General

1. My claim was billed as Medicare primary, but it rejected indicating another insurance is primary. I verified in the common working file (CWF) that the patient's MSP file has been updated. What do I need to do to be paid for this claim?
2. Why is it that my MSP Cost Avoid adjustment claims do not process in 14 days like most of my initial claims do?

1. My claim was billed as Medicare primary, but it rejected indicating another insurance is primary. I verified in the common working file (CWF) that the patient's MSP file has been updated. What do I need to do to be paid for this claim?

   You should adjust your rejected claim and include the following information:

   • Condition code D9
     
   • Adjustment reason code OT
     
   • Remarks - 'Cost avoid resubmission, CWF updated, Medicare Primary'
     
   • Additionally, you will need to delete every line on page 2 and rekey all the charges as covered.  If you need assistance, please call the customer contact center for PA providers at 1-800-560-6170 and MD/DC providers call 1-866-488-0545.

   Date Posted: 04/25/2008

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2. Why is it that my MSP Cost Avoid adjustment claims do not process in 14 days like most of my initial claims do?

   An MSP Cost Avoid adjustment claim requires manual intervention because there is a condition code 'D9' on the claim.  Any time a provider uses a 'D9' condition code on an adjustment claim, it will suspend because a claims processor must manually verify what a provider is changing on the claim as well as all the appropriate information is included in the claim submission. It is imperative to use the most appropriate claim change condition code to indicate why the adjustment is being done. This may eliminate the need for manual intervention and allow your claim to process more quickly.  If you need additional assistance, please call the customer contact center for PA providers at 1-800-560-6170 and for MD/DC providers, call 1-866-488-0545.

   Date Posted: 04/25/2008

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