CMS Pub. 100-05, ch. 5, § 40.7.3.3

Claims Where MSP Amounts Appear at the Claim Level and Not at the

Service Detail Line

(Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22)

There may be situations where the primary payer may identify the CARCs at the line

level, but may also include additional CARCs and adjustments at the header level.

Although receiving such MSP claims is a rare occurrence it is possible that these types of

claims may be sent on 5010 claim transactions or on hardcopy claims.

The current Medicare Secondary Payer Payment Module (MSPPAY) calculates MSP

claims payment for MSP claims received at the header level or at the detail level.

Currently, when there is MSP information at the header level that is not identified at the

detail the share system turns on the apportioning switch in MSPPAY to apportion the

MSP claims to the detail lines. In situations where the claim level OTAF, primary payer

allowed amount and/or primary payer paid amounts are not equal to the sum of the

corresponding detail amounts, but the claim balances, this manual section instructs the

Part B shared systems to use the claim level amounts to determine Medicare’s secondary

payment. This involves determining the MSP amounts utilizing the CAS adjustments as

instructed in previous MSP and MSP CARC change requests, and then send these

amounts, along with the claim detail information, to MSPPAY so MSPPAY can

apportion the MSP amounts to the detail. A/B MACs (Part B) may refer to the 5010 ASC

X12

837professional claim implementation guide - Front matter, Balancing

section, specifically 1.4.4.1 for additional reference as needed.

To summarize this balancing, the claim level primary paid amount must equal the sum of

the line level primary paid amounts less any claim level reductions.

Submitted

Charges

Submitted

Primary Payment

Submitted

CARCs

Claim Level $200 $170 CO-xx $30

Line 1 $100 $100

Line 2 $100 $100

The above claim is considered in balance by version 837 balancing rules, however, the

sum of the line level primary paid amounts does not equal the claim level primary paid

amount.