MSP Required Form Locators

Form Locators Required for Billing MSP Claims

Description Payer Code Value Code Billed
Working Aged A 12
End Stage Renal Disease (ESRD) B 13
Conditional Payment C Appropriate Value Code for Primary Payer
No-Fault D 14
Workers Compensation E 15
Public Health or Federal Agency F 16
Disability G 43
Federal Black Lung Program H 41
Veteran Affairs I 42
Liability L 47

 

Note: When billing electronically the Payer Code is automatically entered by the system based on the value code the provider enter.

When Medicare is secondary to other payers, the following Form Locators must be completed for MSP claims.

Form Locator Description Value Codes Associated
31-34 Occurrence code for beginning date of coordination period for ESRD patients or date of accident 13,14,15,47 (only for liability claims)
39-41 a-d Bill appropriate value code and amount paid by other insurance.

Amount is actual amount paid by the insurance		 12,13,14,15,43,47
50a Report specific Payer Code and group insurance name 12,13,14,15,41,42,43
58a Name of individual who carries insurance 12,13,14,15,41,42,43
59a Patient relationship to insured 12,13,14,15,41,42,43
60a Insured Unique ID (Medicare number) 12,13,14,15,41,42,43
61a Insurance group name – Name of the group or plan through which that insurance is provided 12,13,14,15,41,42,43
62a Insurance group number 12,13,15,43
65a Name of the employer providing health benefits to the individual identified in FL58a 12,13,14,15,41,42,43
80 Remarks – Additional information 12,13,14,15,41,42,43

 

Providers must include Claim Adjustment Segments (CAS) related group codes, Claim Adjustment Reason Codes (CARC) and associated adjustment amounts on MSP 837 claims sent to Medicare for processing. This includes all adjustments made by the primary payer, which explains why the claim's billed amount was not fully paid.

If the primary payer denied the service(s), submit the appropriate CARC to explain the reason for the denial. Certain CARC combinations cannot be processed by Medicare and may result in a denial due to insufficient explanation or conflicting information. Claims denied for these reasons must be resubmitted with the correct CARC codes. Do not include CARC codes that are not applicable to the claim. A full set of CARC codes is available.

Note: Noridian cannot inform providers the correct CARC code to use.

 

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