MSP Form Locators - JF Part A
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.
