CMS Pub. 100-05, ch. 5, § 50.2.9

MSPPAYO performs the necessary payment calculation for outpatient, home health, and hospice

bills with service.

A. MSPPAYAO Sending Data Elements

MSPPAY, or MSPPAYOL, when the claim is calculated to the line level, must send the

following data elements to MSPPAYAO:

NO. Field Name Definition/Use Source/Value

1 TEST SWITCH Indicator to turn on function

within the MSP software to

display sending and returning

data. Used to identify payment

problems.

T = display send/return data;

Space = do no display data.

2 THRU DATE Ending service date of the

period included on the bill

(CCYYMMDD)

THRU DATE CC

THRU DATE YY

THRU DATE MM

THRU DATE DD

Supplied by the A/B MAC (Part

A) system from the From-Through dates of the claim

Value = "19" thru "20"

Value = "00" thru "99"

Value = "01" thru "12"

Value = "01" thru "31"

3 RECORD ID Identifies the bill type. Outpatient = "HMOP"

Home health = "HMHH"

Hospice = "HMHC"

4 CLMNO Health Insurance Claim

Number (HICN)

Supplied by the A/B MAC (Part

A) system from the claim.

5 DOC CNTL

NUM

Assigned document control

number.

Assigned and supplied by the

A/B MAC (Part A) system.

NO. Field Name Definition/Use Source/Value

6 FULLY PAID

CLAIM IND

Indicator that reflects claim is

fully paid by the third party

payer.

Supplied by the A/B MAC (Part

A) system. Can be identified by

a "0" frequency indicator in

Type of Bill, or Condition Code

"77" on the claim.

MSPPAYO Values:

Y = Fully paid by other payer.

Space = Not fully paid by other

payer.

7 NUM OF OTHER

PAYERS

The number of other payers

who are primary to Medicare.

Supplied by the A/B MAC (Part

A) system. Values = "01" thru

"10"

8 THIRD PARTY

PAYER TABLE

MSP AMOUNT

MSP code(s) and MSP amount

comprise third party data.

MSP CODE - Code(s)

identifying the other payer:

12 = EGHP (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)

Amount(s) paid by the other

payer.

Supplied by the A/B MAC (Part

A) system from claim Value

Codes 12-16 and 41-47. May

occur up to 10 times.

.

NO. Field Name Definition/Use Source/Value

9 TOTAL

COVERED

CHARGES

Total charges covered by

Medicare. Code(s), MSP

amount(s), and the total

covered charges on the bill.

Claim Value Code Amounts

10 OBLIGATED TO

ACCEPT

Amount the provider agrees to

accept as payment in full,

when this amount is less than

charges but higher than the

payment received from the

primary payer. This field only

needs to be completed when a

value code "44," or CAS group

code CO amount, appears on

the bill. It is reported in

addition to the MSP amount(s),

and the total covered charges

on the bill.

11 FILLER Eighteen value spaces

12 MED PAYMENT

AMOUNT

Medicare payment without

regard to deductibles and

coinsurance.

Computed and supplied by the

A/B MAC (Part A) system.

13 BLOOD

DEDUCTION

Dollar amount of blood

deductible charged by

Medicare

Claim Value Code 06 Amount

14 CASH

DEDUCTION

Dollar amount of deductible

charged by Medicare.

Claim Value Code 07 Amount

15 FILLER Sixty-eight value spaces

16 TOTAL COIN

AMT

The total coinsurance amount

chargeable to the beneficiary.

Computed and supplied by the

A/B MAC (Part A) system.

17 FILLER Six value spaces

18 FILLER Twenty-nine value spaces

19 MED PRIMARY

PAYMENT

The Medicare reimbursement

amount less applicable

deductible and coinsurance.

Computed and supplied by the

A/B MAC (Part A) system.

20 PROVIDER

PAYMENT AMT

The Medicare reimbursement

amount to be paid to the

provider.

Computed and supplied by the

A/B MAC (Part A) system.

21 PATIENT

PAYMENT AMT

The Medicare reimbursement

amount to be paid to the

patient.

Computed and supplied by the

A/B MAC (Part A) system.

22 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

A) system.

NO. Field Name Definition/Use Source/Value

23 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 A) system.

24 CHARGES SD

(CHARGES

SUBJECT TO

DEDUCTIBLE)

Charge amount subject to the

deductible.

Computed and supplied by the

A/B MAC (Part A) system.

25 FILLER Nine value spaces.

26 RESERVED FOR

CMS

Space reserved for future

enhancements.

One hundred ninety-eight value

spaces.

27 RESERVED FOR

USER

Space reserved for user as

necessary.

One-hundred ninety value

spaces.

28 PPS IND An indicator that identifies a

prospective payment

computation

"P" = PPS

Spaces = Non-PPS

B. MSPPAYAO Returning Data Elements

MSPPAYAO will return the following data elements to MSPPAYOL when the claim is

calculated to the line level for outpatient claims. Refer to §50.2.7.B for field definitions not

reflected below.

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 MSPPAYAO.

Valid values "3000" thru

"3999"

(See §50.2.3 above; also refer

to the technical and user

documentation released with

the software.)

2 BLOOD

DEDUCTION TO

CWF

Amount of blood deductible

to report to the Common

Working File (CWF).

Unless otherwise specified,

MSPPAY is the source of all

the following, possibly

modified by MSPPAYAI.

3 CASH DEDUCTION

TO CWF

Dollar amount of deductible

to report to the Common

Working File (CWF)

4 FILLER Seventy-seven value spaces.

5 TOTAL COIN AMT

TO CWF

The total coinsurance amount

to report to the Common

Working File

No. Field Name Definition/Use Source/Value

6 FILLER Nine Value Spaces

7 MED SECONDARY

PAYMENT

Medicare's secondary

payment computed by the

MSP software.

8 PROVIDER

PAYMENT AMT

9 PATIENT

PAYMENT AMT

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 FILLER Three value spaces.

14 G-R-H (GRAMM-RUDMANN-HOLLINGS)

SAVINGS

REDUCTION

(Gramm-Rudmann-Hollings)

The amount of the MSP

savings reduced for Gramm-Rudmann-Hollings.

15 GROSS MEDICARE

PAYMENT (H)

The amount Medicare pays

excluding deductibles and

coinsurance.

16 NON-EGHP PYMT

SDC

The amount paid by a non-EGHP to be reflected on the

PS&R. The primary payer

amount designated to lab

charges reimbursed by 100%

is not reflected in this figure.

(This field is only returned

for claims with services

"thru-dates" prior to

11/13/89)

No. Field Name Definition/Use Source/Value

17 MSP PYMT SDC The amount excluding "MSP

CASH DEDUCTIBLE, MSP

BLOOD DEDUCTIBLE,

AND MSP TOTAL

COINSURANCE

AMOUNT" paid by an

EGHP or LGHP to be

reflected on the PS&R

report. This amount when

added to the "MSP CASH

DEDUCTIBLE, MSP

BLOOD DEDUCTIBLE,

and the MSP TOTAL

COINSURANCE

AMOUNT," reflects the total

primary payer amount. The

primary payer amount

designated to lab charges

reimbursed at 100% is not

reflected in this figure. (This

Field is only returned for

claims with service "thru-dates" prior to 11/13/89.)

18 PS&R AMOUNT The primary payer amount

used in the Provider

Statistical Report System.

19 FILLER Nine value spaces.

20 SAVINGS MSP

EGHP

Amount saved by Medicare

when a GHP has made a

payment for a working aged

beneficiary (MSP Code 12).

21 SAVINGS MSP

ESRD

Amount saved by Medicare

when a GHP has made a

payment for an ESRD

beneficiary (MSP Code 13).

22 SAVINGS MSP

AUTO

Amount saved by Medicare

when another insurer has

made payment in an

automobile/no-fault situation

(MSP Code 14).

23 SAVINGS MSP

WORK

Amount saved by Medicare

when workers' compensation

payment has been made

(MSP Code 15).

No. Field Name Definition/Use Source/Value

24 SAVINGS MSP

FEDS

Amount saved by Medicare

when PHS or other Federal

agency made payment (MSP

Code 16).

25 SAVINGS MSP BL Amount saved by Medicare

when Black Lung payment

has been dame by the

Department of Labor (MSP

Code 41).

26 SAVINGS MSP VA Amount saved by Medicare

when payment has been

made by the Department of

Veteran's Affairs (MSP

Code42).

27 SAVINGS MSP

DSAB

Amount saved by Medicare

when an LGHP has made a

payment for a disabled

beneficiary (MSP Code 43).

28 SAVINGS MSP

LIAB

Amount saved by Medicare

when payment has been

made by a liability insurer

(MSP Code 47).

29 SAVINGS TOTAL Total savings to the

Medicare program when

Medicare is the secondary

payer and a primary

payers(s) has made some

payment. Includes all MSP

codes 12-16, 41- 43 and 47.

30 SAVINGS NON-EGHP

Total savings to the

Medicare program for all

non-EGHP payments for a

Medicare beneficiary.

Includes MSP codes 14, 15,

16, 41 and 47. (This field is

only returned for claims with

service "thru-dates" prior to

11/13/89.

31 SAVINGS EGHP Total savings to the

Medicare program for all

EGHP payments for a

Medicare beneficiary.

Includes MSP codes 12, 13,

and 42. (This field is only

returned for claims with

No. Field Name Definition/Use Source/Value

service "thru-dates" prior to

11/13/89.)

32 MSP

COMPUTATION 1

The result of the gross

amount payable by Medicare

minus the amount paid by the

primary payer for covered

services.

33 MSP

COMPUTATION 2

The result of the gross

amount payable by Medicare

minus applicable deductible

and coinsurance amounts

34 MSP

COMPUTATION 3

The result of the provider

charges (or an amount the

provider is obligated to

accept as payment in full if

that is less than the charges),

minus the amount paid by the

primary payer

35 MSP

COMPUTATION 4

The result of the provider

charges (or an amount the

provider is obligated to

accept as payment in full, if

that is less than the charges),

minus applicable deductible

and coinsurance amounts

36 RESERVED FOR

CMS

Space reserved for future

enhancements. (200 value

spaces)

37 RESERVED FOR

USER

Space reserved for user as

needed. (153 value spaces)