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Tax Payer Checksheet

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									           Medicare Secondary
           Payer (MSP) Conditional
           Claims
          When Primary Payer Does Not
          Make Payment
          August 2009




TMP-EDO-0006 V: 5.0 9/29/08
DISCLAIMER
This information release is the property of NHIC, Corp. It
may be freely distributed in its entirety but may not be
modified, sold for profit or used in commercial
documents. The information is provided “as is” without
any expressed or implied warranty. While all information
in this document is believed to be correct at the time of
writing, this document is for educational purposes only
and does not purport to provide legal advice. All models,
methodologies and guidelines are undergoing continuous
improvement and modification by NHIC, Corp. and the
Centers for Medicare & Medicaid Services (CMS). The
most current edition of the information contained in this
release can be found on the NHIC, Corp. Web site at
www.medicarenhic.com and the CMS Web site at
www.cms.hhs.gov. The identification of an organization
or product in this information does not imply any form of
endorsement.

                         MSP CONDITIONAL CLAIMS            2
                              TMP-EDO-0006 v.5.0 9/29/08
Acronyms
CC     Condition Code
CMS    Centers for Medicare & Medicaid Services
COBC   Coordination of Benefits Contractor
CWF    Common Working File
DDE    Direct Data Entry
DOA    Date of Accident
DOS    Date of Service
EGHP   Employer Group Health Plan
EOB    Explanation of Benefits
ESRD   End-Stage Renal Disease
                          MSP CONDITIONAL CLAIMS            3
                               TMP-EDO-0006 v.5.0 9/29/08
Acronyms
FISS   Fiscal Intermediary Standard System
GHP    Group Health Plan
       Health Maintenance Organization (through
HMO
       employer)
ID     Identification
IOM    Internet-Only Manual
IP     Inpatient
LGHP   Large Group Health Plan
MSP    Medicare Secondary Payer
MSPRC Medicare Secondary Payer Recovery Contractor
OC     Occurrence Code

                        MSP CONDITIONAL CLAIMS            4
                             TMP-EDO-0006 v.5.0 9/29/08
Acronyms
OC    Occurrence Code

OP    Outpatient

PIP   Personal Injury Protection

RTP   Return to Provider

UB    Uniform Billing

VC    Value Code




                        MSP CONDITIONAL CLAIMS            5
                             TMP-EDO-0006 v.5.0 9/29/08
Objective

Educate providers on why, when, and how to submit MSP
conditional claims to Medicare




                       MSP CONDITIONAL CLAIMS            6
                            TMP-EDO-0006 v.5.0 9/29/08
Agenda

General information about conditional claims
Conditional claim coding
Conditional claim scenarios
What you should do now
Open question and answer segment




                           MSP CONDITIONAL CLAIMS            7
                                TMP-EDO-0006 v.5.0 9/29/08
Conditional Claims

  General Information




   TMP-EDO-0006 V: 5.0 9/29/08
MSP - Defined

Refers to situations in which Medicare does not have
primary responsibility for paying health care claims for
Medicare beneficiary
• Beneficiary has other coverage that should pay primary based on
  federal law




                             MSP CONDITIONAL CLAIMS                 9
                                  TMP-EDO-0006 v.5.0 9/29/08
Provider’s MSP Requirements

Any provider that submits claims to Medicare must
• Determine whether or not there are payers primary to Medicare for
  services rendered, and
• Submit claims to those primary payers before submission to
  Medicare




                             MSP CONDITIONAL CLAIMS                   10
                                  TMP-EDO-0006 v.5.0 9/29/08
Did You Know…

Medicare is prohibited from making payment if payment
has been made or can reasonably be expected to be made
promptly, by a primary payer




                       MSP CONDITIONAL CLAIMS            11
                            TMP-EDO-0006 v.5.0 9/29/08
Claim Status with Primary
Payer
Once proper claims have been filed with primary payers,
those payers either
• Make payment on claims, or

• Do not make payment on claims
  –For valid reasons, or

  –Promptly (within 120 days)

  –Because they are not primary, Medicare is primary




                               MSP CONDITIONAL CLAIMS            12
                                    TMP-EDO-0006 v.5.0 9/29/08
Conditional Claims - Defined

Claims submitted to Medicare requesting payment
because primary payer
• Did not make payment for valid reasons, or
  –All MSP VCs except 16 and 42

• Did not make payment promptly (within 120 days)
  –MSP VCs 14, 15, 41 and 47 only

Resemble MSP claims except primary payer’s payment
amount is zero (0000.00)




                             MSP CONDITIONAL CLAIMS            13
                                  TMP-EDO-0006 v.5.0 9/29/08
Primary Payer Did Not Make
Payment for Valid Reason
Only certain reasons are considered valid
• Examples include, but are not limited to:
  –Benefits exhausted/maximum benefit reached

  –Not a covered benefit

  –Preexisting condition

  –Applied payment toward plan’s deductible, coinsurance or co-
   payment




                              MSP CONDITIONAL CLAIMS              14
                                   TMP-EDO-0006 v.5.0 9/29/08
Primary Payer Did Not Make
Payment Promptly
Only applies to specific MSP Provisions
• No-Fault insurance including Med-Pay and PIP (MSP VC 14)

• Workers Compensation (MSP VC 15)

• Federal Black Lung Program (MSP VC 41)

• Liability insurance (MSP VC 47)
  –Provider must withdraw claim with primary payer before
   submitting conditional claim to Medicare




                              MSP CONDITIONAL CLAIMS             15
                                    TMP-EDO-0006 v.5.0 9/29/08
Conditional Payment by
Medicare
Medicare may make conditional payment
• Payment amount is equal to amount that would be paid if Medicare
 were primary




                            MSP CONDITIONAL CLAIMS                   16
                                 TMP-EDO-0006 v.5.0 9/29/08
When Medicare Will Not Make
a Conditional Payment
Conditional payment will not be made if primary payer
has not been billed, has not paid, or has not paid
promptly, because
• Beneficiary refuses to
  –File a claim with insurer, or

  –Cooperate with provider in filing claim

• Provider/beneficiary failed to file proper claim with insurer
  –Unless due to beneficiary’s mental or physical incapacity




                               MSP CONDITIONAL CLAIMS             17
                                    TMP-EDO-0006 v.5.0 9/29/08
Did You Know…

Providers should not submit conditional claims to
Medicare when the reason the primary payer has not
made payment is because the plan is not the appropriate
primary payer for the beneficiary; Medicare is primary.

The following slide contains a list, which is not all-
inclusive, of reasons why Medicare is primary and should
be billed as such.




                        MSP CONDITIONAL CLAIMS            18
                             TMP-EDO-0006 v.5.0 9/29/08
When to Submit a Medicare
Primary Claim
Beneficiary not enrolled in GHP or GHP terminated
• Contact COBC
Beneficiary has GHP but it is not primary to Medicare
• Contact COBC and report any applicable CC
Beneficiary and/or spouse retired
• Report OC 18 and/or 19 with date(s) of retirement
Services not related to prior accident (MSP file on CWF)
• Report in Remarks
Services related to accident, another insurer was primary,
however, Medicare is now primary because case settled
• Contact MSPRC
Services related to accident but no other insurer is primary
• Report OC 05 and DOA; see example on next slide

                                MSP CONDITIONAL CLAIMS            19
                                     TMP-EDO-0006 v.5.0 9/29/08
When to Submit a Medicare
Primary Claim
Situation: Services related to accident, but no other
insurance is primary
• Beneficiary is driver in one-car automobile accident

• Does not carry optional medical payment coverage

• No liability per MSP questionnaire

• No MSP file on CWF to contradict this information


Provider action
• Submit Medicare primary claim
  –Report OC 05 and DOA


                              MSP CONDITIONAL CLAIMS            20
                                   TMP-EDO-0006 v.5.0 9/29/08
Claim Forms and Coding
Conditional Claims




   TMP-EDO-0006 V: 5.0 9/29/08
Claim Forms

CMS-1450/UB-04

Claim entry through FISS/DDE

Electronic claim (837)




                         MSP CONDITIONAL CLAIMS            22
                              TMP-EDO-0006 v.5.0 9/29/08
General Instructions for
Conditional Claims
Providers must report
• Primary payer as first payer

• Medicare as second payer

• All other applicable MSP billing codes in appropriate claim fields (FLs)
  to indicate claim is a conditional claim
   –Use MSP Billing Code Chart (handout), and

  –List billing code options for certain FLs to complete for conditional
   claims, MSP claims as well as Medicare primary claims when
   provider needs to let us know the reason why we are primary

  –Use MSP information collected from beneficiary and/or his/her
   representative/family member

                                 MSP CONDITIONAL CLAIMS                 23
                                      TMP-EDO-0006 v.5.0 9/29/08
Claim Fields to Complete

                    Use MSP Billing Code Chart

Code                                              UB-04 FLs       FISS/DDE

CCs                                               18 – 28         Page 1

OCs and dates                                     31 – 34         Page 1

VC and zero payment                               39 – 41         Page 1

Primary payer code                                N/A             Page 3

Patient’s relationship to insured                 59A             Page 5

Reason primary payer did not pay                  80 (remarks)    Page 4
                                MSP CONDITIONAL CLAIMS                       24
                                     TMP-EDO-0006 v.5.0 9/29/08
CCs

Report applicable MSP-related CCs
• CC 02 – Condition is employment-related


• CC 06 – ESRD beneficiary in first 30 months of entitlement covered
 by an EGHP

• Report, as applicable, any other CC


• Do not report a claim change reason code unless claim is an
 adjustment to a previously submitted claim




                              MSP CONDITIONAL CLAIMS                   25
                                   TMP-EDO-0006 v.5.0 9/29/08
OCs and Dates

Report OC 33 and first date of ESRD MSP coordination
period
• If beneficiary is ESRD beneficiary with EGHP

Report OC and DOA if claim related to accident for which
another plan is primary
• 01 with DOA if Med-Pay

• 02 with DOA if No-Fault

• 03 with DOA if Liability

• 04 with DOA if Workers Compensation

Report, as applicable, any other OC and date
                              MSP CONDITIONAL CLAIMS            26
                                   TMP-EDO-0006 v.5.0 9/29/08
Did You Know…

Automobile No-Fault states include Florida, Hawaii,
Kansas, Kentucky, Massachusetts, Michigan, Minnesota,
North Dakota, New Jersey, New York, Pennsylvania, and
Utah. Puerto Rico, a US commonwealth, is also No-Fault.




                        MSP CONDITIONAL CLAIMS            27
                             TMP-EDO-0006 v.5.0 9/29/08
OC 24 and Date

Report OC 24 and date of primary payer’s denial
• Date of primary payer’s EOB statement or letter that explains reason
  they did not make payment for valid reason

Do not report OC 24 and date of primary payer’s denial
• When conditional claim is result of not receiving a prompt payment
  from primary payer
  –MSP VCs 14, 15, 41 or 47 only




                             MSP CONDITIONAL CLAIMS                    28
                                  TMP-EDO-0006 v.5.0 9/29/08
OC 24 Tip

Report OC 24 on conditional claims only
• Claims that contain OC 24 and date of primary payer’s denial will be
  RTP with reason code 31409 if there is no MSP VC and zero payment
  (0000.00) present




                             MSP CONDITIONAL CLAIMS                 29
                                  TMP-EDO-0006 v.5.0 9/29/08
Correcting Reason Code
31409
If billing conditionally
• Enter appropriate MSP VC and zero payment (0000.00) and all
  required conditional claim coding

If not billing conditionally
• Remove OC 24 and date of primary plan’s denial and code claim as
  intended (Medicare primary or MSP)




                            MSP CONDITIONAL CLAIMS                   30
                                 TMP-EDO-0006 v.5.0 9/29/08
VC and Amount

Report applicable MSP VC:
• 12   =   Working Aged with EGHP (age 65 and over)
• 13   =   ESRD MSP
• 14   =   Med-Pay (automobile or non-automobile)
• 14   =   No-Fault (automobile)
• 15   =   Workers Compensation
• 41   =   Federal Black Lung Program
• 43   =   Disabled with LGHP (under age 65)
• 47   =   Liability (automobile or non-automobile)

VC amount must equal zero ($0000.00)

Do not report a VC 44 and amount

                               MSP CONDITIONAL CLAIMS            31
                                    TMP-EDO-0006 v.5.0 9/29/08
FISS/DDE Claim Entry Page 01
 MAP1711     PAGE 01              NHIC, CORP.                               XXXX681 07/22/09
 XXXXXXX     SC                INST CLAIM ENTRY
 HIC                 TOB 131 S/LOC S B0100 OSCAR                          SV:      UB-FORM
NPI              TRANS HOSP PROV                      PROCESS NEW HIC
PAT.CNTL#:                         TAX#/SUB:                       TAXO.CD:
 STMT DATES FROM           TO           DAYS COV         N-C          CO        LTR
 LAST                              FIRST                     MI       DOB
 ADDR 1                                      2
 3                                    4                                         CARR:
 5                                    6                                          LOC:
ZIP             SEX   MS   ADMIT DATE           HR      TYPE    SRC      D HM        STAT
    COND CODES 01 XX 02     03     04     05     06      07     08       09     10
 OCC CDS/DATE 01 XX MM/DD/YY       02              03              04               05
                06                 07              08              09               10
    SPAN CODES/DATES 01                      02                       03
04                    05                     06                       07
08                    09                     10                       FAC.ZIP
    DCN
         V A L U E C O D E S - A M O U N T S - A N S I                MSP APP IND
01 XX $0000.00             02                            03
04                         05                            06
07                         08                            09
      PLEASE ENTER DATA
        PRESS PF3-EXIT PF5-SCROLL BKWD PF6-SCROLL FWD PF7-PREV                PF8-NEXT


                                          MSP CONDITIONAL CLAIMS                               32
                                                TMP-EDO-0006 v.5.0 9/29/08
Primary Payer Code

In FISS/DDE, report primary payer as first payer and
Medicare as second
• Payer code = C (conditional) for primary payer
  –First payer = Payer A, line A


• Payer code = Z (Medicare) for secondary payer
  –Second payer = Payer B, line B




                             MSP CONDITIONAL CLAIMS             33
                                   TMP-EDO-0006 v.5.0 9/29/08
FISS/DDE Claim Entry Page 03
MAP1713   PAGE 03                NHIC, CORP.                                XXXXX681 07/22/09
XXXXXXX   SC                  INST CLAIM ENTRY
HIC                 TOB 131   S/LOC S B0100 PROVIDER
                                                                    OFFSITE ZIPCD:
  CD ID    PAYER                      OSCAR              RI AB                 EST AMT DUE
A C
B Z
C
DUE FROM PATIENT

MEDICAL RECORD NBR                       COST RPT DAYS        NON COST RPT DAYS
DIAGNOSIS CODES 1             2             3             4            5
     6            7           8             9                    END OF POA IND
ADMITTING DIAGNOSIS             E CODE             HOSPICE TERM ILL IND
IDE
PROCEDURE CODES AND DATES 1                      2
 3                   4                 5                    6
NDC CODE
ESRD HOURS      ADJUSTMENT REASON CODE        REJECT CODE          NONPAY CODE
ATT PHYS         NPI                LN                        FN            MI
OPR PHYS         NPI                LN                        FN            MI
OTH PHYS         NPI                LN                        FN            MI
       PROCESS COMPLETED ---     PLEASE CONTINUE
            PRESS PF3-EXIT PF7-PREV PF8-NEXT PF9-UPDT


                                       MSP CONDITIONAL CLAIMS                                   34
                                              TMP-EDO-0006 v.5.0 9/29/08
Patient’s Relationship to
Insured
When reporting a primary payer as first payer and
Medicare as second, report patient’s relationship to
insured
• 01 through G8
  –01 - Spouse
  –18 - Self
  –19 - Child
  –20 - Employee
  –21 - Unknown
  –39 - Organ Donor
  –40 - Cadaver Donor
  –53 - Life partner
  –G8 - Other relationship
                             MSP CONDITIONAL CLAIMS            35
                                  TMP-EDO-0006 v.5.0 9/29/08
FISS/DDE Claim Entry Page 05
MAP1715   PAGE 05            NHIC, CORP.                             XXXXXA681 07/22/09
XXXXXXX   SC             INST CLAIM ENTRY

HIC               TOB 131 S/LOC S B0100 PROVIDER
INSURED NAME REL CERT-SSN-HIC SEX GROUP NAME  DOB         INS GROUP NUMBER
A            XX

B

C

TREAT. AUTH. CODE




TREAT. AUTH. CODE


TREAT. AUTH. CODE




      PROCESS COMPLETED ---   PLEASE CONTINUE
           PRESS PF3-EXIT PF7-PREV PF8-NEXT PF9-UPDT


                                   MSP CONDITIONAL CLAIMS                                 36
                                        TMP-EDO-0006 v.5.0 9/29/08
Remarks

Report two-position explanation code on all conditional
claims to represent reason primary payer has not made
payment or has not made payment promptly
• Select from list of ten (10) codes
  –NB, PC, CD, FG
  –BE, PE
  –DA
  –DP, LD, PP




                               MSP CONDITIONAL CLAIMS            37
                                    TMP-EDO-0006 v.5.0 9/29/08
FISS/DDE Claim Entry Page 04
MAP1714   PAGE 04                     NHIC, CORP.                                  XXXXX681 07/22/09
XXXXXXX   SC                     INST CLAIM ENTRY
                                                           REMARK PAGE 01
HIC                 TOB 131   S/LOC S B0100    PROVIDER

REMARKS
2-DIGIT EXPLANATION CODE




47 PACEMAKER      48 AMBULANCE      40        THERAPY     41         HOME HEALTH
58 HBP CLAIMS (MED B)               E1        ESRD ATTACH
ANSI CODES - GROUP:    ADJ REASONS:             APPEALS:

      PROCESS COMPLETED ---   PLEASE CONTINUE
PRESS PF3-EXIT PF5-SCROLL BKWD PF6-SCROLL FWD             PF7-PREV          PF8-NEXT   PF9-UPDT

                                       MSP CONDITIONAL CLAIMS                                          38
                                               TMP-EDO-0006 v.5.0 9/29/08
NB, PC, CD, and FG

                                                                  Can use with
Code                Description
                                                                  MSP VCs
                                                                  12, 13, 14, 15, 41,
 NB    Not a covered benefit
                                                                  43
 PC    Pre-existing condition                                     12, 13, 43
       Primary payment applied toward plan
 CD                                                               12, 13, 43
       deductible and/or coinsurance
       Beneficiary did not follow rules of GHP
       (VCs 12, 13, 43) or rules of Workers
       Compensation (VC 15)
 FG    •Untimely filing with primary payer                        12, 13, 15, 43
       •Out of network (we will pay once)
       •No prior authorization

                                MSP CONDITIONAL CLAIMS                              39
                                     TMP-EDO-0006 v.5.0 9/29/08
Did You Know…

All conditional claims submitted with an FG explanation
code for GHP rejections due to out of network, untimely
filing or no prior authorization will suspend for
investigation. There must be remarks explaining which
primary health plan guideline the beneficiary failed to
follow or the claim will be returned (RTP).




                        MSP CONDITIONAL CLAIMS            40
                             TMP-EDO-0006 v.5.0 9/29/08
BE and PE (Benefits
Exhausted)

                                                              Can use with
Code   Description
                                                              MSP VCs
       Benefits exhausted                                     12, 13, 14, 15,
  BE
       No-Fault states should use PE; not BE                  41, 43
       PIP exhausted toward other medical
  PE                                                          14
       expenses
Both codes require date benefits exhausted in MM/DD/YY
format. If primary payer does not provide exact date, report
date of primary payer’s EOB statement or rejection/denial
letter.


                            MSP CONDITIONAL CLAIMS                              41
                                 TMP-EDO-0006 v.5.0 9/29/08
Did You Know…

If No-Fault or Med-Pay benefits have been exhausted, the
case is not also a Liability, then Medicare considers itself
to be primary following the date on which benefits have
exhausted. However, we must process claims
conditionally until the COBC or MSPRC terminates the
online MSP file on the CWF.




                         MSP CONDITIONAL CLAIMS            42
                              TMP-EDO-0006 v.5.0 9/29/08
DA (Primary Payer Does Not
Pay Promptly)
                                                            Can use with MSP
  Code     Description
                                                            VCs
           120 days have passed since
    DA                                                      14, 15, 41, 47
           primary payer was billed


Code requires date primary payer was billed in MM/DD/YY
format. Do not report OC 24 and date when reporting
explanation code of DA.




                          MSP CONDITIONAL CLAIMS                             43
                               TMP-EDO-0006 v.5.0 9/29/08
DP, LD, PP

Code    Description (Report only with MSP VC 47)
        Response received from liability stating they need more time
  DP
        so there will be a delay in their payment
        Response received from liability insurer stating they feel they
  LD
        are not responsible for claim
  PP    Patient paid by liability insurer

Code PP used only for claims involving liability insurance
payments to patient where provider is not expecting any
payment from patient. PP may not be used for medical
payment insurance payments to patient. Providers are required
to pursue those dollars.



                               MSP CONDITIONAL CLAIMS                 44
                                    TMP-EDO-0006 v.5.0 9/29/08
Did You Know…

Conditional claims will be RTP if they do not contain a
two-position explanation code or if they do not contain
an acceptable two-position explanation code.




                        MSP CONDITIONAL CLAIMS            45
                             TMP-EDO-0006 v.5.0 9/29/08
Claim Fields to Complete

                 Use MSP Information Collected

Code                        UB-04 FLs                         FISS claim entry
Payer Name                  50A                               Page 3

Insured’s name              58A                               Page 5

Insured’s unique ID         60A                               Page 5

Insurance group name        61A                               Page 5

Insurance group number      62A                               Page 5

Insurance address           80                                Page 6

Employer Name               65A                               N/A

                           MSP CONDITIONAL CLAIMS                                46
                                 TMP-EDO-0006 v.5.0 9/29/08
FISS/DDE Claim Entry Page 03
MAP1713   PAGE 03                 NHIC, CORP.                              XXXXX681 07/22/09
XXXXXXX   SC                  INST CLAIM ENTRY
HIC                 TOB 131   S/LOC S B0100 PROVIDER
                                                                    OFFSITE ZIPCD:
  CD ID    PAYER NAME                 OSCAR              RI AB                 EST AMT DUE
A C        COMPLETE INSURER NAME
B Z        MEDICARE
C
DUE FROM PATIENT        0.00

MEDICAL RECORD NBR                       COST RPT DAYS        NON COST RPT DAYS
DIAGNOSIS CODES 1             2             3             4            5
     6            7           8             9                    END OF POA IND
ADMITTING DIAGNOSIS             E CODE             HOSPICE TERM ILL IND
IDE
PROCEDURE CODES AND DATES 1                      2
 3                   4                 5                    6
NDC CODE
ESRD HOURS      ADJUSTMENT REASON CODE        REJECT CODE          NONPAY CODE
ATT PHYS         NPI                LN                        FN            MI
OPR PHYS         NPI                LN                        FN            MI
OTH PHYS         NPI                LN                        FN            MI
       PROCESS COMPLETED ---     PLEASE CONTINUE



                                       MSP CONDITIONAL CLAIMS                                  47
                                              TMP-EDO-0006 v.5.0 9/29/08
FISS/DDE Claim Entry Page 05
MAP1715   PAGE 05             NHIC, CORP.                            XXXXX681 07/22/09
XXXXXXX   SC               INST CLAIM ENTRY

HIC               TOB 131 S/LOC S B0100 PROVIDER
INSURED NAME REL CERT-SSN-HIC SEX GROUP NAME  DOB         INS GROUP NUMBER
A

B

C

TREAT. AUTH. CODE




TREAT. AUTH. CODE


TREAT. AUTH. CODE

      PROCESS COMPLETED ---   PLEASE CONTINUE
           PRESS PF3-EXIT PF7-PREV PF8-NEXT PF9-UPDT



                                   MSP CONDITIONAL CLAIMS                                48
                                        TMP-EDO-0006 v.5.0 9/29/08
FISS/DDE Claim Entry Page 06
MAP1716   PAGE 06              NHIC, CORP.                                XXXXX681 07/22/09
XXXXXXX   SC               INST CLAIM ENTRY
HIC               TOB 131 S/LOC S B0100 PROVIDER
            MSP ADDITIONAL INSURER INFORMATION
1ST INSURERS ADDRESS 1
1ST INSURERS ADDRESS 2
                CITY                  ST      ZIP
2ND INSURERS ADDRESS 1
2ND INSURERS ADDRESS 2
                CITY                  ST      ZIP
PAYMENT DATA --- DEDUCTIBLE              COIN                   CROSSOVER IND
PARTNER ID

PAID DATE         PROVIDER PAYMENT                  PAID BY PATIENT
REIMB RATE         RECEIPT DATE 072209 PROVIDER INTEREST
CHECK/EFT NO              CHECK/EFT ISSUE DATE            PAYMENT CODE
                            PRICER DATA
DRG      OUTLIER AMT               TTL BLNDED PAYMT             FED SPEC
GRAMM RUDMAN ORIG REIMBURSEMENT AMT              NET INL
TECH PROV DAYS       TECH PROV CHARGES
 OTHER INS ID              CLINIC CODE
      PROCESS COMPLETED ---     PLEASE CONTINUE
PRESS PF3-EXIT PF7-PREV PAGE PF9-UPDT ENTER-CONTINUE


                                     MSP CONDITIONAL CLAIMS                                   49
                                          TMP-EDO-0006 v.5.0 9/29/08
Did You Know…

Providers should maintain any documentation on file that
supports their request for conditional payment from
Medicare, such as the primary payer’s EOB statement,
denial/rejection letter, etc..




                        MSP CONDITIONAL CLAIMS            50
                             TMP-EDO-0006 v.5.0 9/29/08
Conditional Claim
Scenarios




TMP-EDO-0006 V: 5.0 9/29/08
Claim Scenario #1
Stewart Stillworks
Beneficiary
• Is an OP in your facility on 05/10/09
• Over age 65
• Works at Actively Working Co. (over 20 employees)
• GHP through XYZ Insurance is primary
Provider
• Total charges = $500
• Expects to receive $400
XYZ Insurance
• Paid zero; per EOB statement dated 6/10/09, entire payment was
  applied toward plan’s deductible



                              MSP CONDITIONAL CLAIMS               52
                                   TMP-EDO-0006 v.5.0 9/29/08
Claim Scenario #1

Based on information you have, conditional claim should
include:


CC                              None
OC                              24 and 06/10/09
MSP VC                          12
MSP VC amount                   $0000.00
Primary payer name              XYZ Insurance
Remarks                         CD




                        MSP CONDITIONAL CLAIMS            53
                             TMP-EDO-0006 v.5.0 9/29/08
Claim Scenario #2
Carl Crash
Beneficiary
• Is an IP at your facility 01/01/09-01/04/09
• Services related to automobile accident on 11/24/08

Provider
• Total charges = $5000

No-Fault Insurance
• Slow Down Insurance Co.
• Paid zero; per EOB statement dated 02/01/09, benefits are
  exhausted as of 12/31/08



                              MSP CONDITIONAL CLAIMS            54
                                   TMP-EDO-0006 v.5.0 9/29/08
Claim Scenario #2

Based on information you have, conditional claim should
include:


CC                     None
OCs                    02 with 11/24/08 & 24 with 02/01/09
MSP VC                 14
MSP VC amount          $0000.00
Primary payer name     Slow Down Insurance Co.
Remarks                PE and 12/31/08




                        MSP CONDITIONAL CLAIMS            55
                             TMP-EDO-0006 v.5.0 9/29/08
Claim Scenario #3
Pam N. Delayed
Beneficiary
• Is an OP at your facility on 12/01/08
• Services are related to fall in grocery store on 12/01/08

Provider
• Total charges = $500
• Filed proper claim with liability on 12/10/08
• Has not been paid promptly so decides to withdraw claim with
  liability and request conditional payment from Medicare

Liability Insurer
• Sorry You Fell Co.


                               MSP CONDITIONAL CLAIMS            56
                                    TMP-EDO-0006 v.5.0 9/29/08
Claim Scenario #3

Based on information you have, conditional claim should
include:



CC                      None
OCs                     03 with 12/01/08
MSP VC                  47
MSP VC amount           $0000.00
Primary payer name      Sorry You Fell Co.
Remarks                 DA with 03/10/09
                        (date must be equal to 120th day from
                        date primary plan billed)


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Did You Know…

Providers should always check the online MSP files on
CWF to determine if there is a matching MSP file for the
claim about to be submitted to Medicare. If there is no
online MSP file present on the CWF, contact the COBC
before submitting any MSP and/or conditional claim to
Medicare.




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What You Should Do Now

Check internal systems and processes to ensure that your
facility submits conditional claims when required and in
accordance with Medicare’s instructions
• Use this presentation and supporting documentation for assistance

Develop, implement and follow internal policies for
submitting MSP conditional claims

Contact appropriate entity for MSP information when
necessary

Continue to attend MSP educational sessions

Sign up for NHIC list serve on Web site


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CMS References

IOMs available on CMS’s Web site
• Billing codes (including those used for conditional billing)
  –CMS IOM Publication 100-04, Medicare Claims Processing Manual
     •Chapter 25, Section 75
• Conditional billing policies
  –CMS IOM Publication 100-05, Medicare Secondary Payer Manual
     •Chapter 1, Sections 10.7 and 30
     •Chapter 3, Section 40.3.1
     •Chapter 5, Section 40.6



      http://www.cms.hhs.gov/Manuals/IOM/list.asp


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When to Contact COBC
                  Telephone Inquiries
                   1 (800) 999-1118


Report employment changes, any other insurance
coverage information

Report liability, automobile/no-fault, workers
compensation case

General MSP questions/concerns

Questions regarding MSP development letters and MSP
questionnaires

http://www.cms.hhs.gov/COBGeneralInformation/

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When to Contact MSPRC
                    Telephone Inquiries
                     1 (866) 677-7220


MSP post-payment recovery functions and workloads

Obtain conditional payment amount or Medicare’s final
recovery claim amount

Ask questions regarding MSP recovery demand letters or
repayment to Medicare

Request waiver of recovery with respect to beneficiary
MSP debt
• http://www.cms.hhs.gov/MSPRGenInfo/, or
• http://www.msprc.info
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When to Contact NHIC, Corp.
                   Customer Care Center
                   Part A - (877) 757-7783
                   RHHI - (866) 289-0423

Ask questions on submitting claims

Processing claims for primary or secondary payment

Accepting return of inappropriate Medicare payment

Regarding Medicare claim/service denials, adjustments




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NHIC, Corp. References

Conditional billing article on Web site
• Part A providers link:
  –http://www.medicarenhic.com/PA/PartA_msp.shtml


• Home Health & Hospice providers link:
  –http://www.medicarenhic.com/RHHI/RHHI_msp.shtml




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   Questions?




TMP-EDO-0006 V: 5.0 9/29/08
Question #1

Conditional claims are claims submitted to request
  payment from Medicare after the primary payer has
  made payment.

      1. True
      2. False




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Question #2

If a provider submits a claim to a beneficiary’s GHP but
receives a denial indicating that the GHP is not primary
because the beneficiary retired, it should submit a
conditional claim to Medicare.

   1. True
   2. False




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Question #3

If a provider submits a claim to a beneficiary’s GHP but
receives a an EOB statement indicating that the GHP
applied their full payment toward the plan’s
deductible, it may submit a conditional claim to
Medicare.

    1. True
    2. False




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Question #4

If a provider submits a claim to a beneficiary’s
automobile Med-Pay plan but that plan does not make
payment within 90 days, it may submit a conditional
claim to Medicare.

    1. True
    2. False




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Question #5

Conditional claims resemble MSP claims except that
the primary payer’s payment amount is zero.

   1. False
   2. True




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Question #6

If Medicare makes a conditional payment on a claim, the
payment amount is equal to the amount that Medicare
would pay on the claim if Medicare were primary.

   1. True
   2. False




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Question #7

All claims submitted to Medicare conditionally must have
an OC 24 and date.

      1. True
      2. False




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Question #8

FISS DDE requires that the primary payer code be ‘C’
for all conditional claims regardless of the MSP VC that
is reported.

   1. True
   2. False




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Question #9

All claims submitted conditionally because primary
payer applied their payment toward plan’s deductible
should have a two-position explanation code of CD in
Remarks.

   1. True
   2. False




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Question #10

Claims submitted conditionally with a two-position
explanation codes of BE, PE or DA do not require an
associated date in MM/DD/YY format.

   1. True
   2. False




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Thank You for Your
Attendance




  TMP-EDO-0006 V: 5.0 9/29/08
 www.medicarenhic.com
        MEDICARE ADMINISTRATIVE CONTRACTOR
              JURISDICTION 14 A/B/MAC



NHIC, Corp.
75 Sgt William B Terry Dr.
Hingham, MA 02043
www.medicarenhic.com




                             TMP-EDO-0006 V: 5.0 9/29/08

								
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