PC-ACE Pro32 Medicare as Secondary Payer (MSP)
Contents
1. Common Electronic Data Interchange MSP Claim Entry Claim Level If there is any line level information it should be submitted as described above However sometimes the information from the primary insurance only indicates payment information at the claim level When this happens the Billing Line Items MSP COB sub tab will not be used Instead additional information will be added to the Ext Payer Insured COB Info Primary sub tab The adjustment amounts for the entire claim will be added as well as the date the primary determined payment or non payment See below Professional Claim Form Patient Info General Insured Information Billing Line Items Est Patient General Ext Pat Gen 2 Est Payer Insured Primary Payer Insured Secondary Payer lnsured Tertiary Payer Insured COB Into Primary COE Info Secondary Common Payer MSP Information Additional Adjustment COB Amounts MOA Information AMNSI 837 Only OTAF 0 00 Claim Level Adjustments CAS COE r MOA Amounts Mum Code Amount Zer Payment Ind E ooo Do mo E m e amass no 2 on ___ _ ifs ii eoo Medicare Outpatient Adjudication MOA Remarks Codes EE eee eee Claim Adjudication Date 05 1 5 2010 Cancel CAUTION Do not enter adjustments at both claim and line level This will throw the claim out of balance and the claim will not be savable as a clean claim until one set of adjustments or the othe2. Patient ID National Government Services Last Revision July 24 2013 Page 11 of 13 A CMS Contracted Agent National Government Services Inc CEDIN Common Electronic Data Interchange Also on the Ext Payer Insured tab information will need to be added to the COB Info Primary sub tab COB MOA Amounts is where claim level values for what the primary paid and what the primary allowed will be entered Professional Claim Form Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Primary Payer lnsured Secondary Payer Insured Tertiary Payer Insured COB Info Secondary Common Payer MSP Information M Additional Adjustment COB Amounts 7 MOA Information ANSI 837 Only OTAF 0 00 Claim Level Adjustments CAS COB MOA Amounts Num Group Reason Amount Units Amount Zero Payment Ind 1 AE ooo El ajh D 00 o E a oi Medicare Outpatient Adjudication MOA Remarks Codes eee eee Claim Adjudication Date ame Code D is used for the primary paid amount Use the F2 key or right click option to bring up a list of codes Select D Payer paid amount See above for a completed COB Info Primary sub tab Once this tab is completed the claim should be ready to save National Government Services Last Revision July 24 2013 Page 12 of 13 A CMS Contracted Agent National Government Services Inc CEDIN
3. 20 left for the patient to pay The patient s responsibility may be displayed on the primary EOB or it can also be calculated For the example the allowed 3641 40 minus the paid 2 913 12 equals patient responsibility 728 28 The example presumes this patient responsibility is all in one type and is added as PR 2 and 728 28 CAUTION Be careful with what is entered in the claim adjustment or CAS section to explain the adjustments What is entered here can directly impact Medicare payment CEDI does not have any guidance for what to select for the reason codes It is also important to understand that if the primary paid nothing on this line then the adjustments will have to total the ENTIRE amount of the claim If the primary paid zero in our example the CAS entries for CO and PR would have to total 5 000 The final thing to enter on this sub tab is the date the primary determined payment or non payment on this charge line in the box for Adj Payment Date Return to the Line Item Details sub tab To enter a second charge line click in the second row under LN and enter the charge line Note that the other sub tabs change to display Line2 Professional Claim Form Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line Item Details Extended DetailsfLine 2 Ext Details 2 Line 2 Ext Details 3 Line 2 MSP COB Line
4. Amount Paid Units B U Line OTAF oo afp pekea I Ca 100 a Sii ee eee eee l En CT I eh x Line Adjustment CAS amp Miscellaneous Adjudication int for SVD 1 above SVD 1 above Procedure Code Description Line Level Adjustments CAS Num Group Reason Amount Units 1 fico 45 1358 60 0000 Adi Payment Date 05 15 2010 2 NFR e 728 28 f 0 000 Remaining Owed 000 3 m pad Save Cancel The Approved and the OTAF are no longer required and should be omitted Service Line Adjudication SVD Information Click in the line for SVD 1 You will only enter information on the SVD 1 line In this area each SVD represents payment by a different insurance NOT information for different charge lines P S Enter P to indicate payment information in this row is for the primary insurance Proc Qual Enter HC for all HCPCS codes Code Enter the HCPCS code from the charge line Enter Modifiers if entered on the charge line Paid Amount Enter what the primary insurance actually paid for this charge line Verify that the Line Adjustment CAS amp Miscellaneous Adjudication Info reads for SVD 1 above This should always state for SVD1 even when entering multiple charge lines as they will go on separate tabs Line Level Adjustments CAS This is where the difference between the item s total cost and what was actually paid by the primary is explained There is a lot of variation in what will be entered
5. Pfr SortBy PayerID Payer Description PayerLOB Payer State List Filter Options Show all payers no filter applied C Filter list to include Payer IDs starting with Filter list to include Payer Names starting with View Update Copy Delete This will produce the Payer Information screen Payer Information Screen Payer Information Paver ID LOE Receiver ID 15408 Override PON CoM Full Description ACME INSURANCE Address amp Contact Information Flags Address Source E 1 EST TO Media City State ip Usage H INDIANAPOLIS IN 46250 Contact Name Phone PrintLink Matching Descriptions Note Only the fields entered in the example above should be filled in National Government Services Last Revision July 24 2013 Page 2 of 13 A CMS Contracted Agent National Government Services Inc INA Common Electronic Data Interchange Payer ID This is a five character identification number used to identify the payer or insurance company in electronic transactions This field is required but the primary insurance may not have a Payer ID The field has to have a unique entry for every insurance company entered into PC ACE Pro32 It is recommended that the real Payer ID be obtained if possible from the primary insurance If it is not possible to obtain that ID enter the payer ID for the first insurance as XX XXX with subsequent insurances entered as XXXX1 XXX X2
6. Phys Q emano eano fr e ff a 0 EEEN TEEN ee ERE EEEN E E bier t tt bit B i i ff jf i ___jf j j Jj os _f _jf ff fj i __ j iii wi a _f _j ff jf f jf i i ii Sal 28 Total Charge 0 00 Recalculate 29 Amount Paid 0 00 30 Balance Due Save Cancel Diagnosis Code The diagnosis code will be entered without the decimal The example uses diagnosis code 344 9 but it is entered as 3449 for example Box 24b This is the Place of Service The example uses 12 for Home but the proper place of service for the patient should be selected Box 24e This is a pointer telling the claim to look at the row of diagnosis codes and use the one in the box indicated for this charge line Since there is one diagnosis code in the example is entered If two are listed in the row of diagnosis codes valid entries in box 24e would be 1 2 or 12 Box 24f This is for the total charges of the line item This is not to be adjusted based on what the primary insurance did with the claim It is the original item charge Thus in the example above the item is billed originally as a 5 000 item Box 24h This may be used if there is a Certificate of Medical Necessity CMN or the supplier signed DME MAC Information Form DIF for this charge line Enter a C in the box under Nationa Government Services Last Revision July 24 2013 Page 7 of 13 A CMS Contracted Agent National Government
7. etc These values are not important in the Medicare processing system but are required in the electronic claims format Instead the name of the primary insurance is used by the payment systems to confirm that it went to the correct primary LOB This is the abbreviation for Line of Business It identifies what type of insurance company the primary was and will most likely be COM for commercial or BS for Blue Shield Full Description This is the name of the primary insurance and it is used to confirm the claim was submitted to the correct primary insurance in the Medicare payment systems The address should be entered for the primary insurance after the Full Description Flags These control how the software makes use of the payer entry Source This is also used to identify the type of insurance and will most likely be CI for commercial insurance or BL for Blue Cross Blue Shield Right click on this field to be sure that the correct entry is being selected Media This is used to determine how this insurance will be used for claim billing Use the F2 look up feature to select E for electronic or P for paper Usage This controls when the insurance will be displayed as an option during the entry of patient information Select H to limit the payer to Professional claims only Once the insurance is loaded click the Save button and close Reference File Maintenance Patient Selection and Setup Open the Professional Cl
8. here and the primary EOB may not supply exactly what is needed In this example for instance there are two adjustments There may be one or there may be more than two Take a look at the primary EOB and search for every reason why the primary marked down their reimbursement amount to get to what they paid In this example the item cost 5 000 but the primary insurance paid 2 913 12 This leaves 2 086 88 unaccounted for The first adjustment is probably a CO or contractual obligation adjustment that explains the amount that was written off as being not approved or disallowed or ineligible Right click in the Group and Reason boxes to find a list of valid entries Find a Reason that best describes the reason the amount was not allowed Be aware that these codes can have end dates and only select codes that are still active For the example 45 is selected to Q National Government Services Last Revision July 24 2013 Page 9 of 13 A CMS Contracted Agent National Government Services Inc INA Common Electronic Data Interchange explain the disallowed amount This amount may or may not be listed on the primary EOB but it can be calculated by taking the item s full cost and subtracting the allowed amount This example s equation for this line is 5 000 3641 40 1 358 60 CO 45 and 1358 60 are entered Next the example has the primary insurance paying 80 of what was allowed with the remaining
9. 2 Diagnosis Codes 1 8 3449 ooo E mooo 24a Service Dates 24b 24c 24d 24d Modifiers 24e 24f 24g 24h 24 LN From Thru PS EMG Proc 1 2 Diagnosis Charges Units EPFP AT Rendering Phys 1 eama feao fra es fr sooo 10 feria yams Je eee yp a i ff ff fj jf i i a _fv _f ff ff fj i i s l J J J J og a _ _f jf if f fj tf __f jfjjj_ jg 28 Total Charge 0 00 Recalculate 29 Amount Paid _ 0 00 30 Balance Due ___ Save Cancel E nationa Government Services Last Revision July 24 2013 Page 10 of 13 A CMS Contracted Agent National Government Services Inc CEDIN Common Electronic Data Interchange Follow the instructions above to enter the information for this charge line on all three of the required tabs Line Item Details Extended Details Line 2 MSP COB Line 2 Be sure to enter all information on the SVD 1 line for all charge lines you enter Repeat as needed for any additional charge lines When all charge lines are entered complete with Ordering Provider and MSP COB information on each line return to the Line Item Details sub tab to enter any patient paid amount leave Amount Paid as 0 00 if the patient did not pay on this claim and click on the Recalculate button See below Professional Claim Form Patient Info amp General Insured Information Biling Line Items Ext Patient General Ext Pat Gen 2 Ext
10. National Government Services Inc INA Common Electronic Data Interchange PC ACE Pro32 Medicare as Secondary Payer MSP This document is meant to assist in setting up and building a Medicare as Secondary Payer claim This document includes Payers Saee SOU Dipset secstacs pe ratuteetahoes voce dasesatices E 2 Payer Iniormaton Sorocii seernes EEE ones 2 Patent oclechion and So eseese eer r EE e a 3 Setting up the Patient s Insurance Information cccccccsnsssssseessssseeeeeeeeeeeeees 4 IVA SPC Va iii Wy TS ECV ea eign ato cee de aiseciot cus E 6 MSP Claim Entry Claim Level cccccccsssssseccccccecaeeseeeeccceeeseeeeeseeeeeeeeeeeaeesees ees 13 This document is intended as a help guide for setting up a Medicare as Secondary Payer MSP claim in the PC ACE Pro32 software It is not intended to replace the general help accessible by the F1 key or specific item help accessible by right clicking or selecting the F2 key on a specific item functions or the PC ACE Pro32 User Manual itself For help with any questions not covered here please consult these documents In addition the CEDI technical support staff is not trained in billing The information in this document is accurate to the best of our knowledge but there may be specifics required for billing that we are unaware of If you have questions on how to bill MSP claims contact the jurisdiction that will be processing the claims for payment PC ACE Pro32 was designe
11. Payer Insured Line Item Details Extended Details Line 3 Ext Details 2 Line 3 Ext Details 3 Line 3 MSP COB Line 3 Diagnosis Codes 1 8 04521 f oOo ooo TOS rr rd 24a Service Dates 24b 24c 24d 24d Modifiers 24e 24f 24g 24h 24j LN From Thru PS EMG Proc 1 2 Diagnosis Charges Unts EPFP AT Rendering Phys 1 oroas as fre ea fr sooo ro Pf 2 foros farmeivanes e 1 sear 0 Pps a ormas ornas fre feos ft er 0 PP to pep lit ey ees A EEE a E N a l N 28 Total Charge 5599 06 Recalculate 29 Amount Paid 30 Balance Due 5599 06 Save Cancel Once the Recalculate button has been clicked go to the Ext Payer Insured tab and select the Secondary Payer Insured sub tab Right click in the Insurance Type box to select the reason why Medicare is the second payer These values are all numeric and are listed first Insurance Type 47 has been selected in the example below Professional Claim Form Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Primary Payer Insured Secondary Payer Insured Tertiary Payer Insured COB Info Primary COB Info Secondary Miscellaneous Secondary Payer Insured Information Payer Address Payer Insured Reference IDs Types City St Zip Payer Source MB Insurance Type 47 Insured s Contact
12. Services Inc CEDIN Common Electronic Data Interchange column AT to have the CMN tab added to the row of sub tabs CMN entry will not be covered further in this document Once the information for Line 1 is entered and with the cursor still flashing in the first charge line click on the Extended Details Line 1 sub tab This tab is where any third or fourth modifiers would be added More importantly on every charge line for Medicare DME the Ordering Provider must be selected Right click in the Ordering Provider name field to bring up the Physician Setup screen Here you can either select a previously entered Ordering Provider or add a new Ordering Provider by selecting New in the bottom left corner Use the Select option to add the Ordering Provider to the claim When finished it should look like this the entry area for the modifiers is indicated as well although it is not used in this example Professional Claim Form Patient Info amp General Insured Information Biling Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line ltem Details Extended Details Line 1 Ext Details 2 Line 1 Ext Details 3 Line 1 MSP COB Line 1 Miscellaneous Extended Details 24d Modifiers 3 amp 4 Hospice Employed E Purch Charges _ 0 00 Sales Tax Anesthesia Other Minutes ___0 Co Pay Status Initial Treatment _ _ Postage Claim Units Type Code Purchased Services E Shipp
13. aims Processing menu and select List Claims to enter the claim management area Click on the New button in the lower left corner to enter a new claim This will pop up a blank Professional Claim Form Right click in either Patient Control Number or Patient Name to bring up the Patient Selection screen If the patient is listed already highlight them click on the Select button and proceed to Claim Entry If the patient is not listed click on the New button in the lower left corner to bring up the Patient Information tabs The General Information tab will be filled in the same as it would be for a Medicare Primary claim The Primary Insured Prof tab will be the information for the primary or non Medicare insurance The following is an example of what the information may look like National Government Services Last Revision July 24 2013 Page 3 of 13 ACMS Contracted Agent National Government Services Inc CEDIN Common Electronic Data Interchange Setting up the Patient s Insurance Information Patient Information General Information Extended Info Primary Insured Inet Primary Insured Prof Secondary Insured 4 Paver ID Paver Name LOB DOK MIDWEST SECURITY INSURANCE COM Group Hame Group Number Claim Office TEST GROUP INC Mlooo0d Clear All Fields For Insured Insured Information F7 Employer Information F8 Rel Las
14. atient has authorized payment to the provider WY National Government Services Last Revision July 24 2013 Page 4 of 13 A CMS Contracted Agent National Government Services Inc CEDIN Common Electronic Data Interchange Now go to the Secondary Insured tab It should look like this Patient Information General Information Extended Info Primary Insured Inst Primary Insured Prof Secondary Insured aie Payer ID Payer Name Insured Information Options f Common Inst amp Prof Group Name Group Number Claim Office f Separate Inst amp Prof Clear All Fields For Insured Rel Last Name First Name MI Gen Insured ID B ee eee Address Sex Assign of Benefits DOB j_ _ Release of Info a City Zip Employ Status i ROI Date f2 County Phone Insured Information F7 Employer Information F8 Retire Date of 2 This tab needs to be separated into two tabs one for Institutional and one for Professional Click in the radio button for Separate Inst amp Prof in the upper right corner of this screen to do this The screen should now look like this Patient Information Primary Insured Inst Primary Insured Prof Secondary Insured Inst Secondary Insured Prof Tettic Payer Name LOB Group Name Group Number Claim Office Clear All Fields For Insured Insured Information F7 Employer Information F8 Last Name First Name MI Gen Ins
15. ax ID fior 111119 SSN EIN JE 27 Provider Accepts Assignment a PIN No 31 Provider SOF v Date o 01720093 Facility Dental coea Frequency a 33 GRP No Save Cancel Proceed to the Billing Line Items tab where the Line Item Details sub tab will be displayed The Line Item Details sub tab is where the diagnosis code s and charge line s National Government Services Last Revision July 24 2013 Page 6 of 13 A CMS Contracted Agent National Government Services Inc INA Common Electronic Data Interchange will be entered This example will demonstrate how to enter an MSP claim with three charge lines Please keep in mind that CEDI does not handle questions related to medical policy or coding and the example s use of a diagnosis code and procedure codes without modifiers 1s not intended to demonstrate a payable claim This is merely to illustrate how to enter the information in the software Enter the diagnosis code and first charge line information to get something like this Professional Claim Form Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line Item Detail Extended Details Line 1 Ext Details 2 Line 1 Ext Details 3 Line 1 MSP COB Line 1 24a Service Dates 24b 24c 24d 24d Modifiers 24e 24f 24g 24h 24 LN From Thru PS EMG Proc 1 2 Diagnosis Charges Units EPFP AT Rendering
16. d for both Institutional Medicare Part A or hospital and Professional Medicare Part B or office visits and Durable Medical Equipment or DME billing Since this is a DME support document we will not be covering Medicare Part A or Part B functions If you have any questions please contact the CEDI Help Desk at ngs cedihelpdesk wellpoint com or at 866 311 9184 National Government Services Last Revision July 24 2013 Page 1 of 13 ACMS Contracted Agent National Government Services Inc CEDIN Common Electronic Data Interchange Payers Insurance Setup When entering a Medicare as Secondary Payer MSP claim in PC ACE Pro32 the first step is to verify that the primary insurance is loaded into the software To check this go to Reference File Maintenance and the Payer tab The insurance should be listed with the Usage set to Prof Only If the primary is already on the list you can proceed directly to Patient Selection If it is not on the list the primary insurance will have to be added Select the New button in the lower left igi Reference File Maintenance File View Reports Patient Payer Provider Inst Provider Prof Codes Misc DME MAC JURISDICTION C Prof Only DME MAC JURISDICTION D Prof Only COM AMERICAN INCOME LIFE INSURANCE COMPANY Prof Only COM ROADRUNNER COVERAGE AL Prof Only COM MIDWEST SECURITY INSURANCE CO wil Prof Only BS ACMEINSURANCE IN
17. ed The Professional Claim Form will be displayed again this time with the patient s data in it MSP Claim Entry Line Level Once the patient is selected there are two more fields that must be entered on the Patient Info amp General tab They are Patient Condition Related To Employment and COB The COB field will be entered as Y in order to turn on the MSP tabs elsewhere in the claim form These two fields are indicated and entered in the example below Professional Claim Form Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured LOB MCB Biling Provider fi 111111111 26 Patient Control No D5555 8 Pat Status Death 12 Legal NPI 2 Patient Last Name First Name Ml Gen 3 Bithdate Sex MS ES SS Ind SOF Rep Exempt DOE JOHN if mma Mf T EN f 5 Patient Address 1 Patient Address 2 Patient City State Patient Zip County Patient Phone 1234 MAIN STREET ANY TOWN IN 12345 866 311 9184 10 Patient Condition Related To ROI ROlDate Otherlns 14 Date Ind of Current 15 First Date 16 UTW Disability Dates amp Type Employment Accident fy 0017203 fo 2 if Eze Eee i 17 Referring Phys Name Last Org First Mid Suffix Feferring Phys IDs Types 18 Hospitalization Dates 20 Outside Lab Chgs rf Pa wf af ooo 19 Reserved For Local Use 22 Medicaid Resubmission Code amp Ref No a 25 Fed T
18. ed Date 2 Line Level Supporting Provider Information Last Org Name First Name Ml Suffix Provider IDs 7 Types Payer IDs Rendering Purch Service PO fe ma fp fo x Supervising a pO iz P00 hi x Referring o C o fo x oo E A n a a Asst Surgeon Pe pO BE fl fp fC x Save Cancel Note If a narrative is required for this charge line enter it on the Ext Details 3 Line 1 sub tab Instructions on narrative entry are not included with this document The MSP COB Line 1 sub tab is where information from the primary insurance s explanation of benefits EOB will be entered Depending on how the primary EOB lists information the values may be listed or may need to be calculated so having a calculator nearby may come in handy nationa Government Services Last Revision July 24 2013 Page 8 of 13 A CMS Contracted Agent National Government Services Inc CEDIN Common Electronic Data Interchange Here is a completed sub tab Professional Claim Form Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line Item Details Extended Details Line 1 Ext Details 2 Line 1 Ext Details 3 Line 1 MSP COB Line 1 Common Line MSP Amounts Additional Line level Adjudication COB Information ANSI 837 Use Only Approved 0 00 Service Line Adjudication SYD Information SYD P S Proc Qual Code Modifiers 1 thru 4 Paid
19. r is removed E Nationa Government Services Last Revision July 24 2013 Page 13 of 13 A CMS Contracted Agent
20. t Name First Mame MI Gen Insured ID Address 1234 CHERRY TREE LN De M Assign of Benefits Y CO B hA Release of Info a au eee Employ Status 9 ROIDae _ _ MELVIN Ml 48454 i Ee County Phone Retire Date _ _of_ o JO Save Cancel Right click in the Payer ID field to select the primary insurance This should fill in the Payer Name and LOB fields based on what was entered in the Payer tab of Reference File Maintenance Group Name and Group Number should be entered based on what is present on the patient s ID card for the primary insurance If these fields are not on the card they may be left blank Insured Information The Rel field should be selected by right clicking on the box and selecting the appropriate code for the patient s relationship to the actual policyholder Thus if the primary insurance is under the spouse s name 01 would be selected as an example The required fields above will need to be entered for the policyholder If 18 for Self is selected the name address information and other general information fields will automatically populate from the General Information tab Two of the fields will not fill in automatically even if 18 Self is selected These will need to be entered manually Insured ID This is the identification number used by the primary insurance to identify the patient Assign of Benefits This indicates whether or not the p
21. ured ID Address ET Sex a Assign of Benefits 0B ZZ Release of Info E City State Zip Employ Status E ROI Date 2 County Phone O Retire Date 4 Save Cancel This will be where the Medicare information 1s entered The same four areas entered for a typical Medicare as Primary patient are entered here Payer ID Rel Insured ID and Assign of Benefits When these are entered it should look more like this National Government Services Last Revision July 24 2013 Page 5 of 13 ACMS Contracted Agent National Government Services Inc CEDIN Common Electronic Data Interchange Patient Information Frimary Insured lnt Primary Insured Frot Secondary Insured Inst Secondary Insured Prat Terti 4 Payer ID Payer Hame LOE 17003 DME MAC JURISDICTION E MCB Group Name Group Number Claim Office Clear All Fields For Insured Insured Information F7 Employer Information F8 Rel Last Mame First Name MI Gen Insured ID fig DOE JOHN E s990000004 Address 1234 MAIN STREET SER M Assign of Benefits Y ooo oB 10T4IS0T Release of Info v City State Zip Employ Status ROIDate 01 01 2009 ANY TOWN IN 12345 Retire Date _ County Phone 66 311 9184 Save Cancel Click the Save button to save the patient record This will return the display to the Patient Selection screen where the Select button is used to choose the patient that was just enter
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