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April 29, 2016

Claim Adjustment Segment (CAS) Information Required When Billing Medicare Secondary Payer (MSP) Claims/Adjustments

Change Request (CR) 8486 implemented changes that now allow providers to submit Medicare Secondary Payer (MSP) claims and adjustments via the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE). This CR also requires allMSP claims, regardless of whether they are submitted electronically (5010 format), or via the FISS DDE, to include claim adjustment segment (CAS) information. The following provides details about submitting CAS information on MSP claims/adjustments.

FISS DDE - If you enter an MSP claim via the FISS DDE, the CAS information must be entered on the new "MSP Payment Information" screen (MAP1719). This screen is accessible by pressing F11 from Claim Page 03. The "MSP Payment Information" screen for "Primary Payer 1" will display. Entry for a second payer (if there is one) is available by pressing F6 to display the "MSP Payment Information" screen for "Primary Payer 2."

Screen Shot

Electronically– If you enter an MSP claim electronically (5010 format), the CAS information is reported in Loops 2320 – 2330I as follows:

PAID DATE
  • 2330B DTP segment Primary Adjudication or Payment Date

PAID AMOUNT
  • 2320 AMT segment Primary Payer Paid Amount

GRP
  • 2320 CAS segment Claim Level Adjustments
  • CAS01 CO PR OA

CARC
  • 2320 CAS segment Claim Level Adjustments
  • CAS02 Adjustment Reason Code
  • CAS05, CAS08, CAS11, CAS14, CAS17 if multiple CARCs for the same group code

AMT
  • 2320 CAS segment Claim Level Adjustments
  • CAS03 Adjustment Amount
  • CAS06, CAS09, CAS12, CAS15, CAS18 if multiple CARCs for the same group code

Paper MSP Claims - MSP paper claims may only be submitted when services are related to Black Lung, or when the provider meets the small provider exception as indicated in the Centers for Medicare & Medicaid Services (CMS) Pub. 100-04, Ch. 24 §90.

Note: Paper claims related to Black Lung, must include a copy of the Department of Labor (DOL) denial notice and a copy of workers' compensation insurer denial notice (if applicable). Paper claims submitted due to the small provider exception must include the prior payer's remittance statement and documentation indicating that the provider meets the small provider exception. The CGS Claims department will enter the required CAS information based on the submitted documentation.

CAS Information
The prior payer's 835 Electronic Remittance Advice (ERA) typically includes CAS information. The following table provides the "MSP Payment Information" (Map1719) field descriptions and guidance on how to complete the fields.

FISS Field

How to Complete

PAID DATE

Enter the paid date shown on the primary payer's remittance advice.

PAID AMOUNT

Enter the paid amount shown on the primary payer's remittance advice. This amount must equal the dollar amount entered for MSP Value Codes 12, 13, 14, 15, 16, 43, and 47.

GRP

Enter the Group Code shown on the primary payer's remittance advice. Valid codes are:

CO

Contractual Obligation

PI

Payer Initiated Reductions

OA

Other Adjustment

PR

Patient Responsibility

NOTE: Group Code CO should only be used when Value Code 44 (Obligated to Accept as Payment in Full, or OTAF)

CARC

Enter the Claim Adjustment Reason Code (CARC) shown on the primary payer's remittance advice. This is a 4-digit field. This must be a valid code. If the CARC code is a 2 (coinsurance amount), enter a "2", not "02".

NOTE: CARC codes explain why there is a difference between the total billed amount and the paid amount. The word 'adjustment' in relation to a CARC code is not the same as a "claim" adjustment (type of bill 327 or 817). 

For a current list of valid CARC codes, refer to the Washington Publishing Company websiteExternal Website

You can also search through a list of CARC codes by accessing the FISS DDE Inquiry screen option 68 (ANSI REASON CODES) and type "C" in the RECORD TYPE field.

AMT

Enter the dollar amount associated with the group code and CARC.

NOTE: This dollar amount reflects the difference between what was billed by the provider and what was paid by the primary payer.

The AMT field must equal the total submitted charges (revenue code 0001) minus the amount entered in the PAID AMOUNT field (the amount paid by the primary payer).  For example:

Total billed amount (0001 revenue code)

2000.00
-1500.00
500.00

Minus PAID AMOUNT (primary paid amount)

Equals the AMT field

NOTE: If Value Code 44 is billed, the dollar amount entered in the AMT field must be the difference between the total charges and the VC 44 amount.

Total billed amount (0001 revenue code)

2000.00
-1500.00
500.00

Minus the Value Code 44 amount

Equals the AMT field

If the CAS code information is not available from the prior payer, providers need to determine the appropriate Group Code and Claim Adjustment Reason Code (CARC) to submit. This information is available from the following websites:

Return to Provider (RTP) Reason Codes
MSP claims will automatically be sent to the RTP file when one or more of the following reason codes apply.

Reason Code

Reason Code Description / How to Resolve

31686

The dollar amount in the PD AMT field on the MSP Payment Information screen (MAP 1719) is not equal to the submitted charges and there are no entries present in the GROUP or CARC fields.

How to Resolve:Verify that the PAID AMOUNT field equals the dollar amount entered for MSP Value Codes 12, 13, 14, 15, 16, 43, and 47. The GRP and CARC fields must also be completed.

31687

This reason code has been assigned to your claim because:

  • The claim shows Medicare primary but there is information present on the MSP Payment Information screen (MAP 1719) for Primary Payer 1 or Primary Payer 2

    How to Resolve: If Medicare is primary, the MSP Payment Information screen for Primary Payer 1 and Primary Payer 2 must be blank.

  • Medicare is secondary and no information is present on the MSP Payment Information Screen (MAP 1719) for Primary Payer 1.

    How to Resolve:  If Medicare is the secondary payor, the MSP Payment Information screen for Primary Payer 1 must be completed.

  • Medicare is secondary and the MSP Payment Information screen (MAP 1719) has information present for Primary Payer 2

    How to Resolve:  If Medicare is the secondary payor, the MSP Payment Information screen for Primary Payer 1 must be completed. Information for primary payer 2 is only required when Medicare is the tertiary payer.

  • Medicare is the tertiary payer and information is missing on the MSP Payment Information screen (MAP 1719) for Primary Payer 1 or Primary Payer 2

    How to Resolve:  If Medicare is the tertiary payor, the MSP Payment Information screen for Primary Payer 1 and Primary Payer 2 must be completed.

  • Medicare is secondary or tertiary and the PD DT or PD AMT field on the MSP Payment Information screen (MAP 1719) is blank for Primary Payer 1 and/or Primary 2 (Note: zeros (0.00) may be entered in the PD AMT field. However no entry or blank space is acceptable)

    How to Resolve: When Medicare is the primary or tertiary payer, the PAID DATE and PAID AMOUNT fields must be completed. Enter the paid date shown on the primary payer's remittance advice in the PAID DATE field, and enter the paid amount shown on the primary payer's remittance advice in the PAID AMOUNT field. This amount must equal the dollar amount entered for MSP Value Codes 12, 13, 14, 15, 16, 43, and 47.

  • Medicare is secondary and at least one GROUP/CARC combination is not present for Primary Payer 1

    How to Resolve:When Medicare is the secondary payer, the GRP and CARC field for Primary Payer 1 on the "MSP Payment Information" screen (MAP 1719) must be completed.

  • Medicare is tertiary and at least one GROUP/CARC combination is not present for Primary Payer 2

    How to Resolve: When Medicare is the tertiary payer, the GRP and CARC field for Primary Payer 2 on the "MSP Payment Information" screen (MAP 1719) must be completed.

31688

This claim was submitted showing Medicare as the secondary or tertiary payer and one of the following has occurred:

  • An invalid CARC code has been entered on the MSP Payment Information screen (MAP1719)

  • The PAID DATE field on the MSP Payment Information screen (MAP1719) is prior to the effective date for one or more of the CARC codes entered

  • The PAID DATE field on the MSP Payment Information screen (MAP1719) occurs after the termination date for one or more or the CARC codes entered.

How to Resolve:  The CARC code entered must be a valid code. Refer to the Washington Publishing Company website for a list of valid codes and the date it became valid.

31689

The claim has been submitted showing Medicare as the secondary or tertiary payer and the dollar amount entered in the PAID AMOUNT field on the MSP Payment Information screen (MAP1719) is not equal to the dollar amount entered for the MSP Value code (12, 13, 14, 15, 41, 43 or 47).

How to Resolve: Review the dollar amount entered in the PAID AMOUNT field on the MSP Payment Information screen and ensure that it equals the dollar amount entered for MSP Value Codes 12, 13, 14, 15, 16, 43, and 47.

31690

Primary Payer information has been entered on the MSP Payment Information screen (MAP1719) (F11 on page 3 of claim) for Primary Payer 2; however, information is not present for Primary Payer 1. If there is only one primary payer, information must be entered only for Primary Payer 1.

How to Resolve:  When Medicare is the secondary payer, the MSP Payment Information screen for Primary Payer 1 must be completed. The Primary Payer 2 screen is only completed when Medicare is the teritary payer.

31691

The claim has been submitted showing Medicare as the secondary payer; the total submitted charges on the claim minus the total of the CARC amounts on the MSP Payment Information screen (MAP1719) does not equal the PAID AMT field on the screen.

How to Resolve: The AMT field on the MSP Payment Information screen must equal the total submitted charges (revenue code 0001) minus the amount entered in the PAID AMOUNT field (the amount paid by the primary payer and the amount submitted with Value Codes 12, 13, 14, 15, 16, 43, or 47. For example:

$5000.00 (revenue code 0001)
-$4000.00 (primary paid amount (also the amount entered in the PAID AMOUNT field, which must equal VC 12, 13, 14, 15, 16, 43, or 47)
= $1000.00  (AMT field)

31693

Medicare is not the primary payer and the date entered in the PAID DATE field is not valid or is in the wrong format for Primary Payer 1 or Primary Payer 2. The correct format is MMDDYY. Correct and F9 or resubmit the claim.

How to Resolve: The PAID DATE field on the MSP Payment Information screen must be a valid date and in the correct format (MMDDYY).

For additional guidance with submitting MSP claims, please refer to the following resources:

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