MSP Utilization Edits and Resolution for Claims Submitted to

40.8 - MSP Utilization Edits and Resolution for Claims Submitted to CWF (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) Error Code Error Description Resolution 6801 GHP MSP indicated on claim - no MSP auxiliary record exists on CWF data base. Prepare an "I" MSP maintenance transaction and resubmit claim to CWF. See §10.1 for criteria to submit "I". If "I" criteria is not met, submit an MSP inquiry via ECRS. Error Code Error Description Resolution 6802 GHP MSP indicated on claim - no match on MSP auxiliary file. (1) Analyze CWF auxiliary file. (2) Create a new "I" MSP auxiliary record, or if "I" record criteria is not met, submit an MSP inquiry or CWF assistance request via ECRS; and (3) Resubmit claim. NOTE: Match criteria: MSP types are equal, validity indicator equals "Y," dates of service are within MSP period and NO override code is indicated on claim. 6803 GHP MSP auxiliary record exists - no GHP MSP indicated on claim but dates of service match a GHP occurrence. (1) Deny claim. Advise beneficiary/provider: "Resubmit claim with other payer's Explanation of Benefits for possible secondary payment. If other insurance has terminated, resubmit with documentation showing termination dates of other insurance." If you have documentation showing termination of the insurance coverage indicated in the CWF, MSP occurrence, process as follows: (2) Post a termination date; or (3) Resubmit claim as MSP. If the termination date is incorrect, submit a CWF assistance request via ECRS. 6805 GHP MSP conditional payment claim and matching MSP record with “I”or "Y" validity indicator not found for these dates of service. (1) A/ B MACs only: Create an "I" MSP Auxiliary Record when it fits the criteria for adding an "I" record. (2) Submit MSP inquiry or CWF assistance request via ECRS. (3) Resubmit claim. 6806 MSP override code equals "M" and no GHP MSP record found with overlapping dates of service. If record was deleted in error, request CWF assistance request. Do not recreate record with "I" validity indicator. 6810 Part A claim was processed and only a Part B (Insurer type = "K") matching record was found. 6811 Part B claim was processed and only a Part A (Insurer type = "J") matching record was found. 6815 WC Medicare Set-Aside exists (Insurer type= “W”). Medicare contractor payment not allowed. Error Code Error Description Resolution 6816 No-Fault over-rideable utilization error code to be used when a valid (Y) ORM indicator is on the MSP CWF auxiliary file and the diagnosis codes on the claim match the diagnosis codes (or match within the family of diagnosis codes) on the open MSP ORM record on CWF. MACs shall deny the claim(s) as a Medicare payment is not allowed. 6817 Workers’ Compensation over-rideable utilization error code to be used when a valid (Y) ORM indicator is on the MSP CWF auxiliary file and the diagnosis codes on the claim match the diagnosis codes (or match within the family of diagnosis codes) on the open MSP ORM record on CWF. MACs shall deny the claim(s) as a Medicare payment is not allowed. 6818 Liability over-rideable utilization error code to be used when a valid (Y) ORM indicator is on the MSP CWF auxiliary file and the diagnosis codes on the claim match the diagnosis codes (or match within the family of diagnosis codes) on the open MSP ORM record on CWF. MACs shall deny the claim(s) as a Medicare payment is not allowed. 6819 A non-GHP ('D', 'H' or 'L') MSP auxiliary record exists, and no non-GHP MSP is indicated on the claim, but the Dates of Service match, the diagnosis on the claim is a match within the family of diagnosis codes OR a non-GHP ('E') MSP auxiliary record exists, and no non-GHP MSP is indicated on the claim, but the Dates of Service match, the diagnosis on the claim is an exact match or a match within the family of diagnosis codes. 6821 Non-GHP MSP indicated on claim; no MSP Auxiliary file exists. This indicates no Non-GHP MSP file found. 6822 Non-GHP MSP indicated on the claim; a Non-GHP match does not exist on MSP Auxiliary file. 6823 Beneficiary has a non-GHP MSP Type record 'S' on the Auxiliary file; there is a matching diagnosis on the claim and auxiliary file, and the claim contains payment (full or conditional). 6824 Beneficiary has a non-GHP MSP Type record 'T' on the Auxiliary file; there is a matching diagnosis on the claim and auxiliary file, and the claim contains payment (full or conditional). 6825 Non-GHP MSP conditional payment claim, but a non-GHP MSP record with a Validity Indicator equal to 'I' or 'Y' is not present for these Dates of Service. 6826 MSP Override Code is 'N' or Cost Avoid and no non-GHP MSP record is found with overlapping Date of Service. 6830 Part A claim was processed and only a Part B (Insurer Type 'K') matching non-GHP record was found. 6832 The non-GHP MSP occurrence ('D', 'E', 'H', 'L', 'S', 'T', or 'W') does not contain a diagnosis code. 6833 The ICD-9 diagnosis on the claim is not an exact or Family match to the ICD- 10 diagnosis on the open non-GHP MSP Aux record (Value Code '14' (MSP Codes 'D' or 'T'), Value Code '15' (MSP Codes 'E' or 'W'), Value Codes '47' (MSP Codes 'L' or 'S'), or the ICD-10 diagnosis on the claim is not an exact or Family match to the ICD- 9 diagnosis on the open non-GHP MSP Aux record (Value Code '14' (MSP Codes 'D' or 'T'), Value Code '15' (MSP Codes 'E' or 'W'), Value Codes '47' (MSP Codes 'L' or 'S'). 6834 When the claim is secondary and it shows there is a GHP insurer, but the MSP record on CWF has only a non-GHP MSP occurrence. 6835 When the claim is secondary and it shows there is a non-GHP insurer, but the MSP record on CWF has only a GHP MSP occurrence. See discussion in §40.4 above for proper use of override codes.