Medicare Secondary Payer (MSP) Electronic Claim Filing Requirements
Published 03/13/2023
The following tables of loops, segments and elements should assist programmers, software vendors and clearinghouses with billing Part B Medicare Secondary Payer (MSP) claims electronically. These instructions include only the segments and elements required for submitting MSP claims.
| Loop, Segment, Element | Description | Value(s) | Comments |
|---|---|---|---|
| 2000B, SBR, 01 | Payer Responsibility Code | S | |
| 2000B, SBR, 02 | Relationship Code | 18 | |
| 2000B, SBR, 09 | Claim Filing Indicator Code | MA | |
| 2010BA, NM1/IL, 08 | Subscriber Primary Identifier Code | MI | |
| 2010BA, NM1/IL, 09 | Subscriber Primary Identifier | Medicare Beneficiary Identifier (MBI) |
| Loop, Segment, Element | Description | Value(s) | Comments |
|---|---|---|---|
| 2300, HI, 01-1 | Value Information | BE | |
| 2300, HI, 01-2 | Value Code for MSP Type | 12 = Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 = Medicare Secondary End-Stage Disease Beneficiary in the 30 Month Coordination Period With an Employer's Group Health Plan 14 = Medicare Secondary, No-fault Insurance Including Auto is Primary 15= Medicare Secondary Worker's Compensation 16 = Medicare Secondary Public Health Services (PHS) or Other Federal Agency 41 = Medicare Secondary Black Lung 43 = Medicare Secondary Disabled Beneficiary Under Age 65 with Large group Health Plan (LGHP) 47 = Medicare Secondary, Other Liability Insurance is Primary |
|
| 2300, HI, 01-5 | Monetary Amount | Total Amount paid by the primary payer | |
| 2300, HI, 02-1 | Value Information | BE | If provider is obligated to accept, or voluntarily accepts, an amount as payment in full from the primary payer, this segment is required. |
| 2300, HI, 02-2 | Value Information | 44 | |
| 2300, HI, 02-5 | Monetary Amount | Obligated to Accept as Full Payment (OTAF) | |
| 2320, SBR, 01 | Payer Responsibility Code | P | |
| 2320, SBR, 02 | Relationship Code | Refer to Implementation Guide | |
| 2320, SBR, 05 | Insurance Type Code | Refer to Implementation Guide | |
| 2320, SBR, 09 | Claim Filing Indicator Code | Refer to Implementation Guide | |
| 2320, CAS, 01 | Claim Adjustment Group Code | Refer to Implementation Guide | |
| 2320, CAS, 02 | Claim Adjustment Reason Code | See listing of valid codes at https://x12.org/codes | |
| 2320, CAS, 03 | Monetary Amount | Numeric | |
| 2320, CAS, 05-17 | Use as needed to show additional payer adjustments | ||
| 2320, AMT, 01 | Amount Qualifier Code | C4 | |
| 2320, AMT, 02 | Monetary Amount | Amount paid by the primary payer for the claim | |
| 2320, AMT, 01 | Amount Qualifier Code | B6 | |
| 2320, AMT, 02 | Monetary Amount | Amount allowed by the primary payer for the claim | |
| 2320, AMT, 01 | Amount Qualifier Code | T3 | |
| 2320, AMT, 02 | Total Submitted Charges | ||
| 2320, DMG, 01 | Date Time Period Qualifier | D8 | |
| 2320, DMG, 02 | Subscriber Date of Birth | ||
| 2320, DMG, 03 | Subscriber Gender | ||
| 2320, OI, 03 | Assignment of Benefits Indicator | Refer to Implementation Guide | |
| 2320, OI, 06 | Release of Information Code | Refer to Implementation Guide | |
| Loop, Segment, Element | Description | Value(s) | Comments |
|---|---|---|---|
| 2330A, NM1, 01 | Identifier Code | IL | |
| 2330A, NM1, 02 | Type Qualifier | 1 = Person | |
| 2330A, NM1, 03 | Last Name | ||
| 2330A, NM1, 04 | First Name | ||
| 2330A, NM1, 08 | Identification Code Qualifier | MI | |
| 2330A, NM1, 09 | Subscriber Primary Identifier | ||
| 2330B, NM1, 01 | Identifier Code | PR | |
| 2330B, NM1, 02 | Identifier Code | 2 | |
| 2330B, NM1, 03 | Primary Payer Name | ||
| 2330B, NM1, 08 | Primary Payer ID Code Identifier | PI | |
| 2330B, NM1, 09 | Primary Payer ID | Must match 2430, SVD, 01 | |
| 2330B, DTP, 01 | Date Time Qualifier | 573 | |
| 2330B, DTP, 02 | Date Time Format Qualifier | D8 | |
| 2330B, DTP, 03 | Primary Payer Adjudication Date |
The following loop is required if the service line has adjustments applied to it. If no service line exists, this loop is not required.
| Loop, Segment, Element | Description | Value(s) | Comments |
|---|---|---|---|
| 2430, SVD, 01 | Primary Payer ID | Must match 2330B, NM1, 09 | |
| 2430, SVD, 02 | Monetary Amount | Amount paid by the primary payer for the service line | |
| 2430, CAS, 01 | Claim Adjustment Group Code | Refer to Implementation Guide | |
| 2430, CAS, 02 | Claim Adjustment Reason Code | See listing of valid codes at https://x12.org/codes | |
| 2430, CAS, 03 | Monetary Amount | ||
| 2430, CAS, 05-17 | Use as needed to show additional payer adjustments | ||
| 2430, DTP, 01 | Date Time Qualifier | 573 | Use if service line's adjudication date is different than what is given in 2330B, DTP, 03 |
| 2430, DTP, 02 | Date Format Qualifier | D8 | |
| 2430, DTP, 03 | Primary Payer Adjudication Date | ||
If you have questions regarding Part B MSP Electronic claim submission, please contact the Palmetto GBA Provider Contact Center at 855-696-0705 (JM) or 877-567-7271 (JJ).