. Supplied by the A/B MAC (Part B) system. 34 FILLER Sixty-eight value spaces 35 TOTAL COIN AMT The total coinsurance amount chargeable to the beneficiary. Computed and supplied by the A/B MAC (Part B) system. 36 FILLER Six value spaces 37 ASSIGNMENT INDICATOR An indicator that identifies if the claim is assigned or unassigned. From the claim "A" = Assigned claim "B" = Non-assigned claim 38 FILLER Twenty eight value spaces 39 MED PRIMARY PAYMENT The Medicare reimbursement amount less applicable deductible and coinsurance. Computed and supplied by the A/B MAC (Part B) system. 40 PROVIDER PAYMENT AMT The Medicare reimbursement amount to be paid to the provider. Computed and supplied by the A/B MAC (Part B) system. 41 PATIENT PAYMENT AMT The Medicare reimbursement amount to be paid to the patient. Computed and supplied by the A/B MAC (Part B) system. 42 G-R-H PERCENT (GRAMM- RUDMANN - HOLLINGS) The applicable percent reduction required by the Gramm-Rudmann-Hollings Act. Supplied by the A/B MAC (Part B) system. No. Field Name Definition/Use Source/Value 43 CHARGES NSDC (CHARGES NOT SUBJECT TO DEDUCTIBLE AND COINSURANCE) Charge amount not subject to deductible and coinsurance, i.e., reimbursed at 100%. Computed and supplied by the A/B MAC (Part B) system. 44 CHARGES SD (CHARGES SUBJECT TO DEDUCTIBLE) Charge amount subject to the deductible. Computed and supplied by the A/B MAC (Part B) system. 45 PSYCH CHARGES Allowed psychiatric charges. Computed and supplied by the A/B MAC (Part B) system. 46 PAR INDICATOR Indicator reflecting whether the provider participates in the Medicare program. Supplied by the A/B MAC (Part B) system. "P" = Par Provider "N" = Non-Par Provider 47 LIMITED FEE NON- PAR The fee amount paid to a nonparticipating provider. Computed and supplied by the A/B MAC (Part B) system. 48 LIMITED CHARGES UNASSIGNED The charge for each service on unassigned claims. Computed and supplied by the A/B MAC (Part B) system if LC on the claim exceeds more than 115% of Medicare fee schedule amount. 49 RESERVED FOR CMS Space reserved for future enhancements. One hundred seventy nine value spaces. 50 RESERVED FOR USER Space reserved for user as necessary. One hundred ninety value spaces. B. MSPPAYBL Returning Data Elements. MSPPAYBL will return the following data to MSPPAY: 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. 2 HEADER OR LINE ERROR Reflects if an error was detected at the claim header or line when computing MSP by line. Determined by MSPPAYBL: "H" = Header Error "L" = Line Error No Field Name Definition/Use Source/Value 3 LINE NUMBER OF ERROR Reflects the line of service an error was detected. 4 BLOOD DEDUCTION TO CWF Amount of blood deductible to report to the Common Working File (CWF). 5 CASH DEDUCTION TO CWF Dollar amount of deductible to report to the CWF 6 TOTAL COIN AMT TO CWF The total coinsurance amount to report to the Common Working File. 7 MED SECONDARY PAYMENT Medicare's secondary payment computed by the MSP software. 8 PROVIDER PAYMENT AMT Medicare's secondary payment computed by the MSP software. 9 PATIENT PAYMENT AMT Medicare's secondary payment computed by the MSP software. 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 G-R-H (GRAMM- RUDMANN- HOLLINGS) SAVINGS REDUCTION The amount of the MSP savings reduced for Gramm-Rudmann- Hollings. 14 SAVINGS MSP GHP Amount saved by Medicare when a GHP has made a payment for a working aged beneficiary (MSP Code 12). 15 SAVINGS MSP ESRD Amount saved by Medicare when an EGHP has made a payment for an ESRD beneficiary (MSP Code 13). 16 SAVINGS MSP AUTO Amount saved by Medicare when another insurer has made payment in an automobile/no-fault situation (MSP Code 14). 17 SAVINGS MSP WORK Amount saved by Medicare when workers' compensation payment has been made (MSP Code 15). 18 SAVINGS MSP FEDS Amount saved by Medicare when PHS or other Federal agency made payment (MSP Code 16). No Field Name Definition/Use Source/Value 19 SAVINGS MSP BL Amount saved by Medicare when Black Lung payment has been made by the Department of Labor (MSP Code 41). 20 SAVINGS MSP VA Amount saved by Medicare when payment has been made by the Department of Veteran's Affairs (MSP Code 42). 21 SAVINGS MSP DSAB Amount saved by Medicare when an LGHP has made a payment for a disabled beneficiary (MSP Code 43). 22 SAVINGS MSP LIAB Amount saved by Medicare when payment has been made by a liability insurer (MSP Code 47). 23 SAVINGS TOTAL Total savings to the Medicare program when Medicare is the secondary payer a primary payer(s) has made some payment. Includes all MSP codes 12 - 16, 41 - 43, and 47. 24 RESERVED FOR CMS Space reserved for future enhancements. (123 value spaces) 25 RESERVED FOR USER Space reserved for user as necessary. (118 value spaces) NOTE: THE FOLLOWING FIELDS WILL OCCUR 13 TIMES 26 LINE NUMBER Line of service number 27 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. NOTE: The Source/Value is determined by MSPPAYB Valid values "3000" thru "3999" (See §40.1.3 above; also refer to the technical and user documentation released with the software.) Unless otherwise specified MSPPAY is the source of all the following, possibly modified by MSPPAY. No Field Name Definition 28 BLOOD DEDUCTION TO CWF Amount of blood deductible to report to the CWF 29 CASH DEDUCTION TO CWF Dollar amount of deductible to report to the CWF. 30 FILLER (77 value spaces) 31 TOTAL COIN AMT TO CWF The total coinsurance amount to report to the CWF. 32 FILLER (9 value spaces) 33 MED SECONDARY PAYMENT Medicare's secondary payment computed by the MSP software. 34 PROVIDER PAYMENT AMT Reimbursement paid to the provider. 35 PATIENT PAYMENT AMT Reimbursement paid to the patient. No Field Name Definition/Use Source/Value 36 BLOOD DEDUCTION TO CHG The amount of blood deductible the beneficiary may be charged by the provider. 37 CASH DEDUCTION TO CHG The dollar amount of deductible the beneficiary may be charged by the provider. 38 TOTAL COIN AMT TO CHG The total coinsurance amount chargeable to the beneficiary. 39 FILLER (3 value spaces) 40 G-R-H (GRAMM- RUDMANN- HOLLINGS) SAVINGS REDUCTION The amount of the MSP savings reduced for Gramm-Rudmann- Hollings. 41 GROSS MEDICARE PAYMENT The amount Medicare pays as primary excluding deductibles and coinsurance. 42 FILLER (36 value spaces) 43 SAVINGS MSP GHP Amount saved by Medicare when a GHP has made a payment for a working aged beneficiary (MSP Code 12). 44 SAVINGS MSP ESRD Amount saved by Medicare when an EGHP has made a payment for an ESRD beneficiary (MSP Code 13). 45 SAVINGS MSP AUTO Amount saved by Medicare when another insurer has made payment in an automobile/no-fault situation (MSP Code 14). 46 SAVINGS MSP WORK Amount saved by Medicare when Workers' compensation payment has been made (MSP Code 15). 47 SAVINGS MSP FEDS Amount saved by Medicare when PHS or other Federal agency made payment (MSP Code 16). 48 SAVINGS MSP BL Amount saved by Medicare when Black Lung payment has been made by the Department of Labor (MSP Code 41). 49 SAVINGS MSP VA Amount saved by Medicare when payment has been made by the Department of Veteran's Affairs (MSP Code 42). 50 SAVINGS MSP DSAB Amount saved by Medicare when an LGHP has made a payment for a disabled beneficiary (MSP Code 43). 51 SAVINGS MSP LIAB Amount saved by Medicare when payment has been made by a liability insurer (MSP Code 47). 52 SAVINGS TOTAL Total savings to the Medicare program when Medicare is the secondary payer a primary payer(s) has made some payment. Includes all MSP codes 12 - 16, 41 - 43, and 47. 53 FILLER Eighteen value spaces 54 MSP COMPUTATIO N 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. No Field Name Definition/Use Source/Value 55 MSP COMPUTATIO N 2 The result of the gross amount payable by Medicare minus applicable deductible and coinsurance amounts. 56 MSP COMPUTATIO N 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. 57 FILLER Nine value spaces 58 RESERVED FOR CMS Space reserved for future enhancements. (200 value spaces) 59 RESERVED FOR USER Space reserved for user as necessary. (153 value spaces)