MSP stands for Medicare Secondary Payer. When another insurance is primary over Medicare, Medicare wants to know why. An MSP Reason is the way we transmit that information on an electronic claim.
NOTE: Not including the MSP Reason on a claim will cause secondary claims sent to Medicare to reject.
- To set or change an MSP Reason, you will need to go into the Patient Insurance Setup screen, and select the reason from the drop down menu. You will not be able to select an MSP reason until after Medicare has been saved as an insurance in the Patient Insurance Setup screen.
- There are nine valid, Medicare approved options for the MSP Reason:
MSP Insurance Type
MSP Provision
iSalus Terminology
12
Working Aged – Beneficiaries age 65 or older who are insured through their or their spouse’s current employment. Employer’s group plan has 20 or more employees.
Note: This type must only be used for beneficiaries who are 65 years old or older on the date the service was rendered.
Employer Group
13
End Stage Renal Disease (ESRD) – Beneficiaries enrolled with Medicare solely due to renal failure and are insured through their own, or through a family member’s former or current employment. Medicare is the secondary payer for the first 30 months from the beneficiary’s Medicare eligibility date.
Note: This type is not age specific.
ESRD
14
Automobile/No Fault – No-fault insurance that pays for medical expenses for injuries sustained on the property or premises of the insured, or in the use, occupancy, or operation of an automobile regardless of who may have been responsible for causing the accident.
No-Fault Insurance
15
Workers’ Compensation – Insurance that employers are required to provide to cover employees who become sick or are injured on the job.
Worker’s Compensation
16
Federal Agency (Public Health) – Services that are the direct obligation of another Federal, State or Local Governmental entity.
PHS or Other Fed. Agency
41
Black Lung – Coverage under the Federal Black Lung Program due to black lung disease and other respiratory conditions caused by coal mining in which a Medicare beneficiary may be entitled to have services reimbursed by the United States Department of Labor (DOL).
Black Lung
42
Veterans Administration – A federal program supervised and supported by the Department of Defense that provides medical coverage benefits for beneficiaries who were members of the Armed Forces. Veterans who are Medicare-eligible may elect whether Medicare or VA benefits will handle their claims.
Veteran’s Administration
43
Disability – Beneficiaries under age 65, who are disabled and insured through their current employment or through the current employment of a family member. Employer’s group plan has 100 or more employees.
Note: If the basis of disability is ESRD, the ESRD type should be used when billing Medicare. Also, the Disability type must only be used for beneficiaries who are under 65 years of age on the date the service was rendered.
Large Group Health Plan (LGHP)
47
Liability – Insurance (including a self-insurance plan) that provides payment based on the policyholder’s alleged legal liability for injury or illness or damage to property. It includes homeowner’s liability insurance, malpractice insurance, product liability and general casualty insurance and payments for medical damages made under the “wrongful death” statutes.
Other Liability Insurance
- If an MSP Reason is not selected, claims submitted where Medicare is the secondary payer will be rejected. This rejection detail will be visible in the View Submission History, or in the Messages and Monitoring section in the Claim Detail. The 837-5010 EDI claim format refers to the MSP as an Insurance Type Code, as seen in the rejection.
The NDC (National Drug Code) is a unique product identifier issued by the FDA for drugs intended for human use. Certain insurance companies require that when a drug is reported on a claim, the NDC information must also be attached to that claim.
However, on drug packaging, many NDCs are displayed in a 10-digit format but correct billing of an NDC requires 11-digits in a 5-4-2 format. Conversion from 10 digits to 11 digits requires the placement of an extra zero based on the 10-digit format.
The table below shows common 10-digit NDC formats and how to convert to an 11-digit format with the correct placement of a zero with the additional zero in a bold red.
Hyphens are used to show the formatting examples for NDCs. Do not use hyphens when entering data on your claim. iSALUS healthcare recommends that providers consult with their pharmacy staff or supplier regarding the conversion from 10 digits to 11 digits.
10-Digit Format on Package | 10-Digit Format | Example: 10-Digit NDC | 11-Digit Format | Example: 11-Digit Format w/ additional digit | Example: 11-Digit Conversion |
4-4-2 | 9999-9999-99 | 0002-7597-01 | 5-4-2 | 09999-9999-99 | 00002-7597-01 |
5-3-2 | 99999-999-99 | 50242-040-62 | 5-4-2 | 99999-0999-99 | 50242-0040-62 |
5-4-1 | 99999-9999-9 | 60575-4112-1 | 5-4-2 | 99999-9999-09 | 60575-4112-01 |
Place of Service (POS) Codes are two-digit codes placed on professional claims to specify the entity/setting where service(s) were rendered. In the Choice application, the POS code is assigned in the Service Location setup.
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| POS Code(s) | POS Name | POS Description |
| 1 | Pharmacy | A facility or location where drugs and other medically related items and services are sold, dispensed, or otherwise provided directly to patients. (Effective October 1, 2003) |
| 2 | Telehealth | The location where health services and health related services are provided or received, through a telecommunication system. (Effective January 1, 2017) |
| 3 | School | A facility whose primary purpose is education. (Effective January 1, 2003) |
| 4 | Homeless Shelter | A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters). (Effective January 1, 2003) |
| 5 | Indian Health Service Free-standing Facility | A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization. (Effective January 1, 2003) |
| 6 | Indian Health Service Provider-based Facility | A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients. (Effective January 1, 2003) |
| 7 | Tribal 638 Free-standing Facility | A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members who do not require hospitalization. (Effective January 1, 2003) |
| 8 | Tribal 638 Provider-based Facility | A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members admitted as inpatients or outpatients. (Effective January 1, 2003) |
| 9 | Prison/Correctional Facility | A prison, jail, reformatory, work farm, detention center, or any other similar facility maintained by either Federal, State or local authorities for the purpose of confinement or rehabilitation of adult or juvenile criminal offenders. (Effective July 1, 2006) |
| 10 | Telehealth Provided in Patient's Home | The location where health services and health related services are provided or received, through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology. (This code is effective January 1, 2022, and available to Medicare April 1, 2022.) |
| 11 | Office | Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis. |
| 12 | Home | Location, other than a hospital or other facility, where the patient receives care in a private residence. |
| 13 | Assisted Living Facility | Congregate residential facility with self-contained living units providing assessment of each resident's needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services. (Effective October 1, 2003) |
| 14 | Group Home | A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services (e.g., medication administration). (Effective October 1, 2003) |
| 15 | Mobile Unit | A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services. (Effective January 1, 2003) |
| 16 | Temporary Lodging | A short term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient receives care, and which is not identified by any other POS code. (Effective January 1, 2008) |
| 17 | Walk-in Retail Health Clinic | A walk-in health clinic, other than an office, urgent care facility, pharmacy or independent clinic and not described by any other Place of Service code, that is located within a retail operation and provides, on an ambulatory basis, preventive and primary care services. (This code is available for use immediately with a final effective date of May 1, 2010) |
| 18 | Place of Employment-Worksite | A location, not described by any other POS code, owned or operated by a public or private entity where the patient is employed, and where a health professional provides on-going or episodic occupational medical, therapeutic or rehabilitative services to the individual. (This code is available for use effective January 1, 2013 but no later than May 1, 2013) |
| 19 | Off Campus-Outpatient Hospital | A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. (Effective January 1, 2016) |
| 20 | Urgent Care Facility | Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention. (Effective January 1, 2003) |
| 21 | Inpatient Hospital | A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. |
| 22 | On Campus-Outpatient Hospital | A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. (Description change effective January 1, 2016) |
| 23 | Emergency Room – Hospital | A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided. |
| 24 | Ambulatory Surgical Center | A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis. |
| 25 | Birthing Center | A facility, other than a hospital's maternity facilities or a physician's office, which provides a setting for labor, delivery, and immediate post-partum care as well as immediate care of new born infants. |
| 26 | Military Treatment Facility | A medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF). |
| 27-30 | Unassigned | N/A |
| 31 | Skilled Nursing Facility | A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital. |
| 32 | Nursing Facility | A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than individuals with intellectual disabilities. |
| 33 | Custodial Care Facility | A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component. |
| 34 | Hospice | A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided. |
| 35-40 | Unassigned | N/A |
| 41 | Ambulance - Land | A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured. |
| 42 | Ambulance – Air or Water | An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured. |
| 43-48 | Unassigned | N/A |
| 49 | Independent Clinic | A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only. (Effective October 1, 2003) |
| 50 | Federally Qualified Health Center | A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician. |
| 51 | Inpatient Psychiatric Facility | A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician. |
| 52 | Psychiatric Facility-Partial Hospitalization | A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility. |
| 53 | Community Mental Health Center | A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC's mental health services area who have been discharged from inpatient treatment at a mental health facility; 24 hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission; and consultation and education services. |
| 54 | Intermediate Care Facility/ Individuals with Intellectual Disabilities | A facility which primarily provides health-related care and services above the level of custodial care to individuals but does not provide the level of care or treatment available in a hospital or SNF. |
| 55 | Residential Substance Abuse Treatment Facility | A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board. |
| 56 | Psychiatric Residential Treatment Center | A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment. |
| 57 | Non-residential Substance Abuse Treatment Facility | A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing. (Effective October 1, 2003) |
| 58 | Non-residential Opioid Treatment Facility | A location that provides treatment for opioid use disorder on an ambulatory basis. Services include methadone and other forms of Medication Assisted Treatment (MAT). (Effective January 1, 2020) |
| 59 | Unassigned | N/A |
| 60 | Mass Immunization Center | A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting. |
| 61 | Comprehensive Inpatient Rehabilitation Facility | A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services. |
| 62 | Comprehensive Outpatient Rehabilitation Facility | A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services. |
| 63-64 | Unassigned | N/A |
| 65 | End-Stage Renal Disease Treatment Facility | A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis. |
| 66-70 | Unassigned | N/A |
| 71 | Public Health Clinic | A facility maintained by either State or local health departments that provides ambulatory primary medical care under the general direction of a physician. |
| 72 | Rural Health Clinic | A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician. |
| 73-80 | Unassigned | N/A |
| 81 | Independent Laboratory | A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office. |
| 82-98 | Unassigned | N/A |
| 99 | Other Place of Service | Other place of service not identified above. |
Resources:
CMS Place of Service Code Set: https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set
Type of bill codes are three-digit codes located on an Institutional/Facility Claim that describe the type of bill a provider is submitting to a payer. In a Choice database, this information is stored in the Bill Code field in Service Location setup; only the first and second digits are used. Each digit has a specific purpose and is required on an Institutional/Facility Claim in order to be submitted to the payer.
First Digit = Type of Facility
Digit | Description |
| 1 | Hospital |
| 2 | Skilled Nursing Facility (SNF) |
| 3 | Home Health |
| 4 | Religious Nonmedical (Hospital) |
| 5 | Religious Nonmedical (Extended Care) - discontinued 10/01/2005 |
| 6 | Intermediate Care |
| 7 | Clinic or Hospital Based End Stage Renal Disease (ESRD) Facility - requires special second digit |
| 8 | Special facility or hospital (Critical Access Hospital (CAH)) (Ambulatory Surgical Center (ASC)) - requires special second digit |
| 9 | Reserved for National Assignment |
Second Digit = Type of Care
| Digit | Description |
| 1 |
|
| 2 |
|
| 3 |
|
| 4 |
|
| 5 |
|
| 6 |
|
| 7 |
|
| 8 |
|
| 9 |
|
Third Digit = Frequency (NOTE: This is set by default to 1 in the Choice application. There are ways to change it if necessary; please contact the Customer Success team for assistance.)
| Digit | Description |
| 0 | Nonpayment or Zero Claims |
| 1 | Admit through Discharge Claim |
| 2 | Interim (First Claim) |
| 3 | Interim (Continuing Claims) |
| 4 | Interim (Last Claim) |
| 5 | Late Charge Only |
| 7 | Replacement of Prior Claim -or- Corrected Claim |
| 8 | Void -or- Cancel of a Prior Claim |
| 9 | Final Claim for a Home Health PPS Episode |
Resources:
CMS Internet Only Manual (IOM), Publication 100-04, Chapter 25, Section 75.1
Type of Bill Code Structure, Noridian Healthcare Solutions
Type of Bill Codes for the UB-04 Claim Form, verywell health
