CMS Pub. 100-05, ch. 5, § 50.1.8

(MSPPAYBL)

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

The sub-module performs the necessary payment calculation, on a by-line basis, for

physician/supplier claims with service "thru-dates" on or after April 1, 1998.

A. MSPPAYBL Sending Data Elements.

MSPPAY must send the following data to MSPPAYBL:

No. Field Name Definition/Use Source/Value

1 TEST SWITCH Indicator to turn on

function within the MSP

software display sending

and returning data. Used to

identify payment problems.

"T" = display send/return data;

Space = do not display data

2 FILLER 8 value spaces

3 RECORD ID Identification of Part B type

claim being processed =

"HMBL"

4 CLMNO Health Insurance Claim

Number

Supplied by the A/B MAC

(Part B) system.

5 DOC CNTL NUM Assigned document control

number

Assigned and supplied by the

A/B MAC (Part B) system

6 FILLER 1 value space

7 APPORTION

SWITCH

Determine whether to

apportion the Other Payer's

Allowed Amount and

Payment Amount

Supplied by the A/B MAC

(Part B) system

"N" = do not apportion Space

= do apportion

8 TOTAL ACTUAL

CHARGES

Supplied by the A/B MAC

(Part B) system

9 NUM OF OTHER

PAYERS

The number of other payers

who are primary to

Medicare

Supplied by the A/B MAC

(Part B) system. Valid value

'01' thru '10'

NOTE: THE FOLLOWING FIELDS WILL OCCUR 13 TIMES

No. Field Name Definition/Use Source/Value

10 THIRD PARTY

PAYER TABLE

MSP code(s) and MSP

amount comprise third

party data.

MSP Code - Code(s)

identifying the other payer:

12 = GHP (Working Aged)

13 = ESRD (End Stage

Renal disease)

14 = AUTO

(Automobile/No-Fault)

15 = Work (Worker's

Compensation)

16 = FEDS (Federal)

41 = BL (Black Lung)

42 = VA (Veterans)

43 = DSAB (Disability)

47 = Liab (Liability)

Based on information obtained

from the claim, third party

information submitted with the

claim, i.e., explanation of

benefits or appropriate

electronic data elements.

Supplied by the A/B MAC

(Part B) system.

May occur up to 10 times.

MSP AMOUNT Amount(s) paid by the

other payer.

11 OTHER PAYER

ALLOWED AMT

Covered charges allowed

by the third party payer.

Third Party Payer explanation

of benefits

12 NUMBER OF LINES Number of lines to

compute MSP amounts.

Supplied by the A/B MAC

(Part B) system

13 RESERVED FOR

CMS

Space reserved for future

enhancements.

124 value spaces

14 RESERVED FOR

USER

Space reserved for user as

necessary.

100 value spaces

15 LINE NUMBER Line of service number. Supplied by the A/B MAC

(Part B) system. Values "01"

thru "13''

16 DENIED INDICATOR Indicator that reflects

whether Medicare or the

other A/B MAC (Part B)

denied the line of service.

Supplied by the A/B MAC

(Part B) system

"D" = Line of service denied

by the other A/B MAC (Part

B) and/or Medicare.

Space = Line of service

accepted for payment by the

other A/B MAC (Part B)

and/or Medicare.

17 FILLER One value space

18 THRU DATE Ending service date of the

period included on the

claim (CCYYMMDD)

THRU DATE CC

THRU DATE YY

THRU DATE MM

Supplied by the A/B MAC

(Part B) system from Field 24

of the Form CMS-1500

Value = "19" or "20"

Value = "00" thru "99"

Value = "01" thru "12"

No. Field Name Definition/Use Source/Value

THRU DATE DD Value = "01" thru "31"

19 RECORD ID Identifies the claim type. Part B = "HMBL"

20 CLMNO Health Insurance Claim

Number (HICN)

Supplied by the A/B MAC

(Part B) system from Field 1a

of the Form CMS-1500

21 DOC CNTL NUM Assigned document control

number

Assigned and supplied by the

A/B MAC (Part B) system

22 FULLY PAID CLAIM

IND

Indicator that reflects claim

is fully paid by the third

party payer.

Supplied by the A/B MAC

(Part B) system

"Y" = Fully paid by other

payer

Space = Not fully paid by other

payer

23 NUM OF OTHER

PAYERS

The number of other payers

who are primary to

Medicare

Supplied by the A/B MAC

(Part B) system

Valid value "01" thru "10"

24 THIRD PARTY

PAYER TABLE

MSP code(s) and MSP

amount comprise third

party data.

Based on information obtained

from the claim. Third party

information submitted with the

claim, i.e., explanation of

benefits or appropriate

electronic data elements.

25 MSP CODE Code(s) identifying the

other payer:

12 = GHP (Working Aged)

13 = ESRD (End Stage

Renal disease)

14 = AUTO

(Automobile/No-Fault)

15 = Work (Workers'

Compensation)

16 = FEDS (Federal)

41 = BL (Black Lung)

42 = VA (Veterans)

43 = DSAB (Disability)

47 = LIAB (Liability)

Supplied by the A/B MAC

(Part B) system. May occur up

to 10 times

26 MSP AMOUNT Amount(s) paid by the

other payer.

Third party payer explanation

of benefits

27 TOTAL ACTUAL

CHARGES

Total charges billed by the

physician/supplier.

Form CMS-1500, Field 28

28 OBLIGATED TO

ACCEPT

Amount the provider

agrees to accept as

payment in full when this

amount is less than the

charges but higher than the

Third party payer explanation

of benefits

No. Field Name Definition/Use Source/Value

payment received from the

primary payer.

29 OTHER PAYER

ALLOWED AMT

Covered charges allowed

by the third party payer.

Third party payer explanation

of benefits

30 MEDICARE

REASONABLE CHG

&FEE SCHEDULE

The Medicare

reimbursement amount

excluding applicable

deductible and

coinsurance.

Computed and supplied by the

A/B MAC (Part B) system.

31 FILLER Nine value spaces

32 BLOOD DEDUCTION Dollar amount of blood

deductible charged by

Medicare.

Zero for Medicare Part B

33 CASH DEDUCTION Dollar amount of

deductible charged by

Medicare.

Supplied by the A/B MAC

(Part B) system.

34 FILLER Sixty-eight value spaces

35 TOTAL COIN AMT The total coinsurance

amount chargeable to the

beneficiary.

Computed and supplied by the

A/B MAC (Part B) system.

36 FILLER Six value spaces

37 ASSIGNMENT

INDICATOR

An indicator that identifies

if the claim is assigned or

unassigned.

From the claim

"A" = Assigned claim

"B" = Non-assigned claim

38 FILLER Twenty eight value spaces

39 MED PRIMARY

PAYMENT

The Medicare

reimbursement amount less

applicable deductible and

coinsurance.

Computed and supplied by the

A/B MAC (Part B) system.

40 PROVIDER

PAYMENT AMT

The Medicare

reimbursement amount to

be paid to the provider.

Computed and supplied by the

A/B MAC (Part B) system.

41 PATIENT PAYMENT

AMT

The Medicare

reimbursement amount to

be paid to the patient.

Computed and supplied by the

A/B MAC (Part B) system.

42 G-R-H PERCENT

(GRAMM-RUDMANN -

HOLLINGS)

The applicable percent

reduction required by the

Gramm-Rudmann-Hollings

Act.

Supplied by the A/B MAC

(Part B) system.

No. Field Name Definition/Use Source/Value

43 CHARGES NSDC

(CHARGES NOT

SUBJECT TO

DEDUCTIBLE AND

COINSURANCE)

Charge amount not subject

to deductible and

coinsurance, i.e.,

reimbursed at 100%.

Computed and supplied by the

A/B MAC (Part B) system.

44 CHARGES SD

(CHARGES SUBJECT

TO DEDUCTIBLE)

Charge amount subject to

the deductible.

Computed and supplied by the

A/B MAC (Part B) system.

45 PSYCH CHARGES Allowed psychiatric

charges.

Computed and supplied by the

A/B MAC (Part B) system.

46 PAR INDICATOR Indicator reflecting

whether the provider

participates in the

Medicare program.

Supplied by the A/B MAC

(Part B) system.

"P" = Par Provider

"N" = Non-Par Provider

47 LIMITED FEE NON-PAR

The fee amount paid to a

nonparticipating provider.

Computed and supplied by the

A/B MAC (Part B) system.

48 LIMITED CHARGES

UNASSIGNED

The charge for each service

on unassigned claims.

Computed and supplied by the

A/B MAC (Part B) system if

LC on the claim exceeds more

than 115% of Medicare fee

schedule amount.

49 RESERVED FOR

CMS

Space reserved for future

enhancements.

One hundred seventy nine

value spaces.

50 RESERVED FOR

USER

Space reserved for user as

necessary.

One hundred ninety value

spaces.

B. MSPPAYBL Returning Data Elements.

MSPPAYBL will return the following data to MSPPAY:

No Field Name Definition/Use Source/Value

1 RETURN

CODE

Numeric code indicating the

results from processing the

secondary payment computation

and savings. Identifies a fully or

partially paid bill as well as

invalid sending data.

Determined by MSPPAYB

Valid values "3000" thru

"3999" (See §40.1.3 above;

also refer to the technical

documentation released with

the software.) Unless

otherwise specified MSPPAY

is the source of all the

following, possibly modified

by MSPPAY.

2 HEADER OR

LINE ERROR

Reflects if an error was detected

at the claim header or line when

computing MSP by line.

Determined by MSPPAYBL:

"H" = Header Error

"L" = Line Error

No Field Name Definition/Use Source/Value

3 LINE

NUMBER OF

ERROR

Reflects the line of service an

error was detected.

4 BLOOD

DEDUCTION

TO CWF

Amount of blood deductible to report to the Common Working

File (CWF).

5 CASH

DEDUCTION

TO CWF

Dollar amount of deductible to report to the CWF

6 TOTAL COIN

AMT TO CWF

The total coinsurance amount to report to the Common Working

File.

7 MED

SECONDARY

PAYMENT

Medicare's secondary payment computed by the MSP software.

8 PROVIDER

PAYMENT

AMT

Medicare's secondary payment computed by the MSP software.

9 PATIENT

PAYMENT

AMT

Medicare's secondary payment computed by the MSP software.

10 BLOOD

DEDUCTION

TO CHG

The amount of blood deductible the beneficiary may be charged

by the provider.

11 CASH

DEDUCTION

TO CHG

The dollar amount of deductible the beneficiary may be charged

by the provider.

12 TOTAL COIN

AMT TO CHG

The total coinsurance amount chargeable to the beneficiary.

13 G-R-H

(GRAMM-RUDMANN-HOLLINGS)

SAVINGS

REDUCTION

The amount of the MSP savings reduced for Gramm-Rudmann-Hollings.

14 SAVINGS

MSP GHP

Amount saved by Medicare when a GHP has made a payment for

a working aged beneficiary (MSP Code 12).

15 SAVINGS

MSP ESRD

Amount saved by Medicare when an EGHP has made a payment

for an ESRD beneficiary (MSP Code 13).

16 SAVINGS

MSP AUTO

Amount saved by Medicare when another insurer has made

payment in an automobile/no-fault situation (MSP Code 14).

17 SAVINGS

MSP WORK

Amount saved by Medicare when workers' compensation

payment has been made (MSP Code 15).

18 SAVINGS

MSP FEDS

Amount saved by Medicare when PHS or other Federal agency

made payment (MSP Code 16).

No Field Name Definition/Use Source/Value

19 SAVINGS

MSP BL

Amount saved by Medicare when Black Lung payment has been

made by the Department of Labor (MSP Code 41).

20 SAVINGS

MSP VA

Amount saved by Medicare when payment has been made by the

Department of Veteran's Affairs (MSP Code 42).

21 SAVINGS

MSP DSAB

Amount saved by Medicare when an LGHP has made a payment

for a disabled beneficiary (MSP Code 43).

22 SAVINGS

MSP LIAB

Amount saved by Medicare when payment has been made by a

liability insurer (MSP Code 47).

23 SAVINGS

TOTAL

Total savings to the Medicare program when Medicare is the

secondary payer a primary payer(s) has made some payment.

Includes all MSP codes 12 - 16, 41 - 43, and 47.

24 RESERVED

FOR CMS

Space reserved for future enhancements. (123 value spaces)

25 RESERVED

FOR USER

Space reserved for user as necessary. (118 value spaces)

NOTE: THE FOLLOWING FIELDS WILL OCCUR 13 TIMES

26 LINE

NUMBER

Line of service number

27 RETURN

CODE

Numeric code indicating the results from processing the

secondary payment computation and savings. Identifies a fully

or partially paid bill as well as invalid sending data.

NOTE: The Source/Value is determined by MSPPAYB Valid values "3000" thru "3999"

(See §40.1.3 above; also refer to the technical and user documentation released with the

software.) Unless otherwise specified MSPPAY is the source of all the following,

possibly modified by MSPPAY.

No Field Name Definition

28 BLOOD

DEDUCTION

TO CWF

Amount of blood deductible to report to the CWF

29 CASH

DEDUCTION

TO CWF

Dollar amount of deductible to report to the CWF.

30 FILLER (77 value spaces)

31 TOTAL COIN

AMT TO CWF

The total coinsurance amount to report to the CWF.

32 FILLER (9 value spaces)

33 MED

SECONDARY

PAYMENT

Medicare's secondary payment computed by the MSP software.

34 PROVIDER

PAYMENT

AMT

Reimbursement paid to the provider.

35 PATIENT

PAYMENT

AMT

Reimbursement paid to the patient.

No Field Name Definition/Use Source/Value

36 BLOOD

DEDUCTION

TO CHG

The amount of blood deductible the beneficiary may be charged

by the provider.

37 CASH

DEDUCTION

TO CHG

The dollar amount of deductible the beneficiary may be charged

by the provider.

38 TOTAL COIN

AMT TO CHG

The total coinsurance amount chargeable to the beneficiary.

39 FILLER (3 value spaces)

40 G-R-H

(GRAMM-RUDMANN-HOLLINGS)

SAVINGS

REDUCTION

The amount of the MSP savings reduced for Gramm-Rudmann-Hollings.

41 GROSS

MEDICARE

PAYMENT

The amount Medicare pays as primary excluding deductibles

and coinsurance.

42 FILLER (36 value spaces)

43 SAVINGS MSP

GHP

Amount saved by Medicare when a GHP has made a payment

for a working aged beneficiary (MSP Code 12).

44 SAVINGS MSP

ESRD

Amount saved by Medicare when an EGHP has made a payment

for an ESRD beneficiary (MSP Code 13).

45 SAVINGS MSP

AUTO

Amount saved by Medicare when another insurer has made

payment in an automobile/no-fault situation (MSP Code 14).

46 SAVINGS MSP

WORK

Amount saved by Medicare when Workers' compensation

payment has been made (MSP Code 15).

47 SAVINGS MSP

FEDS

Amount saved by Medicare when PHS or other Federal agency

made payment (MSP Code 16).

48 SAVINGS MSP

BL

Amount saved by Medicare when Black Lung payment has been

made by the Department of Labor (MSP Code 41).

49 SAVINGS MSP

VA

Amount saved by Medicare when payment has been made by the

Department of Veteran's Affairs (MSP Code 42).

50 SAVINGS MSP

DSAB

Amount saved by Medicare when an LGHP has made a payment

for a disabled beneficiary (MSP Code 43).

51 SAVINGS MSP

LIAB

Amount saved by Medicare when payment has been made by a

liability insurer (MSP Code 47).

52 SAVINGS

TOTAL

Total savings to the Medicare program when Medicare is the

secondary payer a primary payer(s) has made some payment.

Includes all MSP codes 12 - 16, 41 - 43, and 47.

53 FILLER Eighteen value spaces

54 MSP

COMPUTATIO

N 1

The result of the total actual charge by the physician/supplier, or

the limiting charge (if the claim is unassigned), or an amount the

physician/supplier is obligated to accept as payment in full, if

that is less than the charges, minus the amount paid by the

primary payer for covered services.

No Field Name Definition/Use Source/Value

55 MSP

COMPUTATIO

N 2

The result of the gross amount payable by Medicare minus

applicable deductible and coinsurance amounts.

56 MSP

COMPUTATIO

N 3

The result of the higher of the primary payer's allowed or the

Medicare allowed minus the amount paid by the primary payer.

The Medicare allowed and the primary payer's allowed are

determined without regard to the Medicare or primary plan's

deductible or coinsurance, respectively.

57 FILLER Nine value spaces

58 RESERVED

FOR CMS

Space reserved for future enhancements. (200 value spaces)

59 RESERVED

FOR USER

Space reserved for user as necessary. (153 value spaces)