Reason Code Narrative

THIS RECORD CONTAINS NO MSP AND AN MSP AUXILIARY RECORD EXISTS AT THE HOST. A COMPARE OF THE 03 TRAILER HAS BEEN COMPLETED AND THE FIRST OCCURRENCE WITH A 'Y' OR 'I' VALIDITY AND THE CLAIM DATES OF SERVICE ARE WITHIN THIS PAYER'S EFFECTIVE AND TERMINATION DATES.

Common Reason Code Errors

• Claims are billed Medicare primary; however, an open Liability file exists in CWF.

Common Reason Code Corrections

• Collect primary insurer information from beneficiary and resubmit claim electronically, with correct primary payer information and Medicare as secondary payer.
  • Reflect Liability payments with value code 47
  • The applicable occurrence code with date of accident or injury
    • 01 - Accident/Medical Coverage
    • 02 - No-Fault Insurance Involved, including auto accident
    • 03 - Accident/TORT liability
• If claim is not related to open Liability file, resubmit claim including detailed remarks explaining that the claim is not related.
• If primary payer is denying payment on claim, resubmit claim including detailed remarks explaining why Liability insurance did not pay (benefits exhausted, no med pay, etc.).
  • Conditional billing requires
    • Occurrence code 24 with date of insurance denial
    • Medicare listed as secondary payer
    • Value code 47 with a $0.00 amount
    • Appropriate occurrence code
• If beneficiary will not provide primary insurance information, resubmit claim with a 08 condition code and a detailed remark explaining why beneficiary will not or cannot provide primary insurance information.

Resource

• CMS Internet Only Manual (IOM), Publication 100-05, Medicare Secondary Payer (MSP) Manual, Chapter 3, Section 30.2.1.2

View reason code list, return to Reason Code Guidance page.