Diagnosis Driven MSP Claim Rejections

If a provider bills a claim to Medicare which contains a matching or similar diagnosis code to the beneficiary's open no-fault or liability Medicare Secondary Payer (MSP) file.

  1. Provider must research claim to determine if another insurance is primary to Medicare
  2. If it is unrelated to open file, provider may adjust claim in Direct Date Entry (DDE) or electronically and must include a comment within remarks which indicates claim is not related to open file. Comment example: Not related to open liability record. In addition to comment, explain type of record that is open
    • Documentation and medical records must also support that it is unrelated
  3. Noridian MSP department will review comments to determine appropriate claim processing

If a provider's remit contains the below Claim Adjustment Reason Codes (CARCs), it is always the responsibility of the primary insurance and facility comments will not be accepted.  

  • CARC 19
  • CARC 20
  • CARC 21

See CMS Change Request (CR)8984 for details on this guideline and the CARC codes.

If a provider adjusts a claim with dates of service older than one year, they must follow the Reopening request process and adjust the claim with a XXQ TOB. See the CMS Medicare Learning Network (MLN) Matters Special Edition (SE)1426 for guidelines.

Noridian will accept comments for the below codes.

34544 - CLAIM SUBMITTED AS MEDICARE PRIMARY AND A POSITIVE AUTO/NO FAULT RECORD EXISTS AT CWF. THE CONTRACTOR ID IS EQUAL TO '11122'. THE CLAIM SHOULD BE BILLED TO PRIMARY INSURER. SERVICE IS WITHIN THE 120 DAY PROMPTLY PERIOD.

34545 - CLAIM SUBMITTED AS MEDICARE PRIMARY AND A POSITIVE WORKERS' COMP RECORD EXISTS AT CWF. THE CLAIM SHOULD BE BILLED TO THE WORKER COMP CARRIER. THE ORIGINATING CONTRACTOR IS '11122'. SERVICE IS WITHIN THE 120 DAY PROMPTLY PERIOD.

34549 - CLAIM SUBMITTED AS MEDICARE PRIMARY AND A POSITIVE LIABILITY RECORD EXISTS AT CWF. THE CLAIM SHOULD BE BILLED TO PRIMARY INSURER. THE ORIGINATING CONTRACTOR IS '11122'. SERVICE IS WITHIN THE 120 DAY PROMPTLY PERIOD.

34009 - CLAIM SUBMITTED AS MEDICARE PRIMARY AND A POSITIVE AUTO/NO FAULT RECORD EXISTS AT CWF. THE CLAIM SHOULD BE BILLED TO PRIMARY INSURER. SERVICE IS WITHIN THE 120 DAY PROMPTLY PERIOD.

34010 - CLAIM SUBMITTED AS MEDICARE PRIMARY AND A POSITIVE AUTO/NO FAULT RECORD IS PRESENT ON THE MSP FILE; HOWEVER, NO INSURER INFORMATION IS AVAILABLE.

34013 - CLAIM SUBMITTED AS MEDICARE PRIMARY AND A POSITIVE WORKER'S COMP OR WORKER'S COMP SET-ASIDE RECORD EXISTS AT CWF. THE CLAIM SHOULD BE BILLED, TO WORKERS COMPENSATION. SERVICE IS WITHIN THE 120 DAY PROMPTLY PERIOD.

34014 - CLAIM SUBMITTED AS MEDICARE PRIMARY AND A POSITIVE WORKER'S COMPENSATION OR WORKER'S COMPENTSATION SET-ASIDE RECORD IS PRESENT ON THE MSP FILE; HOWEVER, NO INSURER INFORMATION IS AVAILABLE. MEDICARE CRITERIA INDICATES CLAIM SHOULD BE BILLED TO THE EMPLOYER GROUP HEALTH PLAN (EGHP).

34074 - CLAIM SUBMITTED AS MEDICARE PRIMARY AND A POSITIVE AUTO/NO FAULT RECORD EXISTS AT CWF. HOWEVER, AN OCCURRENCE CODE '05' EXISTS ON THE CLAIM AND THE OCCURRENCE DATE EQUALS THE MSP EFFECTIVE DATE.                

34075 - CLAIM SUBMITTED AS MEDICARE PRIMARY AND A POSITIVE WORKER'S COMP OR WORKER'S COMP SET-ASIDE RECORD EXISTS AT CWF. HOWEVER, AN OCCURRENCE CODE '04' IS PRESENT ON THE CLAIM AND THE SERVICE DATES ARE EQUAL TO OR GREATER THAN THE OCCURRENCE DATE.

34300 - CLAIM SUBMITTED AS MEDICARE PRIMARY AND A POSITIVE WORKERS' COMP RECORD EXISTS AT CWF. THE CLAIM SHOULD BE BILLED TO EMPLOYER GROUP HEALTH PLAN (EGHP). THE ORIGINATING CONTRACTOR IS '11110' SERVICE IS WITHIN THE 120 DAY PROMPTLY PERIOD.

34288 - CLAIM SUBMITTED AS MEDICARE PRIMARY AND A POSITIVE WORKERS' COMP RECORD EXISTS AT CWF. THE CLAIM SHOULD BE BILLED TO EMPLOYER GROUP HEALTH PLAN (EGHP). THE ORIGINATING CONTRACTOR IS '11109'. SERVICE IS WITHIN THE 120 DAY PROMPTLY PERIOD.

34312 - CLAIM SUBMITTED AS MEDICARE PRIMARY AND A POSITIVE WORKERS' COMP RECORD EXISTS AT CWF. THE CLAIM SHOULD BE BILLED TO EMPLOYER GROUP HEALTH PLAN (EGHP). THE ORIGINATING CONTRACTOR IS '11111'. SERVICE IS WITHIN THE 120 DAY PROMPTLY PERIOD.

34299 - CLAIM SUBMITTED AS MEDICARE PRIMARY AND A POSITIVE AUTO/NO FAULT RECORD EXISTS AT CWF. THE CLAIM SHOULD BE BILLED TO PRIMARY INSURER. THE ORIGINATING CONTRACTOR IS '11110'. SERVICE IS WITHIN THE 120 DAY PROMPTLY PERIOD.

34381 - CLAIM SUBMITTED AS MEDICARE PRIMARY AND A POSITIVE LIABILITY RECORD EXISTS AT CWF. THE CLAIM SHOULD BE BILLED TO PRIMARY INSURER. THE ORIGINATING CONTRACTOR IS '11141'.  SERVICE IS WITHIN THE 120 DAY PROMPTLY PERIOD.

 

Last Updated May 13, 2019