CMS Pub. 100-05, ch. 6, § 30.3.1

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