Medicare Claim, but MSP denial

If your Medicare claim rejects (R status) due to MSP, and your HH episode is not related to the beneficiary’s primary insurance, i.e. Work Comp, you can adjust the claim for resubmission.  There are 5 things you must do, while adjusting the claim in DDE.

1.      Use the correct condition code to show Medicare is primary.

2.      Use Adjustment Code OT

3.      Delete and rekey all line items

4.      Make a statement under REMARKS screen, i.e. “Medicare not related to Work Comp”

5.      Make sure the diagnosis on the claim is not a diagnosis that the primary insurance would reimburse.

After all changes have been made, press F9 to update claim.  If you have any issues in DDE, please contact CGS or Palmetto for assistance.

For detailed instructions on how to use DDE, click here for the CGS DDE Provider Guide.  For Palmetto GBA users click here for the DDE Guide.