MSP Inquiries and Solutions - JE Part A

Q1. What if a CARC code on the Primary Payer's Remittance Advice (RA) is not included in the list published on the Washington Publishing Company website?
A1. Providers must find the most appropriate corresponding code on the website. Noridian is unable to tell providers which CARC code to use.

Q2. A provider's claims are being returned with the Reason Code 33981. Why is this happening?
A2. See CMS Change Request (CR)6426. Business Requirement 6426.4.3.3 states that when the Contractual Obligation (CO) that is calculated by FISS based off the CARC codes amount does not match the Value Code (VC) 44 amount, the claim will be returned.

The example below will be returned with Reason Code 33981. The VC 44 is stating that the Obligated to Accept (OTAF) amount is $2,000.00. However, when the CO 45 (Provider discount) is subtracted from the billed amount, the amount is $1000.00. ($5000.00 $4000.00=$1000.00) The $1000.00 and $2000.00 do not match, therefore the claim will be returned.

Example: Working Aged Primary. Primary Insurance paid $2000.00 and the Obligated to Accept amount is $3000.00 (Provider write-off is $2000.00)
Information on Claim
Billed amount - $5,000.00
VC 12 - $1,000.00
VC 44 - $2,000.00
CARC CO 45 - $4,000.00

Q3. Are providers required to submit a claim to Medicare if the primary payer paid the claim in full?
A3. Providers are required to submit all inpatient claims and outpatient claims needed to satisfy the Part B deductible; however, in case future changes are required, we do recommend that all Part B services are submitted to avoid timely filing issues. The claims should be filed as covered claims but will be processed without payment.

Q4. If the primary payer makes no payment due to the reimbursement being included in the deductible and co-insurance, how should the provider bill the claim since the value code will contain $0.00?
A4. Use Occurrence Code 24 (date insurance denied) and the denial date.

Q5. What happens if a provider bills Medicare as primary but there is an open MSP record?
A5. The claim will not be paid.

Q6. If a patient is unavailable (deceased or otherwise), how does a provider get their primary payer information?
A6. Providers may contact family members/estate for the insurance information or can notify the BCRC and they will assist in the investigation.

Q7. What insurance information does a provider need to include on a Part A claim so it processes correctly?
A7. Include the name of other insurance, address of Primary Insurance, effective date of the Primary Insurance, policy number, and patient relationship

This can be on the claim or in the comment/remarks. Failure to include all of this information can result in delay of payment of the claim for several months because the Benefits Coordination & Recovery Center (BCRC) will send a letter to the beneficiary for the missing information and wait for the response. The claim cannot be paid until the case is put on the national record by the BCRC with all the necessary information.

Q8. When should a provider use Condition Code 08?
A8. Use Condition Code 08 only when the beneficiary does not provide the other Primary Insurance information. Be sure to include a comment on the claim.

Q9. What is the difference between a Value Code 43 and a 13?
A9. A 43 MSP Record is Disability and a 13 is End Stage Renal Disease (ESRD). The Correct MSP type must be billed or the claim will deny.

Q10. Why is a provider's claim being rejected for an open Non-Group Health Plan when the service is unrelated?
A10. The diagnosis code submitted on the claim is either matching or appears to be related to the open Non-GHP.