MSP Claim Processing

40 - MSP Claim Processing (Rev. 13262; Issued: 06-09-25; Effective:01-01-25 Implementation: 01-06-25) The Common Working File (CWF) performs consistency edit checks on claims submitted to it. Refer to CWF Systems Documentation for the complete record layout and field descriptions. Record names are: • CWF Part B Claim Record, and • CWF Inpatient/SNF Bill Record. The Medicare Secondary Payer (MSP) claims failing the consistency edits shall receive a reject with the appropriate disposition code, reject code, and MSP trailer data. Refer to CWF Systems Documentation, Record Name: CWF, MSP Basic Reply Trailer Data for the complete record layout and field descriptions. Claims passing the consistency edit process are reviewed for utilization compliance. Claims rejected by the utilization review process are rejected with the appropriate disposition code, reject code and MSP trailer data. The shared systems establish their own systematic functionality to apply the CWF MSP information on the claim or at a detail level for Part B and Outpatient claims and ensure the CWF MSP information used to adjudicate the claim is not altered. It has always been the shared systems’ goal to establish functionality to automate MSP cost avoid processing for group health plan claims and to consider the prompt pay period for non- ORM MSP Types 14, 15 and 47 (No-fault, Workers’ Compensation and Liability, including self-insurance) prior to processing the claim. The cost avoid process also applies to ORM non-group health plan claims so that Medicare does not make a mistaken primary payment. CWF also applies MSP editing and override processing at the claim, or detail level, allowing services not applicable to the MSP processing to remain on the claim. The goal of the shared systems is to allow for the least number of claims requiring manual review and processing. Systematic automation prevents delays in processing MSP claims such as: • conflicts between claim and detail level processing, • addition and/or removal of the MSP information from the claim, • manual processing of MSP claims due to the Informational MSP update being rejected by CWF, • Resolving MSP claims errors including secondary payer and 6800 error codes, and • Systematically creating MSP records. The Centers for Medicare & Medicaid Services (CMS) encourages the shared systems, the A/B Medicare Administrative Contractors (MACs) and Durable Medicare Equipment (DME) MACs to provide insight and recommendation to further automate the MSP claims processes. This improvement can be identified and discussed at your functional work group meetings and/or relayed through your designated CMS Contracting Officer Representative (COR) who will refer your recommendation to the appropriate CMS MSP staff.