us-cms-medicare-manuals-pub-100-05-msp105c06•100-05 Medicare Secondary Payer Manual: Chapter 6 - Medicare Secondary Payer (MSP) CWF Process
100-05 Medicare Secondary Payer Manual: Chapter 6 - Medicare Secondary Payer (MSP) CWF Process
us-cms-medicare-manuals-pub-100-05-msp105c06100-05 Medicare Secondary Payer Manual: Chapter 6 - Medicare Secondary Payer (MSP) CWF ProcessGuidance
Medicare Secondary Payer (MSP) Manual Chapter 6 - Medicare Secondary Payer (MSP) Common Working File (CWF) Process Table of Contents (Rev. 13783; Issued: 05-27-26) Transmittals for Chapter 6 10 - General Information 10.1 - Overview of CWF, MSP Processing 10.2 - Definition of MSP/CWF Terms 20 - MSP Maintenance Transaction Record Processing 20.1 - Types of MSP Maintenance Transactions 20.1.1 - MSP Add Transaction 20.1.2 - MSP Change Transaction 20.1.3 - MSP Delete Transaction 20.1.4 - MSP Termination Date Transaction 20.2 - MSP Maintenance Transaction Record A/B MAC and DME MAC MSP Auxiliary File Update Responsibility 30 - CWF, MSP Auxiliary File 30.1 - Integrity of MSP Data 30.1.1 - MSP Effective Date Change Procedure 30.1.2 - CWF/MSP Transaction Request for Contractor Assistance 30.2 - MSP Termination Date Procedure 30.3 - MSP Auxiliary File Errors 30.3.1 - Valid MSP Remarks Codes 30.3.2 - Valid MSP Insurance Type Codes 30.3.3 - Other Effective Date and Termination Date Coverage Edits 30.3.4 - MSP Employee Information Data Code 30.4 - Automatic Notice of Change to MSP Auxiliary File 40 - MSP Claim Processing 40.1 - CWF, MSP Claim Validation
40.2 - CWF Claim Matching Criteria Against MSP Records 40.3 - Conditional Payment 40.4 - Override Codes 40.5 - MSP Cost Avoided Claims 40.6 - Online Inquiry to MSP Data 40.7 - MSP Purge Process 40.8 - MSP Utilization Edits and Resolution for Claims Submitted to CWF 40.9 - CWF MSP Reject for A Beneficiary Entitled to Medicare Part B Only and A GHP 40.10 – ICD-10 and ICD 9-CM Diagnosis Code Tables Involving Non-GHP MSP Claims 40.10.1 - Certain Diagnosis Codes Not Allowed on NGHP MSP Records 50 - Special CWF Processes 50.1 - Extension of MSP-ESRD Coordination Period 50.2 - MSP “W” Records and Accompanying Processes 60 – Converting Health Insurance Portability and Accountability Act (HIPAA) Individual Relationship Codes to Common Working File (CWF) Medicare Secondary Payer (MSP) Patient Relationship Codes
10 - General Information (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) A/B Medicare Administrative Contractors (MACs) (Part A), A/B MACs (Part B), or A/B MACs (Part HHH) (collectively referred to as A/B MACs) and Durable Medical Equipment MACs (DME MACs) obtain information pertinent to the identification of MSP for each beneficiary via the CWF, MSP auxiliary file. The auxiliary file is associated with the beneficiary's master record within CWF. The MSP Contractor completes MSP updates on a daily basis upon receipt of notice that another payer is primary to Medicare (e.g., an explanation of benefits, a beneficiary questionnaire, a notice from a third-party payer, Section 111 reporting, etc.). Every claim for a given beneficiary is validated against the same MSP data housed in a CWF, MSP auxiliary file, thus permitting uniform processing. Contractor claims data inconsistent with a CWF, MSP auxiliary file will cause rejects and/or error conditions. An MSP auxiliary record consistent with an identified MSP situation must be present before a payment is approved for an MSP claim. An MSP auxiliary record is established by an MSP maintenance transaction submitted to CWF. The claim must agree with the MSP auxiliary record that was established, or it will not process. The MSP Contractor is the source for establishing new MSP records, with the exception of four situations described in §10.1, below. The MSP Contractor submits MSP maintenance transactions on the basis of information obtained outside the claims process. Examples include, voluntary MSP insurer data match agreements, MMSEA Section 111 reporting, attorney, beneficiary, provider information, and 411.25 Notices. 10.1 - Overview of CWF MSP Processing (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) The CWF MSP auxiliary file is updated with maintenance transactions from the MSP contractor responsible for coordination of benefits (formerly known as the Benefits Coordination & Recovery Center or Coordination of Benefits Contractor and hereafter termed the “MSP contractor”), except for the following situations: 1. If the A/B Medicare Administrative Contractor (MAC) (Part A), A/B MAC (Part B), or A/B MAC (HHH) (collectively referred to as A/B MACs) or Durable Medical Equipment Medicare Administrative Contractor (DME MAC) receives a phone call or correspondence from an attorney/other beneficiary representative, beneficiary, third-party payer, provider, another insurer’s Explanation of Benefits (EOB) or other source that establishes, exclusive of any further required development or investigation, that MSP no longer applies, it must add termination dates to MSP auxiliary records already established by the MSP contractor with a "Y" validity indicator where there is no discrepancy in the validity of the information contained on CWF. (See §20.1.4) 2. If the A/B MAC receives a claim for secondary benefits and could, without further development (for example, the EOB from another insurer or third-party payer contains all necessary data) add an MSP occurrence and pay the secondary claim, it submits a validity indicator of "I" to add any new MSP occurrences (only if no MSP
record with the same MSP type already exists on CWF with an effective date within 45 days of the effective date of the incoming "I" record). An “I” record is to be added to the CWF within 10 calendar days when the claim is suspended for MSP (internal system or CWF, whichever suspends first) if no MSP record with the same MSP type already exists in CWF. It cannot submit a new record with a "Y" or any record with an "N" validity indicator. Note: Effective October 1, 2021, DME MACs no longer submit “I” records and instead submit an Electronic Correspondence Referral System (ECRS) Inquiry to create an MSP record. 3. If the A/B MAC receives a claim for conditional payment, and the claim contains sufficient information to create an "I" record without further development, it must add the MSP occurrence using an "I" validity indicator (only if no MSP record with the same MSP type already exists on CWF with an effective date within 45 calendar days of the effective date of the incoming "I" record). An “I” record is to be added to the CWF within 10 calendar days when the claim is suspended for MSP (internal system or CWF, whichever suspends first) if no MSP record with the same MSP type already exists in CWF. A/B MACs shall transmit "I" records to CWF via the current HUSP transaction. The CWF will treat the "I" validity indicator the same as a "Y" validity indicator when processing claims. "I" records should only be submitted to CWF if no MSP record with the same MSP type already exists on CWF with an effective date within 45 days of the effective date of the incoming "I" record. Therefore, "I" records submitted to CWF that fail these edit criteria will be rejected with an SP 20 error code. Receipt of an "I" validity indicator will result in a CWF trigger to the MSP contractor. The MSP contractor will develop and confirm all "I" maintenance transactions established by the A/B MAC. If the MSP contractor receives an affirmative confirmation of MSP through its development efforts within 45 calendar days, the MSP contractor will convert the “I” to a “Y” validity indicator. If the MSP contractor has not received confirmation of MSP through its development efforts within 45 calendar days, the MSP contractor will automatically delete the "I" validity indicator. Also, if the MSP contractor develops and determines there is no MSP, the MSP contractor will delete the "I" record. An "I" record should never be established when the mandatory fields of information are not readily available to the A/B MAC on its claim attachment or unsolicited refund documentation. If the A/B MAC has the actual date that Medicare became secondary payer, it shall use that as the MSP effective date. If that information is not available, it shall use the Part A entitlement date as the MSP effective date. It may include a termination date when it initially establishes an "I" record. It may not add a termination date to an already established "I" record. Prior to April 1, 2002, the A/B MACs and DME MACs posted MSP records to CWF where beneficiaries were entitled to Part B benefits, but not entitled to Part A benefits. An MSP situation cannot exist when a beneficiary has GHP coverage (i.e., working aged, disability and ESRD) and is entitled to Part B only. CWF edits to prevent the posting of these MSP records to CWF when there is no Part A entitlement date. If an A/B MAC or DME MAC submits an Electronic Correspondence Referral System (ECRS) transaction to the MSP contractor to add a GHP MSP record where there is no Part A entitlement, the
MSP contractor will return reason code of 61. A/B MACs or DME MACs should not submit an ECRS request to the MSP contractor to establish a GHP MSP record when there is no Part A entitlement. A/B MACs that attempt to establish an "I" record will receive a CWF error. The CWF will continue to allow the posting of MSP records where there is no Part A entitlement, but there is Part B entitlement, and where NGHP situations exist, such as automobile/No-Fault, liability, and workers' compensation. Where a non-employer GHP situation exists, A/B MACs and DME MACs continue to submit ECRS transactions and establish "I" records, as necessary. Note: In the past A/B MACs and DME MACs have sent ECRS requests to the MSP contractor requesting that section 111 records be updated. The MSP contractor has rejected most of these requests based on CMS hierarchy of Section 111 entities taking precedence on updating contractor number 11121 and 11122 MSP records. However, CMS has clarified that the MSP contractor shall accept MACs ECRS requests to update contractor number 11121 and 11122 MSP records based on conditions below. A/B MACs and DME MACs shall continue to submit ECRS requests to the MSP contractor for contractor numbers 11121 and 11122 for the following circumstances: • When the A/B MAC or DME MAC receives information indicating the Group number or policy number of the primary payer has changed, • When the A/B MAC or DME MAC learns of a retirement date for the beneficiary and a termination date must be added to the MSP record, • When the A/B MAC or DME MAC receives information indicating the Insurance Type A, J, or K has changed or conflicts with what is on the CWF MSP Auxiliary file, or • When an A/B MAC or DME MAC receives a primary payer EOB or remittance advice showing payment for a deleted or closed Section 111 GHP MSP record that should remain open. Note: The MSP Contractor will not accept an NGHP record update request for this type of MSP claim situation. Please note it is to the discretion of the MSP Contractor to approve these Section 111 ECRS requests upon review. Approval or denial of such ECRS requests shall be sent to the A/B MACs or DME MACs by the MSP Contractor. MSP Auxiliary maintenance transactions, for the four situations listed above, and claims for payment approval may be submitted to CWF in the same file. The CWF processes the MSP maintenance transactions before processing claims. This procedural flow is to assure processing for claim validation against the most current MSP data. If the MSP claim is accepted, the CWF host will return all MSP data on a beneficiary's auxiliary file to the submitting contractor via an "03" trailer. If the claim is rejected, the host will return only those MSP records that fall within the dates of service on the claim. A maximum of 17 MSP auxiliary records may be stored in CWF for each beneficiary (see §30 below). The validity indicator field of each CWF MSP auxiliary record indicates confirmation that:
Another insurer is responsible for payment ("Y" in the field); A/B MACs and DME
MACs may access the MSP auxiliary file through the online CWF file display utility
Health Insurance Master Record (HIMR).
A/B MACs and DME MACs cannot delete MSP auxiliary records. They send such
requests to the MSP contractor via ECRS. (See Pub. 100-05, Chapter 5, §10.)
10.2 - Definition of MSP/CWF Terms
(Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23)
Following is a list of terms and their definitions used in MSP/CWF processing.
MSP Auxiliary File - Up to 17 beneficiary MSP occurrences/records on the CWF
database.
MSP Auxiliary Record - Record of beneficiary MSP information. One MSP
record/occurrence within the beneficiary's MSP auxiliary file.
Occurrence - One MSP occurrence/record within the beneficiary's MSP auxiliary file.
MSP Effective Date - Effective date of MSP coverage.
MSP Termination Date - Termination date of MSP coverage.
Validity Indicator
• Y - Beneficiary has MSP coverage (there is a primary insurer for this period of
time).
• N - No MSP coverage (the N validity indicator is no longer used, but will be seen
on older MSP CWF records)
• I - See §10.1.
• D – Deleted MSP Record
MSP Types - Reason for other coverage entitlement.
• A = Working Aged
• B = End stage renal disease (ESRD)
• D = Automobile/Liability No-Fault
• E = Workers' Compensation (WC)
• F = Federal, Public Health (note: currently not used)
• G = Disabled
• H = Black Lung (BL)
• L=Liability
• W=Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA)NOTE: VA and other Federal payments are MSP exclusions rather than MSP non- payments. Where the VA authorized services, Medicare does not make payment for items or services furnished by a non-Federal provider pursuant to such an authorization. Although certain MSP billing procedures apply, VA is not an MSP provision. Cost Avoided Claim - A claim returned without payment because CWF indicators indicate another insurer is primary to Medicare. (See Pub. 100-05, Chapter 5 for complete description.) Transaction Type - Identifies type of maintenance record. • 0 = Transaction type to add or change MSP data • 1 = Transaction type to delete MSP data Override Code - Code used to bypass CWF, MSP edit to allow primary Medicare payment. (See §40.4 for a detailed explanation.) MSP Contractor Numbers CWF Source Codes MSP Contractor Numbers Non- payment/ Payment Denial Codes CROWD Special Project Numbers 33333 = Litigation Settlement V 4000 P 55555 = HMO Rate Cell Adjustment U 3000 B,D,T,U,V, or W 77777 = IRS/SSA/HCFA Data Match (I, II, III, IV, V, or VI) Y 1000 Q 88888 = Voluntary Data Sharing Agreements Q 5000 O 99999 = Initial Enrollment Questionnaire T 2000 MSP Contractor Numbers prior to January 1, 2001 CWF Source Codes MSP Contractor Numbers Non- payment/ Payment Denial Codes CROWD Special Project Numbers 0 11100 = MSP Contractor 6000 1 11101 = Initial Enrollment Questionnaire K 6010 2 11102 = IRS/SSA/CMS Data Match E 6020 3 11103 = HMO Rate Cell F 6030
CWF Source Codes MSP Contractor Numbers Non- payment/ Payment Denial Codes CROWD Special Project Numbers 4 11104 = Litigation Settlement G 6040 5 11105 = Employer Voluntary Reporting H 6050 6 11106 = Insurer Voluntary Reporting H 6060 7 11107 = First Claim Development E 6070 8 11108 = Trauma Code Development F 6080 9 11109 = Secondary Claims Investigation G 6090 X 11110 = Self Reports H 7000 Y 11111 = 411.25 J 7010 NOTE: Effective January 1, 2001, the following MSP Contractor numbers and nonpayment/payment denial codes will be used. MSP Contractor Numbers Effective January 1, 2001 CWF Source Codes MSP Contractor Numbers Non- payment/ Payment Denial Codes CROWD Special Project Numbers 0 11100 = MSP Contractor 00 Effective 4/1/2020 6000 1 11101 = Initial Enrollment Questionnaire T 6010 2 11102 = IRS/SSA/CMS Data Match Y 6020 3 11103 = HMO Rate Cell U 6030 4 11104 = Litigation Settlement V 6040 5 11105 = Employer Voluntary Reporting Q 6050 6 11106 = Insurer Voluntary Reporting K 6060 7 11107 = First Claim Development E 6070 8 11108 = Trauma Code Development F 6080
CWF Source Codes MSP Contractor Numbers Non- payment/ Payment Denial Codes CROWD Special Project Numbers 9 11109 = Secondary Claims Investigation G 6090 10 - Effective 4/1/2002 11110 = Self Reports H 7000 11 - Effective 4/1/2002 11111 = 411.25 J 7010 11101, 11102, 11103, 11104, and 11105 use the same non-payment denial codes as their previous contractor numbers (i.e., 33333, 55555, 77777, 88888, 99999). Savings from the old and new numbers, if applicable will be reported together (e.g., 11101 and 99999, etc). There must be a conversion of the MSP savings to the new non- payment/payment denial codes as of January 1, 2001. Additional MSP Contractor Numbers Effective April 1, 2002 Effective April 1, 2002, CWF is expanding the source code field and the nonpayment/ payment denial code field from 1-position fields to 2-position fields. CWF Source Codes MSP Contractor Numbers Non- payment/ Payment Denial Codes CROWD Special Project Numbers 12 11112 = Blue Cross-Blue Shield Voluntary Data Sharing Agreements 12 7012 13 11113 = Office of Personnel Management (OPM) Data Match 13 7013 14 11114 = State Workers' Compensation (WC) Data Match 14 7014 15 11115 = WC Insurer Voluntary Data Sharing Agreements (WC VDSA) 15 7015 16 11116 = Liability Insurer Voluntary Data Sharing Agreements (LIAB VDSA) 16 7016 17 11117 = Voluntary Data Sharing Agreements (No Fault VDSA) 17 7017
CWF Source Codes MSP Contractor Numbers Non- payment/ Payment Denial Codes CROWD Special Project Numbers 18 11118 = Pharmacy Benefit Manager Data 18 7018 19 11119 = Workers’ Compensation Medicare Set-Aside Arrangement 19 7019 20 11120 = COBA 20 N/A 21 11121= MIR Group Health Plan 21 7021 22 11122= MIR Non-Group Health Plan 22 7022 23 11123 = To be determined 23 7023 24 11124 = To be determined 24 7024 25 11125 = Recovery Audit Contractor-California 25 7025 26 11126 = Recovery Audit Contractor-Florida 26 7026 27 11127 = To be determined 27 7027 “” “” “” “” 39 11139 = GHP Recovery 39 7039 41 11141 =NGHP Non Ongoing Responsibility for Medicals (ORM) 41 7041 42 11142 = NGHP ORM Recovery 42 7042 43 11143 = MSP Contractor /Medicare Part C/Medicare Advantage 43 7043 “” “” “” “” 99 11199 = To be determined 99 7099 20 - MSP Maintenance Transaction Record Processing (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) The MSP Contractor shall submit an MSP maintenance transaction to establish an MSP auxiliary record within 10 calendar days of receipt of notice that another payer is primary to Medicare. The CWF applies extensive editing to the maintenance transaction. If an MSP maintenance transaction does not meet all edit criteria, error codes specific to the failed edit(s) will be returned via the CWF MSP Maintenance Transaction Response. A complete record layout and field descriptions are contained in CWF Systems Documentation, Record Name: CWF, MSP Maintenance Transaction Response. For Out- of-Service (OSA) Area transactions, the CWF OSA Maintenance Transaction Response is used. Its complete record layout and field descriptions are contained in CWF Systems Documentation, Record Name: CWF, MSP Maintenance Transaction Response. The consistency edit error codes and edit definitions are contained in CWF Systems
Documentation Record Name: MSP Maintenance Transaction Error Codes. MSP transactions that pass all edits are applied to the CWF, MSP auxiliary file. 20.1 - Types of MSP Maintenance Transactions (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) The three types of maintenance transactions are add, change, and delete. The MSP Contractor shall use MSP maintenance transaction type "O" (zero) for an add or a change transaction. • The transaction is an add when no matching MSP occurrence - NO MATCHING MSP auxiliary record - is found for the beneficiary; • The transaction is a change when a matching MSP occurrence is found. After a successful MSP maintenance transaction processes through CWF, before and after images of the MSP auxiliary file occurrence are written to the MSP Audit File. 20.1.1 - MSP Add Transaction (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) The two situations in which the "add" maintenance transaction is used are: • There is no MSP auxiliary file record for a beneficiary. In this case, the "add" transaction creates an MSP auxiliary record containing the new MSP transaction and sets the MSP indicator on the beneficiary's master record; or • There is an MSP auxiliary file record but no matching occurrence for the beneficiary. In this case, the "add" transaction adds the maintenance transaction as a new occurrence. The following fields are mandatory for a validity indicator of "Y" or "I" (Another insurer is responsible for payment): • Medicare beneficiary identifier; • MSP type (MSP code); • Validity indicator; • MSP effective date; • Contractor identification number; • Insurer name (CWF will allow a space in the second position provided the third position contains a valid character other than a space.); • Patient relationship; and • Insurance type. A "Y" or "I" record CANNOT be established without the insurer name. Note, if the Insurance Company Name is blank, or contains one of the abbreviated values that should not be used as found in the ECRS manual, then it is considered an error. NOTE: Although the insurer address cannot be MANDATORY, it should be provided whenever possible. The following are to be used as default values when creating an “I” record:
(1) MSP Effective Date: Use the Part A entitlement date. (2) Patient Relationship: Use “01” if there is no indication of other insured member, and use “02” if another member is shown, but uncertain of relationship. (3) MSP Type: For GHP, use the current reason for entitlement: working aged (12), disability (43), or ESRD (13). For NGHP, if not identified, the default to be used is No- Fault (14). 20.1.2 - MSP Change Transaction (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) An MSP change transaction occurs when the key fields on the incoming maintenance transaction match those on an existing MSP auxiliary occurrence. An MSP record match occurs when the following items are the same: Medicare beneficiary identifier; MSP type; MSP effective date; Insurance type; and Patient relationship When these items match, the record is overlaid. No change transactions will be permitted to records established, except for the addition of a termination date, by any contractor other than the MSP Contractor. 20.1.3 - MSP Delete Transaction (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) The MSP maintenance type "1" is used to delete an MSP auxiliary occurrence. This transaction checks the beneficiary's master record for an MSP indicator. The MSP Contractor is responsible for submitting this transaction. A/B MACs and DME MACs advise the MSP Contractor, via the ECRS, of the need to process an MSP maintenance type 1 transaction (delete). Only certain MSP contractor numbers may delete MSP occurrences originated or last updated by certain other MSP contractor numbers. No contractor number may update or delete a MSP occurrence originated or last updated by contractor number 11100 except contractor number 11100. Please see the table below for the exact criteria for deletion of MSP occurrences last updated by MSP contractor numbers. A match shall occur in order to delete the MSP occurrence originated or last updated by one MSP contractor number with a delete transaction submitted under a certain MSP contractor number. For example, MSP contractor numbers 11100, 11110, 11141 and 11140 are the only contractor numbers that may delete a MSP occurrence originated or last updated by 11110. The MSP Contractor is the sole contractor that may delete MSP contractor numbers. The MSP Contractor shall maintain the necessary logic to control updating and deleting MSP
occurrences based on MSP contractor numbers. A/B MACs and DME MACs shall follow the current restrictions regarding deletion of MSP records. Originating or Last Updating Contractor Number MSP Contractor Number That Can Update/Delete 11100 11100 11110 11100, 11110, 11139, 11141, 11140, 11142 11141 11100, 11110, 11139, 11141, 11140, 11142 11140 11100, 11110, 11139, 11141, 11140, 11142 11121 11100, 11110, 11141, 11140, 11121, 11143, 11139, 11142 11122 11100, 11110, 11141, 11140, 11121, 11143, 11139, 11142 11143 11100, 11110, 11141, 11140, 11121, 11143, 11139, 11142 11139 11100, 11110, 11141, 11140, 11121, 11143, 11139, 11142 11142 11100, 11110, 11141, 11140, 11121, 11143, 11139, 11142 11105 11100, 11110, 11141, 11140, 11121, 11143, 11105, 11102, 11139, 11142 11102 11100, 11110, 11141, 11140, 11121, 11143, 11105, 11102, 11139, 11142 All others Any The MSP Contractor shall allow (MMSEA Section 111) GHP responsible reporting entities (RREs) to override this update/delete hierarchy reflected in the table above under certain circumstances. MIR GHP RREs must submit an override code to the MSP Contractor after receiving an error on an attempted update/delete. The MSP Contractor applies the update/delete using contractor number 11121. This override capability shall not apply to MSP occurrences originated or last updated by 11100. The MSP Contractor shall apply the same hierarchy rules represented in the table above to transactions that have the effect of adding back or reopening matching MSP occurrences previously deleted. 20.1.4 - MSP Termination Date Transaction (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) A/B MACs and DME MACs add termination dates to MSP auxiliary records already established on CWF with a "Y" validity indicator, where there is no discrepancy in the validity of the information contained on CWF. They handle phone calls and written inquiries relating to simple terminations of existing MSP occurrences. Simple terminations are defined as terminations that can be made to an MSP auxiliary record without further development or investigation. They shall not transfer these calls or written inquiries to the MSP Contractor. In determining whether a call is to be handled by them or the MSP Contractor, the A/B MAC or DME MAC establishes the basis of the
call. The following are examples when not to transfer a termination request to the MSP Contractor for further action. EXAMPLE 1: Scenario: Mr. Doe is calling to report that his employer group health coverage has ended. A/B MACs and DME MAC action: The A/B MACs and DME MACs checks for matching auxiliary record on CWF and terminates, if no conflicting data are presented. The A/B MACs and DME MACs does not transfer the call to the MSP Contractor. EXAMPLE 2: Scenario: Mrs. X is calling to report that she has retired. A/B MACs and DME MACs action: The A/B MACs and DME MACs checks for matching auxiliary record on CWF and terminates if no conflicting data are presented. The A/B MACs and DME MACs does not transfer the call to the MSP Contractor. EXAMPLE 3: Scenario: The A/B MACs or DME MACs receives written correspondence that benefits are exhausted for an automobile case. A/B MACs and DME MACs action: The A/B MAC and DME MAC checks for matching auxiliary record on CWF. The MSP Contractor terminates in accordance with existing guidelines (e.g., accounting of monies spent). EXAMPLE 4 Scenario: Union Hospital is calling to report that the MSP period contained on CWF for beneficiary X should be terminated. A/B MAC and DME MAC action: The A/B MAC and DME MAC checks for matching auxiliary record on CWF and terminates if no conflict in evidence is presented. It does not transfer the call to the MSP Contractor. MSP Contractor Role The MSP Contractor adds termination dates to records not covered in A, above. In addition, the MSP Contractor updates MSP occurrences as a result of a request from an A/B MAC or DME MAC, or as a result of the MSP Contractor development and investigation. The following are examples of when to transfer a termination request to the MSP Contractor for further action.
EXAMPLE 1: Scenario: The termination date is greater than six months prior to the date of accretion (i.e., SP 57 error code) for all MSP Contractor numbers (e.g., 11100-11145, 33333, 77777, 88888, or 99999). (All MSP Contractor numbers follow the old data match 6- month termination rule.) A/B MAC and DME MAC action: The A/B MAC and DME MAC sends a CWF assistance request to the MSP Contractor. MSP Contractor action: The MSP Contractor checks for matching record on CWF and terminates. In cases where discrepant information exists, the MSP Contractor investigates to determine the proper course of action. EXAMPLE 2: Scenario: The A/B MAC and DME MAC receives information with regard to termination that is discrepant with the information contained on CWF. A/B MAC and DME MAC action: The A/B MAC and DME MAC forwards to the MSP Contractor for investigation via ECRS. MSP Contractor action: The MSP Contractor checks for matching record on CWF, investigates, and terminates if appropriate. 20.2 - MSP Maintenance Transaction Record A/B MAC and DME MAC MSP Auxiliary File Update Responsibility (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) The capability to update the CWF MSP auxiliary file is essentially a function of only the MSP Contractor. The A/B MAC and DME MACs do not have the capability to delete any MSP auxiliary file records, including those that a specific A/B MAC or DME MAC established. If it is believed that a record should be changed or deleted, A/B MACs and DME MACs use the MSP Contractor via the ECRS (discussed in Pub. 100-05, Chapter 5, CWF Assistance Request option, to notify the MSP Contractor of the needed revision. A/B MACs and DME MACs process claims in accordance with existing claims processing guidelines. There are only two instances in which A/B MACs and DME MACs retain the capability to update CWF. They are: A. A claim is received for secondary benefits and the contractor could, without further development (for example, the EOB from another insurer or third-party payer contains all necessary data), add an MSP occurrence and pay the secondary claim. A/B MACs must use a validity indicator of "I" to add new MSP occurrences and update CWF. An “I” record is to be added to the CWF within 10 calendar days when the claim is suspended
for MSP (internal system or CWF, whichever suspends first) if no MSP record with the same MSP type already exists in CWF. Note: Effective October 1, 2021, DME MACs no longer submit“I”records and instead submit an Electronic Correspondence Referral System (ECRS) Inquiry to create an MSP record. A/B MACs cannot submit a new record with a "Y" or any record with an "N" validity indicator. B. A claim is received for conditional payment, and the claim contains sufficient information to create an "I" record without further development. A/B MACs add the MSP occurrence using an "I" validity indicator. An “I” record is to be added to the CWF within 10 calendar days when the claim is suspended for MSP (internal system or CWF, whichever suspends first) if no MSP record with the same MSP type already exists in CWF. A/B MACs will transmit "I" records to CWF via the current HUSP transaction. The CWF will treat the "I" validity indicator the same as a "Y" validity indicator when processing claims. Receipt of an "I" validity indicator will result in a CWF trigger to the MSP Contractor. The MSP contractor will develop and confirm all "I" maintenance transactions established by the A/B MAC. If the MSP contractor receives an affirmative confirmation of MSP through its development efforts within 45 calendar days, the MSP contractor will convert the “I” to a “Y” validity indicator. If the MSP contractor has not received confirmation of MSP through its development efforts within 45 calendar days, the MSP contractor will automatically delete the "I" validity indicator. Also, if the MSP contractor develops and determines there is no MSP, the MSP Contractor will delete the "I" record. An "I" record should never be established when the mandatory fields of information are not readily available to an A/B MAC on a claim attachment. If the A/B MAC has the actual date that Medicare became secondary payer, they use that as the MSP effective date. If that information is not available, the A/B MAC shall use the Part A entitlement date as the GHP MSP effective date. A/B MACs may include a termination date when they initially establish an "I" record. However, they may not add a termination date to an already established "I" record. CWF accepts an "I" record only if no MSP record (validity indicator of either "I" or "Y," open, closed, or deleted status) with the same MSP type already exists on CWF with an effective date within 45 calendar days of the effective date of the incoming "I" record. Therefore, "I" records submitted to CWF before 45 calendar days have elapsed will reject with an SP 20 error code. The resolution for these cases is to transfer all available information to the MSP contractor via the Electronic Correspondence Referral System (ECRS) CWF assistance request screen. It will be the responsibility of the MSP contractor to reconcile the discrepancy and make any necessary modifications to the CWF auxiliary file record. A refund or returned check is no longer a justification for submission of an "I" record. Since an "I" record does not contain the source (name and address) of the entity that returned the funds, the MSP contractor lacks the information necessary to develop to that source. Follow the examples below to determine which ECRS transaction to submit.
1. An MSP inquiry should be submitted when there is no existing or related MSP record on the CWF. A “related” record means if an MSP record on CWF matches and has the same HICN/MBI, MSP type, MSP effective date, Insurance type, patient relationship code, and validity indicator. 2. The CWF assistance request should be submitted when the information on the CWF is incorrect or the MSP record has been deleted. 3. The check or voluntary refund either opens and/or closes the MSP case or MSP issue. Under these circumstances, the A/B MACs or DME MACs shall submit an MSP inquiry to open or close the MSP record. Note: The A/B MACs or DME MACs should refer to the ECRS manual for more information regarding closed cases. The check should be deposited to unapplied cash until the MSP contractor makes an MSP determination. 30 - CWF, MSP Auxiliary File (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) A maximum number of 17 MSP auxiliary records may be stored in CWF for each beneficiary. The MSP Contractor is responsible for deletion of a record when the maximum storage is exceeded using the following priority: • Oldest "deleted" (flagged for deletion) occurrence; • Oldest "confirmed no" occurrence; • Oldest termination date; or • Oldest maintenance date for the MSP type to be added. 30.1 - Integrity of MSP Data (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) The CWF MSP data base integrity is totally dependent upon MSP Contractor input, supported by input by A/B MACs and DME MACs to the MSP Contractor. The MSP Contractor is responsible for submitting to CWF MSP information it believes to be of the highest quality. It shall investigate information thoroughly before making changes to an existing CWF MSP auxiliary record. 30.1.1 - MSP Effective Date Change Procedure (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) When the MSP Contractor becomes aware that an MSP effective date is incorrect, it shall perform the following functions:
• Delete the auxiliary record containing the incorrect MSP effective date using an MSP delete transaction; and • Submit a CWF, MSP maintenance transaction with the correct MSP effective date to establish a new auxiliary record. NOTE: When the beneficiary is entitled to both Parts A and B, the MSP Contractor shall use the Part A entitlement date, if the insurance effective date is prior to entitlement to Medicare. 30.1.2 - CWF/MSP Transaction Request for Contractor Assistance (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) Instances occur when the A/B MAC or DME MAC determines that the MSP effective date is not correct. When this happens, the contractor shall advise the MSP Contractor, via ECRS, of the need to change the MSP effective date and shall provide the MSP Contractor with documentation to substantiate the change. 30.2 - MSP Termination Date Procedure (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) A. Future Termination Dates For Non-GHP records, the termination date edits identified for GHP do not apply as the termination date may be more than 6-months from the MSP effective date. For GHP records, the termination date cannot be greater than the current date plus 6 months, except for MSP code = B; and for GHP records, the termination date cannot be greater than the first day the beneficiary turned 65 if the MSP code is B or G. For ESRD, CWF uses the following criteria: • MSP effective date prior to February 1, 1990, allows for termination date up to 12 months after the effective date; • MSP effective date February 1, 1990, through February 29, 1996, allows for termination date up to 18 months after the effective date; or • MSP effective date March 1, 1996, and later allows for termination date up to 30 months after the effective date. B. Termination for "Y" Validity Indicator A CWF MSP auxiliary record with a "Y" validity indicator establishes Medicare as the secondary payer. When posting a termination date to this record, the "Y" validity indicator should not be changed. The record indicates a valid MSP occurrence and all future claims submitted will edit against the time frame posted. The A/B MAC or DME
MAC shall advise the MSP Contractor via ECRS when MSP no longer applies, and the MSP Contractor shall enter the termination date. 30.3 - MSP Auxiliary File Errors (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes. Maintenance transactions to the MSP Auxiliary file reject invalid data with errors identified by a value of "SP" in the disposition field on the Reply Record. A trailer of "08" containing up to four error codes will always follow. Listed below are the possible MSP Maintenance Transaction error codes with a general description. Error Code Definition Valid Values SP11 Invalid MSP transaction record type "HUSP," "HISP," or "HBSP" SP12 Invalid Medicare beneficiary identifier Valid Medicare beneficiary identifier SP13 Invalid Beneficiary Surname Valid Surname SP14 Invalid Beneficiary First Name Initial Valid Initial SP15 Invalid Beneficiary Date of Birth Valid Date of Birth SP16 Invalid Beneficiary Sex Code 0=Unknown, 1=Male, 2=Female SP17 Invalid Contractor Number CMS Assigned Contractor Number SP18 Invalid Document Control Number Valid Document Control Number SP19 Invalid Maintenance Transaction Type 0=Add/Change MSP Data transaction, 1=Delete MSP Data Transaction SP20 Invalid Validity Indicator Y= Beneficiary has MSP Coverage, I= Entered by the A/B MAC or DME MAC – MSP Contractor investigate, N -No MSP coverage SP21 Invalid MSP Code A=Working Aged B=ESRD C= Conditional Payment D= No Fault E= Workers' Compensation
Error Code Definition Valid Values F= Federal G= Disabled H= Black Lung L= Liability SP22 Invalid Diagnosis Code 1-5 Valid Diagnosis Code SP23 Invalid Remarks Code 1-3 See the Valid Remarks Codes Below SP24 Invalid Insurer Type See definitions of Insurer Type codes below SP25 Invalid Insurer Name An SP25 error is returned when the MSP Insurer Name is equal to one of the following: Supplement Supplemental Insurer Miscellaneous CMS Attorney Unknown None N/A Un Misc NA NO BC BX BS BCBX Blue Cross Blue Shield Medicare Medicaid Alphabetic, Numeric, Space, Comma, & - ' . @ # / ; : Insurer Name must be present if Validity Indicator = Y SP26 Invalid Insurer Address 1 and/or Address 2 Alphabetic, Numeric, Space, Comma, & - ' . @ # / ; :
Error Code Definition Valid Values SP27 Invalid Insurer City Alphabetic, Numeric, Space, Comma, & - ' . @ # / ; : SP28 Invalid Insurer State Must match U.S. Postal Service state abbreviation table. SP29 Invalid Insurer Zip Code If present, 1st 5 digits must be numeric. If foreign country "FC" state code, the nine positions may be spaces. SP30 Invalid Policy Number Alphabetic, Numeric, Space, Comma, & - ' . @ # / ; : SP31 Invalid MSP Effective Date (Mandatory) Non-blank, non-zero, numeric, number of days must correspond with the particular month. MSP Effective Date must be no more than 3 months in the future from the current date. SP32 Invalid MSP Termination Date Must be numeric; may be all zeroes if not used; if used, date must correspond with the particular month for GHP records. The MSP Termination Date is Greater than Six Months from the current date for non-Group Health Plan MSP Auxiliary Records. SP33 Invalid Patient Relationship The following codes are valid for all MSP Auxiliary occurrences regardless of accretion date: 01 = Self; the beneficiary is the policy holder or subscriber for the other GHP insurance reflected by the MSP occurrence –or- Beneficiary is the injured party on the Workers Compensation, No- Fault, or Liability claim 02 =Spouse or Common Law Spouse
Error Code Definition Valid Values 03 = Child 04 = Other Family Member 20 = Life Partner or Domestic Partner The following codes are only valid on MSP Auxiliary occurrences with accretion dates PRIOR TO 4/4/2011: 05 = Step Child 06 = Foster Child 07 = Ward of the Court 08 = Employee 09 = Unknown 10 = Handicapped Dependent 11 = Organ donor 12 = Cadaver Donor 13 = Grandchild 14 = Niece/Nephew 15 = Injured Plaintiff 16 = Sponsored Dependent 17 = Minor Dependent of a Minor Dependent 18 = Parent 19 = Grandparent 20 = Life Partner or Domestic Partner SP34 Invalid subscriber First Name Alphabetic, Numeric, Space, Comma, & - ' . @ # / ; : SP35 Invalid Subscriber Last Name Alphabetic, Numeric, Space, Comma, & - ' . @ # / ; : SP36 Invalid Employee ID Number Alphabetic, Numeric, Space, Comma, & - ' . @ # / ; : SP37 Invalid Source Code Spaces, A through W, 0 – 19, 21, 22, 25, 26, 39, 41, 42, 43. See §10.2 for definitions of valid CWF Source Codes.
Error Code Definition Valid Values SP38 Invalid Employee Information Data Code Spaces if not used, alphabetic values P, S, M, F. See §30.3.4 for definition of each code. SP39 Invalid Employer Name Spaces if not used. Valid Values: Alphabetic, Numeric, Space, Comma, & - ' . @ # / ; : SP40 Invalid Employer Address Spaces if not used. Valid Values: Alphabetic, Numeric, Space, Comma, & - ' . @ # / ; : SP41 Invalid Employer City Spaces if not used. Valid Values: Alphabetic, Numeric, Space, Comma, & - ' . @ # / ; : SP42 Invalid Employer State Must match U.S. Postal Service state abbreviations. SP43 Invalid Employer ZIP Code If present, 1st 5 digits must be numeric. If foreign country ‘FC’ is entered as the state code, and the nine positions may be spaces. SP44 Invalid Insurance Group Number Spaces if not used. Valid Values: Alphabetic, Numeric, Space, Comma, & - ' . @ # / ; : SP45 Invalid Insurance Group Name Spaces if not used. Valid Values: Alphabetic, Numeric, Space, Comma, & - ' . @ # / ; : SP46 Invalid Pre-paid Health Plan Date Numeric; number of days must correspond with the particular month. SP47 Beneficiary MSP indicator not on for delete transaction. Occurs when the code indicating the existence of MSP auxiliary record is not equal to "1" and the MSP maintenance transaction type is equal to ‘1.’ SP48 MSP auxiliary record not found for delete data transaction See MSP Auxiliary Record add/update and delete function procedures above.
Error Code Definition Valid Values SP49 MSP auxiliary occurrence not found for delete data transaction See MSP Auxiliary Record add/update and delete function procedures above. SP50 Invalid function for update or delete Contractor number unauthorized See MSP Auxiliary Record add/update and delete function procedures above SP51 MSP Auxiliary record has 17 occurrences and none can be replaced SP52 Invalid Patient Relationship Code which is mandatory for MSP Codes A, B and G when the Validity Indicator is "Y" Accretion Dates prior to 4/4/2011: Patient Relationship must be 01 or 02 for MSP Code A (Working Aged). Patient Relationship must be 01, 02, 03, 04, 05, 18 or 20 for MSP Codes B (ESRD) and G (Disabled). Accretion Dates 4/4/2011 and subsequent: Patient Relationship must be 01 or 02 for MSP Code A (Working Aged). Patient Relationship must be 01, 02, 03, 04, or 20 for MSP Codes B (ESRD) and G (Disabled). SP53 The maintenance transaction was for Working Aged EGHP and there is either a ESRD EGHP or Disability EGHP entry on file that has a termination date after the Effective date on the incoming transaction or is not terminated, and the contract number on the maintenance transaction is not equal to "11102," "11104," “11105," "11106," "33333," "66666,", "77777," "88888," or "99999." SP54 MSP Code A, B or G has an Effective date that is in conflict with the calculated age 65 date of the Bene. For MSP Code A, the Effective date must not be less than the date at age 65. For MSP Code G, the Effective date must not be greater than the date at age 65. SP55 MSP Effective date is less than the earliest
Error
Code
Definition Valid Values
Bene Part A or Part B Entitlement Date.
SP56 MSP Prepaid Health Plan Date must be =
to or greater than MSP Effective date or
less than MSP Termination date.
SP57 Termination Date Greater than 6 months
prior to date added for Contractor
numbers other than 11100 – 11119,
11121, 11122, 11126, 11139, 11141,
11142, 11143, 33333, 55555, 77777,
88888, and 99999.
SP58 Invalid Insurer type, MSP code, and
validity indicator combination.
If MSP code is equal to "A" or
"B" or "G" and validity
indicator is equal to "I" or "Y"
then insurer type must not be
equal to spaces. Mapped
coverage type must equal “J”,
“K”, or “A”.
SP59 Invalid Insurer type, and validity indicator
combination
If validity indicator is equal to
"N" then insurer type must be
equal to spaces.
SP60 Other Insurer type for same period on file
(Non "J" or "K") Insurer type on incoming
maintenance record is equal to "J" or "K"
and Insurer type on matching aux record
is not equal to "J" or "K."
Edit applies only to MSP
codes:
A - Working Aged,
B - ESRD EGHP,
G - Disability EGHP
SP61 Other Insurer type for same period on file
("J" or "K") Insurer type on incoming
maintenance record is not equal to "J" or
"K" and Insurer type on matching aux
record is equal to "J" or "K."
Edit applies only to MSP
codes:
A - Working Aged,
B - ESRD EGHP,
G - Disability EGHP
SP62 Incoming term date is less than MSP
Effective date.
SP66 MSP Effective date is greater than the
Effective date on matching occurrence on
auxiliary file
SP67 Incoming term date is less than posted
term date for Provident
SP72 Invalid Transaction attempted A HUSP add transaction is
received from a A/B MAC and
DME MAC (non-MSP
Contractor) with a validity
indicator other than "I."
SP73 Invalid Term Date/Delete Transaction A MAC attempts to change a
Term Date on an MSPError Code Definition Valid Values Auxiliary record with a "I" or "Y" Validity Indicator that is already terminated, or trying to add Term Date to "N" record. SP74 Invalid cannot update "I" record. A MAC submits a HUSP transaction to update/change an "I" record or to add an "I" record and a match MSP Auxiliary occurrence exists with a "I" validity indicator. SP75 Invalid transaction, no Medicare Part A benefits A HUSP transaction to add a record with a Validity Indicator equal to "I" (from an A/B MAC or DME MAC) or "Y" (from the MSP Contractor) with an MSP Type equal to "A," "B," "C," or "G" and the effective date of the transaction is not within a current or prior Medicare Part A entitlement period, or the transaction is greater than the termination date of a Medicare entitlement period. SP76 MSP Type is equal to W (Workers’ Compensation Medicare Set-Aside) and there is an open MSP Type E (Workers’ Compensation) record. SP77 A diagnosis cannot be added to this occurrence by a Part A/Part B/DME MAC. SP78 The diagnosis code submitted is not allowed on an MSP Type 'D' record. When an incoming HUSP transaction with a Validity Indicator equal to 'I' or 'Y' is received from an A/B, DME MAC or the MSP Contractor for an MSP Type 'D' record, and the transaction contains one of the CMS identified ICD 9 or ICD 10 diagnosis codes.
Error Code Definition Valid Values SP79 A MAC attempts to create/enter a value in the ORM field on the incoming I HUSP record (makes sure that a MAC cannot update or overlay an ORM value in the ORM field). Valid Values for the 1-byte ORM indicator on the CWF MSP Detail screen (MSPD) are: Y (Yes) or a space. A “Y” ORM indicator value denotes that the ORM existed for a period of time, not necessarily that it currently exists. An ORM indicator of a “space” implies that an RRE has not assumed ORM. SP80 A MAC attempted to create/enter an ORM indicator on an MSP record other than a D, E, and L. The 1- byte ORM indicator (valid values = Y or a space) shall only be received on HUSP transactions with MSP Codes “D, E, and L.” SP81 A contractor, other than the following contractor numbers of 11100, 11110, 11122, 11141, and 11142, attempts to update, remove or set the existing ORM record indicator of a “Y” to a “space.” To ensure that no other entity than the following contractor numbers (11100, 11110, 11122, 11142, and 11142) can modify an existing record’s ORM indicator to equal a “space,” if originally it was a “Y.” SP82 MSP Type 'L' or 'D' does not exist. When an incoming HUSP transaction is submitted for LMSA (MSP Type S) and no Liability (MSP Type L) MSP Auxiliary record exists; or when an incoming HUSP transaction is submitted for NFMSA (MSP Type T) and no No-Fault Auto (MSP Type D) MSP Auxiliary record exists. SP83 No Termination Date present for a Liability or No-Fault Auto occurrence. When an incoming HUSP transaction is submitted for LMSA (MSP Type S) and the Liability (MSP Type L) record on the MSP Auxiliary File does not have a Termination Date; or when an incoming HUSP transaction is submitted
Error Code Definition Valid Values for NFMSA (MSP Type T) and the No-Fault Auto (MSP Type D) record on the MSP Auxiliary File does not have Termination Date. SP84 Invalid Effective date for LMSA or NFMSA or open record. An HUSP transaction is submitted by contractor '11144' or '11100' for LMSA (MSP Type S) and posted to the MSP Aux file is a Liability (MSP Type L) with a Termination Date. If the Effective Date of the LMSA (MSP Type S) is not one day after the Termination Date of the Liability (MSP Type L). If the Effective Date of the LMSA (MSP Type S) is one day after the Termination Date of the Liability (MSP Type L), and the diagnosis codes on the LMSA (MSP Type S) are not an Exact or not a Family Match with the Liability (MSP Type L) diagnosis codes. AND/OR An HUSP transaction is submitted by contractor '11145' or '11100' for NFMSA (MSP Type T) and posted to the MSP Aux file is a No-Fault (MSP Type D) with a Termination Date. If the Effective Date of the NFMSA (MSP Type T) is not one day after the Termination Date of the No-Fault (MSP Type D).
Error Code Definition Valid Values If the Effective Date of the NFMSA (MSP Type T) is one day after the Termination Date of the No-Fault (MSP Type D), and the diagnosis codes on the NFMSA (MSP Type T) are not an Exact or not a Family Match with the No- Fault (MSP Type D). SP91 Invalid Employer Size (Mandatory). Field must contain a numeric character. SP99 Medicare ID (HICN or MBI) required if individual is less than 45 years of age. 30.3.1 - Valid MSP Remarks Codes (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) MSP Remark Code Definition 01 Beneficiary retired as of termination date. 02 Beneficiary's employer has less than 20 employees. 03 Beneficiary's employer has less than 100 employees 04 Beneficiary is dually entitled to Medicare, based on ESRD and Age or ESRD and disability 05 Beneficiary is not married. 06 The Beneficiary is covered under the group health plan of a family member whose employer has less than 100 employees. 07 Beneficiary's employer has less than 20 employees and is in a multiple or multi-employer plan that has elected the working aged exception. 08 Beneficiary's employer has less than 20 employees and is in a multiple or multi-employer plan that has not elected the working aged exception. 09 Beneficiary is self-employed. 10 A family member of the Beneficiary is self-employed. 20 Spouse retired as of termination date. 21 Spouse's employer has less than 20 employees. 22 Spouse's employer has less than 100 employees. 23 Spouse's employer has less than 100 employees but is in a qualifying multiple or multi-employer plan.
MSP Remark Code Definition 24 Spouse's employer has less than 20 employees and is multiple or multi- employer plan that has elected the working aged exception. 25 Spouse's employer has less than 20 employees and is multiple or multi- employer plan that has not elected the working aged exception. 26 Beneficiary's spouse is self-employed 30 Exhausted benefits under the plan 31 Preexisting condition exclusions exist 32 Conditional payment criteria met 33 Multiple primary payers, Medicare is tertiary payer 34 Information has been collected indicating that there is not a parallel plan that covers medical services 35 Information has been collected indicating that there is not a parallel plan that covers hospital services 36 Denial sent by EGHP, claims paid meeting conditional payment criteria. 37 Beneficiary deceased. 38 Employer certification on file. 39 Health plan is in bankruptcy or insolvency proceedings. 40 The termination date is the Beneficiary's retirement date. 41 The termination date is the spouse's retirement date. 42 Potential non-compliance case, Beneficiary enrolled is supplemental plan. 43 GHP coverage is a legitimate supplemental plan. 44 Termination date equals transplant date 50 Employment related accident 51 Claim denied by workers comp 52 Contested denial 53 Workers compensation settlement funds exhausted 54 Auto accident - no coverage 55 Not payable by black lung 56 Other accident - no liability 57 Slipped and fell at home 58 Lawsuit filed - decision pending 59 Lawsuit filed - settlement received 60 Medical malpractice lawsuit filed 61 Product liability lawsuit filed 62 Request for waiver filed 70 Data match correction sheet sent 71 Data match record updated 72 Vow of Poverty correction
30.3.2 - Valid MSP Insurance Type Codes (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) MSP Insurer Type Code Definition A GHP Hospital and Medical Coverage -or- Other Non-GHP B GHO C Preferred Provider Organization (PPO) D Third Party Administrator arrangement under an Administrative Service Only (ASO) contract without stop loss from any entity. E Third Party Administrator arrangement with stop loss insurance issued from any entity. F Self-Insured/Self-Administered. G Collectively-Bargained Health and Welfare Fund. H Multiple Employer Health Plan with at least one employer who has more than 100 full and/or part-time employees. I Multiple Employer Health Plan with at least one employer who has more than 20 full and/or part-time employees. J GHP Hospitalization Only Plan - A plan that covers only Inpatient hospital services. K GHP Medical Services Only Plan - A plan that covers only non-inpatient medical services. M Medicare Supplemental Plan, Medigap, Medicare Wraparound Plan or Medicare Carve Out Plan. R GHP Health Reimbursement Arrangement S GHP Health Savings Account SPACES Unknown NOTE: For MSP occurrences with accretion dates of 4/4/2011 and subsequent, the only valid Insurer Type Codes are A, J, K, R, S, and spaces. 30.3.3 - Other Effective Date and Termination Date Coverage Edits (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) If MSP Code: MSP Effective Date Must Be Greater Than A - Working Aged January 1, 1983 (830101) A - Working Aged Calculated Date beneficiary turned 65 (first day of month). B – ESRD October 1, 1981 D - No Fault December 1, 1980 E - Workers' Compensation July 1, 1966 F - Federal/Public Health July 1, 1966
If MSP Code: MSP Effective Date Must Be Greater Than H - Black Lung July 1, 1973 G - Disabled (43) January 1, 1987 G – Disabled Prior to the first day of the month the Beneficiary turns 65. L – Liability December 1, 1980 Other Termination date coverage edits are: • For Group Health Plan (GHP) records the termination date cannot be greater than the current date plus six months, except for MSP code = B, and • For GHP records the termination date cannot be greater than the first day the beneficiary turned 65 if the MSP code is B or G. Note: For Non-GHP records the termination date edits identified above do not apply as the termination date may be more than 6-months from the MSP effective date. 30.3.4 - MSP Employee Information Data Code (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) MSP Employee Information Data Code Valid Values P Patient S Spouse M Mother F Father 30.4 - Automatic Notice of Change to MSP Auxiliary File (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) The Common Working File (CWF) sends MSP transactions to all contractors of record when an MSP auxiliary record is created or changed for any beneficiary. Alerts are sent to the A/B MACs and DME MACs when an update is made to an MSP record. 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. 40.1 - CWF, MSP Claim Validation (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) There are four conditions that may occur when an A/B MAC and DME MAC validates claims against the CWF, MSP auxiliary file: • MSP is indicated on the claim and there is matching data on the CWF, MSP auxiliary record. The claim is accepted and all CWF, MSP auxiliary occurrences are returned, • MSP is indicated on the claim and there is no matching data on an MSP auxiliary record. The claim is rejected and all CWF, MSP occurrences that apply are returned. Section 40.8 describes the CWF, MSP Utilization Error Codes, and the appropriate resolution for those codes, • MSP is not indicated on the claim and the MSP auxiliary file has an occurrence that indicates there is MSP involvement for the time period affected. The claim is rejected and all occurrences that apply are returned, and • MSP is not indicated on the claim and there are no matching occurrences on the CWF, MSP auxiliary file that indicate MSP involvement. The claim is accepted for payment. NOTE: An occurrence applies if the claim service dates are equal to, or greater than, the effective date of the occurrence and less than, or equal to, the termination date of that occurrence, if there is a termination date. 40.2 - CWF Claim Matching Criteria Against MSP Records (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) The matching criteria between the claim and the MSP auxiliary occurrence in CWF is as follows: HICN/MBI, MSP type, MSP effective date and termination date, insurance type, patient relationship code and validity indicator for the same insurer. Note, NGHP records includes matching on the family of diagnosis codes. 40.3 - Conditional Payment (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) To make a conditional payment, A/B MACs and DME MACs indicate conditional payment on the CWF, Part B Claim by placing a "C" in the "MSP code" field (field 97 of the CWF Part B Claim record.). Intermediaries indicate conditional payment on the CWF
Inpatient/SNF Bill by placing zeros (0) in the "value amount" field (position 77b) along with the appropriate "value code." An MSP auxiliary record for the beneficiary with a "Y" validity indicator must be present. The CWF will reject the claim with error code 6805 when a claim for conditional payment is submitted and there is no matching MSP auxiliary record present. 40.4 - Override Codes (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) The CWF will accept MSP override codes. A/B MACs or DME MACs must place the appropriate override code in the "MSP code" field (field 97) of the CWF Part B Claim record. Intermediaries must place the appropriate override code in the CWF (Inpatient/SNF Bill or Outpatient/Home Health/Hospice), "Special Action Code/Override Code, field 90." Override codes must be used only as described below. The CWF employs the following matching criteria for override codes "M" and "N": • Dates of service on the claim fall within the effective and termination dates on auxiliary record; and • Validity indicator is equal to "Y." The correct use of override codes is as follows: A. Override code "M" is used where GHP, LGHP and ESRD services are involved and the service provided is either: • Not a covered service under the primary payer's plan; • Not a covered diagnosis under the primary payer's plan; or • Benefits have been exhausted under the primary payer's plan. B. Override code "N" is used where non-GHP (auto medical, no-fault, liability, Black Lung, and workers' compensation) services are involved and the service is either: • Not a covered service under the primary payer's plan; • Not a covered diagnosis under the primary payer's plan; or • Benefits have been exhausted under the primary payer's plan. Contractors receive error code 6806 when the MSP override code equals "M" or "N" and no MSP record is found with overlapping dates of service.
40.5 - MSP Cost Avoided Claims
(Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23)
A/B MACs and DME MACs shall follow the instructions cited in Pub. 100-05, Chapter 5
for counting savings on MSP cost avoided claims.
They shall submit ALL MSP cost avoided claims to CWF.
Payment/Denial codes are used to identify the reason a claim was denied. Specific codes
for MSP are listed and defined in §10.2 under the MSP/ Contractor Number chart in
that section. A/B MACs (Part B) and DME MACs submit the appropriate code to CWF
in the Health Utilization Part B Claim ("HUBC") claim record in field 63
"Payment/Denial Code" for line item denials. They complete the appropriate code for
full claim denials in the "HUBC" claim record, field 16 "Payment/Denial". A/B MACs
(Part A) submit the appropriate code in the Health Utilization Inpatient Claim (HUIP)
CWF record field 58 "Nonpayment" code for inpatient hospital and SNF claim denials.
They submit the appropriate code in field 59 "No Pay Code" of the CWF record for the
specific type of claim identified in the chart below.
PAYMENT/DENIAL CODE FIELDS IN CWF CLAIM RECORD
Contractor Type of Claim CWF
Record
Field
A/B MAC (Part B)
and DME MAC
Full Claim Denial HUBC 16 Payment/Denial
A/B MAC (Part B)
and DME MAC
Full Line Item
Denial
HUBC 63 Payment/Denial Code
A/B MAC (Part A)
and DME MAC
Inpatient hospital
and inpatient SNF
Denial
HUIP 58 Nonpayment Code
A/B MAC (Part A)
and DME MAC
Health Utilization
Outpatient (HUOP)
HUOP 59 No Pay Code
A/B MAC (HH&H) Health Utilization
Home Health
(HUHH)
HUHH 59 No Pay Code
A/B MAC (HH&H) Health Utilization
Hospice Claim
(HUHC)
HUHC 59 No Pay Code
If a denial indicator is incorrect, the CWF software will correct the denial indicator based
on the matching MSP auxiliary record and send the correct value back to the contractor
on the response record header. It is not necessary for an MSP auxiliary record to be
present in order to post MSP cost avoided savings. If one is present, the A/B MAC or
DME MAC uses the "X" or "Y" override code as appropriate.40.6 - Online Inquiry to MSP Data (Rev. 125, Issued: 03-22-19, Effective: 04-22-19, Implementation: 04-22-19) The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes. The MSP data may be viewed online in CWF via the HIMR access. The user enters the transaction HIMR, which displays the HIMR Main Menu, and enters the MSPA selection. (A complete record layout and field descriptions can be found in the CWF Systems Documentation at http://cms.csc.com/cwf/, Record Name: MSP Auxiliary File and MSP Audit History File.) A user can view a selected CWF, MSP auxiliary record by following the steps outlined below: A. Enter the Medicare beneficiary identifier and MSP record type. If the data entered is invalid, an error message is displayed with the field in error highlighted. If the data entries are valid, a search is done of the beneficiary master file for an MSP indicator. The search of the master file will show one of the following: • The MSP indicator on the beneficiary file is not set. In this case the message "MSP not indicated" is displayed; • No record is found. In this case, a message "MSP auxiliary file not found" is displayed; or • MSP is indicated. In this case, the MSP auxiliary file is read and the screen will display an MSP Record. A successful reading of the MSP file, as noted in the third bullet above, will display an MSP occurrence summary screen that includes: • Summary selection number; • MSP code; • MSP code description; • Validity indicator;
• Delete indicator; • Effective date; and • Termination date, if applicable. B. Enter the summary selection number on the MSP occurrence summary screen. This results in a display of the MSP occurrence detail screen for the selected MSP occurrence. The MSP occurrence detail screen is a full display of the information on the MSP auxiliary file for the particular MSP occurrence. 40.7 - MSP Purge Process (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) The CWF process includes an MSP purge process. The CMS will determine when the purge process will be employed. The criteria for deletion of MSP data from the CWF MSP auxiliary file will be a predetermined number of years from the following dates: • Date of death; • Termination date and last maintenance date; or • Last maintenance date and delete indicator equal to "D." The MSP purge criteria will be parameter driven. All occurrences of MSP data for a beneficiary will be copied to the MSP history audit file, and the MSP indicator on the beneficiary file will be disengaged (turned off) if no other occurrences are present on the file. A Summary report, by originating contractor identification number, will contain the total number of MSP records affected by the purge and the total of each type of MSP occurrence deleted from the MSP auxiliary file. 40.8 - MSP Utilization Edits and Resolution for Claims Submitted to CWF (Rev. 13783; Issued: 05-27-26; Effective: 10-01-26; Implementation: 10-05-26) 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. Applies to MSP types B (13 ESRD) and F (16 Federal Public Health). (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.6831 DME and Part B - Part B and DMERC claims are processed, and only a Part
A (Insurer Type 'J') 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.
6836 DME and Part B - An MSP Auxiliary record exists, and GHP or non-GHP
MSP is indicated on the claim. The claim From Date is prior to the MSP Start
Date; or claim Thru Date is after the MSP Term Date.
6837 DME and Part B - An MSP Auxiliary record exists, and GHP or non-GHP
MSP is indicated on the claim and at least one detail line does not match the
MSP Auxiliary record.
6838 DME and Part B - An MSP Auxiliary record exists with more than one MSP
type for the same claim dates of service. MSP is indicated on the claim.
6839 DME and Part B - A non-GHP ('D' or 'E') MSP auxiliary record exists without
an ORM present and no non-GHP MSP is indicated on the claim. The Date of
Service matches the non-GHP occurrence and the diagnosis codes on the
claim are a match within the family of diagnosis or the diagnosis is an exact
match. The Date of Service is less than or equal to 120 days before the claim
receipt date. A non-GHP ('L') MSP auxiliary record exists without an ORM
present and no non-GHP MSP is indicated on the claim. The Date of Service
matches the non-GHP occurrence and the diagnosis codes on the claim are a
match within the family of diagnosis or the diagnosis an exact match. The Date
of Service is less than or equal to 120 days after the Accretion Date on the
MSP Auxiliary File.
6840 DME and Part B - 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 ('D',
'E'). The ORM indicator is not present, and the Date of Service is less than or
equal to 120 days before the Claim Receipt date. The ICD-9 diagnosis on theclaim is not an exact or family match to the ICD-10 diagnosis on the open non-
GHP MSP Aux record ('L'). The ORM indicator is not present, and the Date of
Service is less than or equal to 120 days after the Accretion Date for the non-
ORM NGHP on the MSP Auxiliary File. 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 ('D', 'E'). The ORM indicator is not present, and the
Date of Service is less than or equal to 120 days before the Claim Receipt.
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 ('L'). The ORM indicator is
not present, and the Date of Service is less than or equal to 120 days after the
Accretion Date for the non-ORM NGHP on the MSP Auxiliary File.
6841 DME and Part B - 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 ('D',
'E', 'L', 'S', 'T', 'W'). ORM indicator is present. 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 ('D', 'E', 'L', 'S', 'T', 'W'). ORM indicator is present.
6842 DME and Part B - An incoming DMEPOS claim (HUDC) is received that
contains an ICD-9 Diagnosis code that is not an exact or family match to the
ICD-10 Diagnosis code on the open non-GHP MSP Auxiliary record ('S', 'T',
or 'W'). Or an incoming DMEPOS claim (HUDC) is received that contains an
ICD-10 Diagnosis code that is not an exact or family match to the ICD-9
Diagnosis code on the open non-GHP MSP Aux record ('S', 'T', or 'W').
6843 Applies only to the MSP G (43 Disabled) and A (12- Working Aged) MSP
Types. The MSP error code performs the following functions:
• If there is an open GHP Record in HIMR;
• The DOS is within the date of the open record at HIMR;
• The MSP type on the claim does not match the MSP Type on the open
record;
• The MSP Type on the claim does not match the patient age (i.e.: age 65 or
greater and MSP Type on the claim is 43 or age less than 65 and MSP
type on the claim is 12), the claim shall be rejected.
6844 When there is an MSP open GHP Record in HIMR, the CWF Error Code sets
when following occurs:
• The DOS is within the date of the open record at HIMR;
• The MSP type on the claim does not match the MSP Type on the open
record;
• The MSP Type on the claim is 43 or 13 and the patient’s age is equal to or
greater than 65;
• An ‘I’ Record should be created, if possible, if not possible the claim
should reject because record was missing vital information.
Note, if another MSP record is open with an incorrect MSP Type, the MAC will
submit an ECRS request to have the incorrect MSP Type end dated. The MACuses CWF secondary disposition of E or F depending on how the MAC wants the claim to suspend. 6845 When there is an open HIMR record, but there is not an open GHP Record in HIMR. The CWF Error Code shall set when the following occurs: • The claim shows GHP MSP on the claim; • The claim suspends for MAC review. See discussion in §40.4 above for proper use of override codes. 40.9 - CWF MSP Reject for A Beneficiary Entitled to Medicare Part B Only and A GHP (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) An MSP situation cannot exist when a beneficiary has GHP coverage (i.e., working aged, disability and ESRD) and is entitled to Part B only. CWF will edit to prevent the posting of these MSP records to CWF when there is no Part A entitlement date. Currently, if a contractor submits an ECRS transaction to the MSP Contractor to add a GHP MSP record where there is no Part A entitlement, the A/B MAC and DME MAC will receive a reason code of 61, MSP cannot exist without Part A entitlement. A/B MACs and DME MACs shall not submit an ECRS request to the MSP Contractor to establish a GHP MSP record when there is no Part A entitlement. A/B MACs and DME MACs that attempt to establish an “I” record will receive a CWF error. The CWF shall continue to allow the posting of Part B MSP records where there is no Part A entitlement when NGHP situations exists, such as automobile, liability, and workers’ compensation. Where an NGHP situation exists, the A/B MAC and DME MAC shall continue to submit ECRS transactions and establish “I” records, as necessary. 40.10 – ICD-10 and ICD 9-CM Diagnosis Code Tables Involving Non- GHP MSP Claims (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) In accordance with The Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Secretary of the Department of Health and Human Services adopts standard medical data code sets for use in standard transactions. According to the ICD-10 final rule, published in the Federal Register on January 16, 2009, the Secretary adopted the ICD-10-CM and ICD-10- PCS code sets for use in appropriate HIPAA standard transactions, including those for submitting health care claims electronically. Entities covered under HIPAA, which includes Medicare and its providers submitting claims electronically, are bound by these requirements and must comply. Medicare also requires
submitters of paper claims to use ICD-10 codes on their claims according to the same compliance date. CMS annually instructs CWF to upload and implement the ICD-10 tables in CWF for NGHP MSP claims transactions. In order to be prepared to meet the time line to implement the annually updated ICD-10 diagnosis codes by the mandated time frame of October, CWF implements the ICD-10 updates effective with each October release. CMS also provides CWF with the Diagnosis and Procedure Codes Conversion Tables that are used to associate ICD-10 codes to ICD-9 codes found in CWF MSP records. CWF loads and converts ICD-10 to ICD-9 diagnosis codes for purposes of determining whether ICD 10 diagnosis codes on incoming MSP claim are related to the NGHP MSP record in CWF. 40.10.1 - Certain Diagnosis Codes Not Allowed on NGHP MSP Records (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) There are certain diagnosis codes that systems must not apply to MSP Type 14, CWF MSP Type D No-Fault records and MSP Type 14, CWF MSP Type L Liability records and MSP Type 15, CWF Type E or W, Workers’ Compensation records. In order for these MSP claims not to deny and process correctly, the CWF must only allow those diagnosis codes related to the accident or injury. CMS has provided a comprehensive list of diagnosis codes that apply and do not apply to NF, L or WC MSP records. The list of diagnosis codes and excluded diagnosis codes may be found at the Coordination of Benefits Overview website at https://www.cms.gov/medicare/coordination-benefits- recovery-overview/icd-code-lists. 50 - Special CWF Processes (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) Special CWF MSP Processes are identified below. 50.1 - Extension of MSP-ESRD Coordination Period (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) Section 4631(b), of the Balanced Budget Act (BBA) of 1997, permanently extends the coordination period to 30 months for any individual whose coordination period began on or after March 1, 1996. Therefore, individuals who have not completed an 18-month coordination period by July 31, 1997, will have a 30-month coordination period under the new law. The Common Working File (CWF) will deny claims for primary payment that are submitted for applicable individuals during the 30-month coordination period. This provision does not apply to individuals who would reach the 18-month point on or before July 31, 1997. These individuals would continue to have an 18-month coordination period.
A one-time utility program was executed in CWF to extend the ESRD coordination period for applicable individuals (those records with a Medicare Secondary Payer (MSP) code of "B" and a coordination period termination date of August 1997, or later) to 30 months. This was done by adding 12 months to all coordination periods with a termination date on or after August 1997. All applicable records were changed by September 1, 1997. Any open records (those which do not have a termination date) remained open until they closed using the existing mechanisms, but following the time guidelines outlined above. That is, any ESRD, MSP termination dates, which were added to CWF where the coordination period ended in August 1997 or later, now reflect the new 30-month period. Claims erroneously submitted for primary payment are rejected with CWF Utilization Error Code 6803. 50.2 - MSP “W’ Record and Accompanying Processes (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) I. Common Working File Requirements (CWF) CWF accepts an MSP code of “W” for Workers’ Compensation Medicare Set-Aside Arrangements (WCMSA) for use on the HUSP records for application on the HUSP Auxiliary File. The CWF indicates the description name for an MSP code “W” record as “WC Medicare Set-Aside. The CWF accepts a contractor number 11119 on incoming MSP “W” HUSP records for application on the MSP Auxiliary file. The CWF accepts a “19” in the source code field on both the HUSP, and HUST transactions for contractor 11119. The CWF shall accept the “Y” validity indicator for HUSP transactions created by contractor 11119. The CWF returns a “19” in the Source Code field of the ‘03’ response trailer. The CWF allows contractors 11100, 11101, 11102, 11103, 11104, 11105, 11106, 11107, 11108, 11109, 11110, 11111, 11112, 11113, 11114, 11115, 11116, 11117, 11118, 11119, 11122, 11125, 11126, 11139, 11140,11141, 11142, 11143, 33333, 55555, 77777, 88888, 99999, to update, delete, change records originated or updated by contractor 11119. CWF will create and send a transaction to the contractor’s shared systems that have processed claims for each beneficiary when an add or change transaction is received for contractor 11119 or from contractor 11119. The CWF uses the following address for contractor number 11119: WCMSA Proposal/Final Settlement P.O. Box 138899 Oklahoma City, OK 73113-8899 The CWF applies the same MSP consistency edits for Workers’ Compensation (WC) code “E” to MSP code “W”.
The CWF maintainer creates error code (6815). The message for this new error code (6815) reads “WC Set-Aside exists. Medicare contractor payment not allowed”. CWF activates this error under the following conditions: • A MSP code “W” record is present. • The record contains a diagnosis code related to the MSP code “W” occurrence. The CWF ensures that error code 6815 is overridden by MACS (A/B) and MACs (DME) with a code N or M, for claim lines or claims on which workers’ compensation set-aside diagnosis do not apply. CWF accepts the new error code (6815) as returned on the 08 trailer. The CWF creates a HUSP transaction error code, SP76, to set when an incoming HUSP transaction with MSP Code “W” is submitted and the beneficiary MSP Auxiliary file contains an open MSP occurrence with MSP code “E” with the same effective date and diagnosis code(s). II. Shared Systems and MACs (A/B) and MACS (DME) A/B MACs and DME MACs shared systems accepts MSP Code “W” to identify a Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) for use on HUSP records for application on the HUSP Auxiliary file. The Medicare shared systems utilizes the description name of ‘WC Medicare Set-Aside’ for MSP code “W” records. The shared systems: • Utilizes contractor number “11119” on incoming MSP ‘W’ HUSP records for application on the MSP Auxiliary file. • Accepts contractor number 11119 and MSP code “W” and source code “19” on the returned 03 CWF trailer. • Accepts “19” in the source code field on the HUSP, and HUST transactions for contractor 11119. • Accepts a “Y” validity indicator, as well as, MSP code W for transactions created by contractor 11119. • Accepts and processes HUST transactions when an add, change or delete transaction is received for contractor 11119 or from contractor 11119. • Reflects CROWD/ report special project number ‘7019’ as Workers’ Compensation Set-Aside Arrangements. • Accepts “19” in the header Payment Indicator field and in the detail Payment Process Indicator field for Contractor 11119.
The MACS (A/B) and MACS (DME) and their systems continue to accept claims with value code 15 for Part A and Insurance Code (15) for Part B and DME MAC against an open “W” MSP Auxiliary file. The shared systems accepts error code (6815) as returned with the 08 trailer. Following receipt of the utilization error code 6815, the A/B MACs and DME MACs systems deny all claims (including conditional payment claims) related to the diagnosis codes on the CWF MSP code “W”, when there is no termination date entered for the “W” code. Upon denying the claim, all contractor shared systems create a “19” Payment Denial Indicator in the header of its HUIP, HUOP, HUHH, HUHC, HUBC, HUDC claims. Upon denying the claim the MACs (B) and MACS (DME), MCS and VMS • Populate a “W” in the MSP code field and • Create a ‘19’ in the HUBC and HUDC claim header transaction and a ‘19’ in the claim detail process. Upon denying the claim MACs (A) and the FISS system • Populate a 15 in the value code field, in addition to the requirements referenced above. For MSP verification purposes, and prior to overriding claims on which the A/B MAC or DME MAC contractor received error code 6815, it shall: • check CWF to confirm that the date of service of the claim is after the termination date of the MSP “W” record. • and confirm the diagnosis code on the claim is related to the diagnosis codes on the MSP W record. MACs (B) and MACs (DME) overrides the payable lines with override code N. The MACs (A) override the payable claims with override code N. If a claim is to be allowed, an ‘N’ is placed on the “001” Total revenue charge line of the claim. The shared systems allows for an override of new error code 6815 with the code N. The Comprehensive Error Rate Testing (CERT) contractor accepts the MSP code “W” in the claim resolution field. The shared systems bypasses the MSPPAY module if there is an open MSP code “W”.
The shared systems does not make payment for those services related to diagnosis codes associated with the “W” Auxiliary record when the claims date of service is on or after the effective date and before or on the termination date of the record. The shared systems makes payment for those services related to the diagnosis codes associated with the “W” auxiliary record when a terminate date is entered and the claims date for service is after the termination date. The shared systems includes Reason Code 201, Group Code “PR”, Remark Code N722 and “Alert” Remark Code MA01, when denying claims based on a ‘W’ MSP auxiliary record on outbound 837 claims. The shared systems utilize Group Code “PR”; Remark Code N722 and “Alert” Remark Code MA01, Reason Code 201, when denying claims based on a “W” MSP auxiliary record for 835 ERA and SPR messages. The shared system will afford appeal rights for denied MSP code “W” claims. III. The MACS (A/B) and MACs (DME): • Shall not make payment for those services related to diagnosis codes associated with an open “W” auxiliary record (not termed). • Shall make payment for those services related to diagnosis codes associated with a termed auxiliary “W” record when the claims date of service is after the termination date. The MACS (A/B) and MACs (DME) will include Reason Code 201, Group Code “PR”, Remark Code N722 and “Alert” Remark Code MA01, when denying claims based on a ‘W’ MSP auxiliary record on outbound 837 claims. The MACS (A/B) and MACs (DME) utilize Group Code “PR”; Remark Code N722 and “Alert” Remark Code MA01, Reason Code 201, when denying claims based on a “W” MSP auxiliary record for 835 ERA and SPR messages. The MACS (A/B) and MACs (DME) and share systems shall afford appeal rights for denied MSP code “W” claims. Those systems responsible for the HETS 270/271 transaction shall ensure that documentation concerning the EB value and qualifier WC is updated. The CROWD/MDX reflects special project number “7019” as Workers’ Compensation Medicare Set-Aside Arrangements. IV. Medicare Residual Payment When WCMSA benefits terminate, or deplete, during a beneficiary’s provider facility stay or upon a physician’s visit.
There are situations where WCMSA benefits may terminate, or deplete, during a beneficiary’s provider facility stay or upon a physician’s visit and a residual Medicare secondary payment is due. Under these circumstances Medicare may make a residual secondary payment. The term “residual payment” is defined as: a payment Medicare makes on a claim where available funds have been exhausted from the WCMSA benefit or responsibility for payment terminates mid-service. The A/B MACs (A/B), DME MACs and shared systems may pay this residual secondary payment by sending the primary payer amounts to the MSPPAY module and calculate Medicare’s payment if such services are covered and reimbursable by Medicare. The MACs (A/B), MACs (DME), and shared systems, receive, accept, and make a residual payment on MSP Type 15 (MSP Code E) WCMSA electronic claims when the CAS segment shows one of the following CARCs and primary payer benefits are terminated, exhausted or the claim contains a partial or zero payment: 27 – Expenses occurred after coverage terminated. 35 – Lifetime benefit maximum has been reached. 119 – Benefit maximum for this time period, or occurrence, has been reached. 149 – Lifetime benefit maximum has been reached for this source/benefit category. The MACs (A/B), MACs (DME), and shared systems receive, accept, and make payment on MSP Type 15, WCMSA paper (hard copy) claims when the claim includes an attached remittance advice (RA)/Explanation of Benefits (EOB) that: 1) Shows the claim with a zero payment or was not paid in full by the primary payer and a residual payment is due; 2) Is a Medicare covered and reimbursable service; and 3) Contains a reason code for denial or similar verbiage if a reason code is not indicated: • Expenses occurred after the coverage terminated; • Lifetime benefit maximum has been reached; • Benefit maximum for this time period, or occurrence, has been reached; or • Lifetime benefit maximum has been reached for this source/benefit category. NOTE: If an MSP Type 15, WCMSA electronic, or hard copy claim, is received and there is a corresponding WCMSA record on CWF and the claim contains a partial, or zero, payment from a primary insurer and the claim, or attached primary payer remittance advice/EOB, does not include a reason code for denial or similar verbiage if a reason code is not indicated, the A/B MACs, DME MACs and shared system deny the claim based on the CWF utilization 6815.
In order for the residual payment to occur, CWF performs the following functions: CWF HUIP, HUOP, HUHH, HUHC (HBIP, HBOP, HBHH, and HBHC for BDS) claims allow for a 1-byte field (Residual Payment Indicator) at the claim header level. Valid values for the field = X or space. CWF HUBC and HUDC (HBBC and HBDC for BDS) claims allow for a 1-byte field (Residual Payment Indicator) at the claim header level and at the detail level. Valid values for the field = X or space. NOTE: The shared systems must ensure that the MACs are able to input an “X” in the header of their claims, and at the service line level, when applicable, that are sent to CWF, for situations when the claim is not paid, or not paid in in full, by the primary payer. CWF shall override the 6815 WCMSA utilization error code when the MACs determine a residual payment should be made on the claim. The MACs make a residual payment by placing the “X” at the header for the Part A claims, or an ‘X’ at either the header or detail line for Part B Professional and DME MAC claims. The A/B MACs, DME MACs and shared systems must send the primary payer’s MSP amounts, found on the incoming WCMSA claim, to MSPPAY for Medicare’s Secondary Payment calculation when a residual payment is expected to be made by Medicare. NOTE: When applicable, the A/B MACs and DME MACs send the attestation form/letter, it received from the reporting entity indicating WCMSA benefits are exhausted, to the MSP Contractor. For ORM, the Section 111 reporting entity shall report that benefits are exhausted via the normal quarterly data file process. 60 - Converting Health Insurance Portability and Accountability Act (HIPAA) Individual Relationship Codes to Common Working File (CWF) Medicare Secondary Payer (MSP) Patient Relationship Codes (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) CMS has realized that its Common Working File (CWF) HUSP transaction does not allow for the correct association of HIPAA individual relationship codes, as found in the HIPAA 837 institutional and professional claims implementation guides, with corresponding MSP Type Codes, such as working aged (A), end-stage renal disease (B), and disability (G). Therefore, effective July 6, 2004, all A/B MACs (A) that receive incoming electronic HIPAA, DDE, or hard copy claims that are in the HIPAA ASC X12 837 format shall convert the incoming individual relationship codes to their equivalent CWF patient relationship codes. Until further notice, A/B MACs (A) shall continue to operate under the working assumption that all providers will be including HIPAA individual relationship codes on incoming claims.
Before CMS’ systems changes are effectuated, A/B MACs (A) may receive SP edits (i.e., SP-33 and SP-52) that indicate that an invalid patient relationship code was applied. A/B MACs (A) are to resolve those edits by manually converting the HIPAA individual relationship code to the CWF patient relationship code, as specified in the conversion chart below. If the A/B MAC (A) receives MSP edits and can determine that the HIPAA individual relationship code rather than the CWF patient relationship code was submitted on the incoming claim, it shall manually work the MSP edits incurred by converting the HIPAA individual relationship code to the appropriate CWF patient relationship code. Until Part A shared system changes are effectuated to convert HIPAA individual relationship codes to CWF patient relationship codes, A/B MACs (A) may move claims with a systems age of 30 days or older that have suspended for resolution of patient relationship code, including SP-33 or SP-52 edits, to condition code 15 (CC-15). The A/B MAC (A) contractor system shall utilize the conversion charts, found below, to cross-walk incoming HIPAA individual relationship codes to the CWF patient relationship code values. For MSP Occurrences with accretion dates PRIOR to 4/4/2011: HIPAA Individual Relationship Codes Convert To CWF Patient Relationship Codes Valid Values 18 01 Patient is Insured 01 02 Spouse 19 03 Natural Child, Insured has financial responsibility 43 04 Natural Child, insured does not have financial responsibility 17 05 Step Child 10 06 Foster Child 15 07 Ward of the Court 20 08 Employee 21 09 Unknown 22 10 Handicapped Dependent 39 11 Organ donor 40 12 Cadaver donor 05 13 Grandchild 07 14 Niece/Nephew 41 15 Injured Plaintiff 23 16 Sponsored Dependent 24 17 Minor Dependent of a Minor Dependent
HIPAA Individual Relationship Codes Convert To CWF Patient Relationship Codes Valid Values 32,33 18 Parent 04 19 Grandparent 53 20 Life Partner 29 N/A Significant Other 30 N/A ? 31 N/A ? 36 N/A ? G8 N/A ? Other HIPAA Individual Relationship Codes N/A ? For MSP Occurrences with accretion dates 4/4/2011 AND SUBSEQUENT: HIPAA Individual Relationship Codes Convert To CWF Patient Relationship Codes Description 18 01 Self; Beneficiary is the policy holder or subscriber for the other GHP insurance reflected by the MSP occurrence –or- Beneficiary is the injured party on the Workers Compensation, No-Fault, or Liability claim 01 02 Spouse 19 03 Child 43 03 Child 17 03 Child 10 03 Child 15 04 Other 20 04 Other 21 04 Other 22 04 Other 39 04 Other 40 04 Other 05 04 Other 07 04 Other 41 01 Self; Beneficiary is the policy holder or subscriber for the other GHP
HIPAA Individual Relationship Codes Convert To CWF Patient Relationship Codes Description insurance reflected by the MSP occurrence –or- Beneficiary is the injured party on the Workers Compensation, No-Fault, or Liability claim 23 04 Other 24 04 Other 32,33 04 Other 04 04 Other 53 20 Life Partner 29 N/A Significant Other 30 N/A ? 31 N/A ? 36 N/A ? G8 N/A ? Other HIPAA Individual Relationship Codes N/A ? A/B MACs (A) allow CWF patient relationship codes, since these files should be populated with information sent back to the A/B MACs (A)’ systems via the automated transaction.
Transmittals Issued for this Chapter
Rev # Issue Date Subject Impl Date CR# R13783MSP 05/27/2026 Creating Additional Medicare Secondary Payer (MSP) Error Codes to Better Identify Incoming MSP Claims that Conflict with MSP Records Found on the Common Working File (CWF) 10/05/2026 14437 R13262MSP 06/09/2025 Updates to the Medicare Carrier System (MCS), the Viable Information Processing Systems Medicare Systems (VMS) and the Common Working File (CWF) Processes to Capture and Further Automate the Medicare Secondary Payer (MSP) Processes 01/06/2025 13591 R13168MSP 04/16/2025 Updates to the Medicare Carrier System (MCS), the Viable Information Processing Systems Medicare Systems (VMS) and the Common Working File (CWF) Processes to Capture and Further Automate the Medicare Secondary Payer (MSP) Processes- Rescinded and replaced by Transmittal 13262 01/06/2025 13591 R12773MSP 08/09/2024 Updates to the Medicare Carrier System (MCS), the Viable Information Processing Systems Medicare Systems (VMS) and the Common Working File (CWF) Processes to Capture and Further Automate the Medicare Secondary Payer (MSP) Processes- Rescinded and replaced by Transmittal 13168 01/06/2025 13591 R12078MSP 06/14/2023 Significant Updates to Internet Only Manual (IOM) Publication (Pub.) 100-05 Medicare Secondary Payer (MSP) Manual, Chapter 6 05/29/2023 13160 R11996MSP 04/27/2023 Significant Updates to Internet Only Manual (IOM) Publication (Pub.) 100-05 Medicare Secondary Payer (MSP) Manual, Chapter 6 ) – Rescinded and replaced by Transmittal 12078 05/29/2023 13160
R11381MSP 04/29/2022 Updating the Common Working File (CWF) Logic Tied to Medicare Secondary Payer (MSP) Investigational Records to Match Newly Revised Development Timeframes 10/03/2022 12678 R10753MSP 05/11/2021 Update the Common Working File (CWF) to Accept a Group Health Plan (GHP) and non-GHP (NGHP) Medicare Secondary Payer (MSP) Effective Date 3 Months from the Current Date for Medicare Enrolled and Medicare Entitled Beneficiaries 10/04/2021 12176 R10243MSP 07/31/2020 Updating the Common Working File (CWF) to allow for a Medicare Secondary Payer (MSP) Termination Date Greater than the Current Date Plus Six Months for non-Group Health Plan (NGHP) MSP Auxiliary Records 01/04/2021 11771 R125MSP 03/22/2019 Update to Publication (Pub.) 100-05 to Provide Language-Only Changes for the New Medicare Card Project 04/22/2019 11193 R124MSP 08/31/2018 Updates to Chapters 5 and 6 of Publication 100-05 to Further Clarify Medicare Secondary Payer (MSP) Processes that Include Electronic Correspondence Referral System (ECRS) Requests Submissions and Timely Submission of MSP I Records, General Inquiries and Hospital Reviews 10/01/2018 10855 R121MSP 06/01/2018 Update the International Classification of Diseases, Tenth Revision (ICD-10) 2019 Tables in the Common Working File (CWF) for Purposes of Processing Non- Group Health Plan (NGHP) Medicare Secondary Payer (MSP) Records and Claims 10/01/2018 10803
R119MSP 04/07/2017 Implement the International Classification of Diseases, Tenth Revision (ICD-10) 2018 General Equivalence Mappings (GEMs) Tables in the Common Working File (CWF) for Purposes of Processing Non- Group Health Plan (NGHP) Medicare Secondary Payer (MSP) Records and Claims 10/02/2017 9947 R114MSP 09/18/2015 Claims Processing Medicare Secondary Payer (MSP) Policy and Procedures Regarding Ongoing Responsibility for Medicals (ORM) 07/06/2015 8984 R113MSP 08/06/2015 Instructions for the Shared Systems and Medicare Administrative Contractors (MACs) to follow when a Medicare Residual Payment must be Paid on Workers’ Compensation Medicare Set- aside Arrangement (WCMSA) or for Ongoing Responsibility of Medicals (ORM) Non-Group Health Plan (NGHP) Medicare Secondary Payer (MSP) Claims 01/04/2016 9009 R110MSP 03/06/2015 Claims Processing Medicare Secondary Payer (MSP) Policy and Procedures Regarding Ongoing Responsibility for Medicals (ORM) – Rescinded and replaced by Transmittal 114 07/06/2015 8984 R107MSP 10/24/2014 Update to Pub. 100-05, Chapters 05 and 06 to Provide Language-Only Changes for Updating ICD-10 and ASC X12 11/28/2014 8947 R95MSP 08/23/2013 Update of the Common Working File (CWF) to not Allow Certain Diagnosis Codes on No-Fault Medicare Secondary Payer (MSP) Records 01/06/2014 8351 R94MSP 06/28/2013 Update the Medicare Secondary Payer Manuals to Indicate Unsolicited Refund Documentation is No Longer a Justification for Submission of an “I” Record 07/30/2013 8253
R89MSP 08/30/2012 Expanding the Coordination of Benefits (COB) Contractor Numbers to Include 11139 and 11142 for the Common Working File (CWF) 01/07/2013 7906 R88MSP 08/17/2012 Expanding the Coordination of Benefits (COB) Contractor Numbers to Include 11139 and 11142 for the Common Working File (CWF) 01/07/2013 7906 R81MSP 07/29/2011 Requesting the Common Working File (CWF) to Cease Submitting First Claim Development (FCD) and Trauma Code Development (TCD) Alerts to the Coordination of Benefits Contractor (COBC) 01/03/2012 7483 R77MSP 01/21/2011 Categorizing Diagnosis Codes 500-508 and 800-999 on Incoming Medicare Secondary Payer (MSP) Claims and on the MSP Auxiliary File for non-Group Health Plan (GHP) Claims 07/05/2011 7149 R76MSP 11/19/2010 Common Working File (CWF) Medicare Secondary Payer ( MSP) Coordination of Benefits Contractor (COBC) Number Update and Implementation of MSP Group Health Plan (GHP) COBC Hierarchy Rules as related to Mandatory Insurer Reporting 04/04/2011 7216 R74MSP 04/28/2010 New Medicare Secondary Payer Insurer Type Codes 10/04/2010 6768 R65MSP 03/20/2009 New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Workers Compensation Medicare Set- Aside Arrangements (WCMSAs) to Stop Conditional Payments 04/06/2009/ 07/06/2009 5371
R64MSP 01/09/2009 New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Workers Compensation Medicare Set- Aside Arrangements (WCMSAs) to Stop Conditional Payments - Rescinded and replaced by Transmittal 65 04/06/2009/ 07/06/2009 5371 R61MSP 10/03/2008 Expanding the Mandatory Insurer Reporting (MIR) Coordination of Benefits (COB) Contractor Numbers for the Common Working File (CWF) 01/05/2009 6182 R60MSP 09/19/2008 Expanding the Mandatory Insurer Reporting (MIR) Coordination of Benefits (COB) Contractor Numbers for the Common Working File (CWF) - Rescinded and replaced by Transmittal 61 01/05/2009 6182 R43MSP 10/31/2005 Expanding the Voluntary Data Sharing Agreement (VDSA) Coordination of Benefit (COB) Contractor Numbers for the Common Working File (CWF) 04/03/2006 3826 R31MSP 07/08/2005 Full Replacement of CR 3770,Expanding the Number of Source Identifiers for Common Working File (CWF) MSP Records 10/03/2005 3909 R12MSP 03/05/2004 Converting HIPAA Individual Relationship Codes to Common Working File (CWF) Patient Relationship Codes 03/19/2004 3117 R09MSP 02/06/2004 Converting Health Insurance Portability and Accountability ct (HIPAA) Individual Relationship Codes to Common Working File (CWF) Patient Relationship Codes 07/06/2004 3116 R08MSP 02/06/2004 Common Working File MSP Modifications 07/06/2004 2775 R06MSP 01/162004 Automatic Notice of Change to MSP Auxiliary File 01/01/2004 2608 R01MSP 10/01/2003 Initial Issuance of Manual N/A N/A
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