Medicare Secondary Payer (MSP) Manual 
Chapter 6 - Medicare Secondary Payer (MSP)  
Common Working File (CWF) Process 
 
Table of Contents 
(Rev. 11996, 04-27-23) 
 
Transmittals for Chapter 6 
 
10 - General Information 
10.1 - Overview of CWF, MSP Processing 
10.2 - Definition of MSP/CWF Terms 
20 - MSP Maintenance Transaction Record Processing 
20.1 - Types of MSP Maintenance Transactions 
20.1.1 - MSP Add Transaction 
20.1.2 - MSP Change Transaction 
20.1.3 - MSP Delete Transaction 
20.1.4 - MSP Termination Date Transaction 
20.2 - MSP Maintenance Transaction Record A/B MAC and DME MAC  MSP 
Auxiliary File Update Responsibility 
30 - CWF, MSP Auxiliary File 
30.1 - Integrity of MSP Data 
30.1.1 -  MSP Effective Date Change Procedure 
30.1.2 - CWF/MSP Transaction Request for Contractor Assistance  
30.1.3 - CWF/MSP Transaction Request for Contractor Assistance 
30.2 - MSP Termination Date Procedure 
30.3 - MSP Auxiliary File Errors 
30.3.1 - Valid MSP Remarks Codes 
30.3.2 - Valid MSP Insurance Type Codes 
30.3.3 - Other Effective Date and Termination Date Coverage Edits 
30.3.4 - MSP Employee Information Data Code 
30.4 - Automatic Notice of Change to MSP Auxiliary File 
40 - MSP Claim Processing 
40.1 - CWF, MSP Claim Validation  40.2 - CWF Claim Matching Criteria Against MSP Records 
40.3 - Conditional Payment 
40.4 - Override Codes 
40.5 - MSP Cost Avoided Claims 
40.6 - Online Inquiry to MSP Data 
40.7 - MSP Purge Process 
40.8 - MSP Utilization Edits and Resolution for Claims Submitted to CWF 
40.9 - CWF MSP Reject for A Beneficiary Entitled to Medicare Part B Only and 
A GHP 
40.10  ICD-10 and ICD 9-CM Diagnosis Code Tables Involving Non-GHP MSP 
Claims  
40.10.1 - Certain Diagnosis Codes Not Allowed on NGHP MSP Records  
50 - Special CWF Processes 
50.1 - Extension of MSP-ESRD Coordination Period 
50.2 - MSP W Records and Accompanying Processes  
50.3 - MSP W Records and Accompanying Processes 
60  Converting Health Insurance Portability and Accountability Act (HIPAA) Individual 
Relationship Codes to Common Working File (CWF) Medicare Secondary Payer 
(MSP) Patient Relationship Codes  
   10 - General Information 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
A/B Medicare Administrative Contractors (MACs) (Part A), A/B MACs (Part B), or A/B 
MACs (Part HHH) (collectively referred to as A/B MACs) and Durable Medical 
Equipment MACs (DME MACs) obtain information pertinent to the identification of MSP 
for each beneficiary via the CWF, MSP auxiliary file. The auxiliary file is associated with 
the beneficiary's master record within CWF. 
 
The MSP Contractor completes MSP updates on a daily basis upon receipt of notice that 
another payer is primary to Medicare (e.g., an explanation of benefits, a beneficiary 
questionnaire, a notice from a third-party payer, Section 111 reporting, etc.). Every claim 
for a given beneficiary is validated against the same MSP data housed in a CWF, MSP 
auxiliary file, thus permitting uniform processing. Contractor claims data inconsistent 
with a CWF, MSP auxiliary file will cause rejects and/or error conditions. An MSP 
auxiliary record consistent with an identified MSP situation must be present before a 
payment is approved for an MSP claim. An MSP auxiliary record is established by an 
MSP maintenance transaction submitted to CWF. The claim must agree with the MSP 
auxiliary record that was established, or it will not process. 
 
The MSP Contractor is the source for establishing new MSP records, with the exception 
of four situations described in 10.1, below.  The MSP Contractor submits MSP 
maintenance transactions on the basis of information obtained outside the claims process. 
Examples include, voluntary MSP insurer data match agreements, MMSEA Section 111 
reporting, attorney, beneficiary, provider information, and 411.25 Notices. 
 
10.1 - Overview of CWF MSP Processing 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
The CWF MSP auxiliary file is updated with maintenance transactions from the MSP 
contractor responsible for coordination of benefits (formerly known as the Benefits 
Coordination & Recovery Center or Coordination of Benefits Contractor and hereafter 
termed the MSP contractor), except for the following situations: 
  1.   If the A/B Medicare Administrative Contractor (MAC) (Part A), A/B MAC 
(Part B), or A/B MAC (HHH) (collectively referred to as A/B MACs) or Durable 
Medical Equipment Medicare Administrative Contractor (DME MAC) receives a phone 
call or correspondence from an attorney/other beneficiary representative, beneficiary, 
third-party payer, provider, another insurers Explanation of Benefits (EOB) or other 
source that establishes, exclusive of any further required development or investigation, 
that MSP no longer applies, it must add termination dates to MSP auxiliary records 
already established by the MSP contractor with a "Y" validity indicator where there is no 
discrepancy in the validity of the information contained on CWF. (See 20.1.4) 
  2.   If the A/B MAC receives a claim for secondary benefits and could, without 
further development (for example, the EOB from another insurer or third-party payer 
contains all necessary data) add an MSP occurrence and pay the secondary claim, it 
submits a validity indicator of "I" to add any new MSP occurrences (only if no MSP  record with the same MSP type already exists on CWF with an effective date within 45 
days of the effective date of the incoming "I" record). An I record is to be added to the 
CWF within 10 calendar days when the claim is suspended for MSP (internal system or 
CWF, whichever suspends first) if no MSP record with the same MSP type already exists 
in CWF. It cannot submit a new record with a "Y" or any record with an "N" validity 
indicator.  Note: Effective October 1, 2021, DME MACs no longer submit I records 
and instead submit an Electronic Correspondence Referral System (ECRS) Inquiry to 
create an MSP record.    
  3.   If the A/B MAC receives a claim for conditional payment, and the claim 
contains sufficient information to create an "I" record without further development, it 
must add the MSP occurrence using an "I" validity indicator (only if no MSP record with 
the same MSP type already exists on CWF with an effective date within 45 calendar days 
of the effective date of the incoming "I" record). An I record is to be added to the CWF 
within 10 calendar days when the claim is suspended for MSP (internal system or CWF, 
whichever suspends first) if no MSP record with the same MSP type already exists in 
CWF.   
A/B MACs shall transmit "I" records to CWF via the current HUSP transaction. The 
CWF will treat the "I" validity indicator the same as a "Y" validity indicator when 
processing claims. "I" records should only be submitted to CWF if no MSP record with 
the same MSP type already exists on CWF with an effective date within 45 days of the 
effective date of the incoming "I" record. Therefore, "I" records submitted to CWF that 
fail these edit criteria will be rejected with an SP 20 error code.  Receipt of an "I" validity 
indicator will result in a CWF trigger to the MSP contractor. The MSP contractor will 
develop and confirm all "I" maintenance transactions established by the A/B MAC.  If 
the MSP contractor receives an affirmative confirmation of MSP through its development 
efforts within 45 calendar days, the MSP contractor will convert the I to a Y validity 
indicator. If the MSP contractor has not received confirmation of MSP through its 
development efforts within 45 calendar days, the MSP contractor will automatically 
delete the "I" validity indicator.  Also, if the MSP contractor develops and determines 
there is no MSP, the MSP contractor will delete the "I" record. An "I" record should 
never be established when the mandatory fields of information are not readily available to 
the A/B MAC on its claim attachment or unsolicited refund documentation. If the A/B 
MAC has the actual date that Medicare became secondary payer, it shall use that as the 
MSP effective date. If that information is not available, it shall use the Part A entitlement 
date as the MSP effective date. It may include a termination date when it initially 
establishes an "I" record. It may not add a termination date to an already established "I" 
record. 
Prior to April 1, 2002, the A/B MACs and DME MACs posted MSP records to CWF 
where beneficiaries were entitled to Part B benefits, but not entitled to Part A benefits.  
An MSP situation cannot exist when a beneficiary has GHP coverage (i.e., working aged, 
disability and ESRD) and is entitled to Part B only.  CWF edits to prevent the posting of 
these MSP records to CWF when there is no Part A entitlement date.  If an A/B MAC or 
DME MAC submits an Electronic Correspondence Referral System (ECRS) transaction 
to the MSP contractor to add a GHP MSP record where there is no Part A entitlement, the 
MSP contractor will return reason code of 61.  A/B MACs or DME MACs should not 
submit an ECRS request to the MSP contractor to establish a GHP MSP record when  there is no Part A entitlement. A/B MACs that attempt to establish an "I" record will 
receive a CWF error. 
The CWF will continue to allow the posting of MSP records where there is no Part A 
entitlement, but there is Part B entitlement, and where NGHP situations exist, such as 
automobile/No-Fault, liability, and workers' compensation.  Where a non-employer GHP 
situation exists, A/B MACs and DME MACs continue to submit ECRS transactions and 
establish "I" records, as necessary. Note: In the past A/B MACs and DME MACs have 
sent ECRS requests to the MSP contractor requesting that section 111 records be updated. 
The MSP contractor has rejected most of these requests based on CMS hierarchy of 
Section 111 entities taking precedence on updating contractor number 11121 and 11122 
MSP records. However, CMS has clarified that the MSP contractor shall accept MACs 
ECRS requests to update contractor number 11121 and 11122 MSP records based on 
conditions below. A/B MACs and DME MACs shall continue to submit ECRS requests 
to the MSP contractor for contractor numbers 11121 and 11122 for the following 
circumstances:  
  When the A/B MAC or DME MAC receives information indicating the Group 
number or policy number of the primary payer has changed,  
  When the A/B MAC or DME MAC learns of a retirement date for the beneficiary 
and a termination date must be added to the MSP record,  
  When the A/B MAC or DME MAC receives information indicating the Insurance 
Type A, J, or K has changed or conflicts with what is on the CWF MSP Auxiliary 
file, or 
  When an A/B MAC or DME MAC receives a primary payer EOB or remittance 
advice showing payment for a deleted or closed Section 111 GHP MSP record 
that should remain open. Note:  The MSP Contractor will not accept an NGHP 
record update request for this type of MSP claim situation. 
Please note it is to the discretion of the MSP Contractor to approve these Section 111 
ECRS requests upon review. Approval or denial of such ECRS requests shall be sent to 
the A/B MACs or DME MACs by the MSP Contractor. 
MSP Auxiliary maintenance transactions, for the four situations listed above, and claims 
for payment approval may be submitted to CWF in the same file. The CWF processes the 
MSP maintenance transactions before processing claims. This procedural flow is to 
assure processing for claim validation against the most current MSP data. If the MSP 
claim is accepted, the CWF host will return all MSP data on a beneficiary's auxiliary file 
to the submitting contractor via an "03" trailer. If the claim is rejected, the host will return 
only those MSP records that fall within the dates of service on the claim. A maximum of 
17 MSP auxiliary records may be stored in CWF for each beneficiary (see 30 below). 
The validity indicator field of each CWF MSP auxiliary record indicates confirmation 
that: 
Another insurer is responsible for payment ("Y" in the field); A/B MACs and DME 
MACs may access the MSP auxiliary file through the online CWF file display utility 
Health Insurance Master Record (HIMR). 
A/B MACs and DME MACs cannot delete MSP auxiliary records.  They send such 
requests to the MSP contractor via ECRS.  (See Pub. 100-05, Chapter 5, 10.) 
 
  10.2 - Definition of MSP/CWF Terms 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
Following is a list of terms and their definitions used in MSP/CWF processing. 
 
MSP Auxiliary File - Up to 17 beneficiary MSP occurrences/records on the CWF 
database.  
 
MSP Auxiliary Record - Record of beneficiary MSP information. One MSP 
record/occurrence within the beneficiary's MSP auxiliary file.  
 
Occurrence - One MSP occurrence/record within the beneficiary's MSP auxiliary file. 
 
MSP Effective Date - Effective date of MSP coverage. 
 
MSP Termination Date - Termination date of MSP coverage. 
 
Validity Indicator 
 
  Y - Beneficiary has MSP coverage (there is a primary insurer for this period of 
time). 
  N - No MSP coverage (the N validity indicator is no longer used, but will be seen 
on older MSP CWF records) 
  I - See 10.1.  
  D  Deleted MSP Record 
 
MSP Types - Reason for other coverage entitlement.  
 
  A = Working Aged 
  B = End stage renal disease (ESRD) 
  D = Automobile/Liability No-Fault 
  E = Workers' Compensation (WC) 
  F = Federal, Public Health (note:  currently not used) 
  G = Disabled 
  H = Black Lung (BL) 
  L=Liability 
  W=Workers Compensation Medicare Set-Aside Arrangement (WCMSA)  
 
NOTE: VA and other Federal payments are MSP exclusions rather than MSP non-
payments. Where the VA authorized services, Medicare does not make payment for items 
or services furnished by a non-Federal provider pursuant to such an authorization. 
Although certain MSP billing procedures apply, VA is not an MSP provision. 
  Cost Avoided Claim - A claim returned without payment because CWF indicators 
indicate another insurer is primary to Medicare. (See Pub. 100-05, Chapter 5 for 
complete description.) 
 
Transaction Type - Identifies type of maintenance record. 
 
  0 = Transaction type to add or change MSP data 
  1 = Transaction type to delete MSP data  
 
Override Code - Code used to bypass CWF, MSP edit to allow primary Medicare 
payment. (See 40.4 for a detailed explanation.) 
 
MSP Contractor Numbers 
 
CWF  MSP Contractor Numbers  Non- CROWD Special 
Source    payment/  Project Numbers 
Codes  Payment   
  Denial Codes 
 
  33333 = Litigation Settlement  V  4000 
P  55555 = HMO Rate Cell  U  3000 
Adjustment 
B,D,T,U,V,  77777 = IRS/SSA/HCFA Data  Y  1000 
or W   Match (I, II, III, IV, V, or VI)  
Q  88888 = Voluntary Data Sharing  Q  5000 
Agreements  
O  99999 = Initial Enrollment  T  2000 
Questionnaire  
MSP Contractor Numbers prior to January 1, 2001 
 
CWF  MSP Contractor Numbers  Non- CROWD Special 
Source    payment/  Project Numbers 
Codes  Payment   
  Denial Codes 
 
0  11100 = MSP Contractor    6000 
1  11101 = Initial Enrollment  K  6010 
Questionnaire  
2  11102 = IRS/SSA/CMS Data  E  6020 
Match  
3  11103 = HMO Rate Cell  F  6030 
4  11104 = Litigation Settlement   G  6040 
5  11105 = Employer Voluntary  H  6050 
Reporting  
6  11106 = Insurer Voluntary  H  6060 
Reporting   CWF  MSP Contractor Numbers  Non- CROWD Special 
Source    payment/  Project Numbers 
Codes  Payment   
  Denial Codes 
 
7  11107 = First Claim  E  6070 
Development  
8  11108 = Trauma Code  F  6080 
Development 
9  11109 = Secondary Claims  G  6090 
Investigation  
X  11110 = Self Reports  H  7000 
Y  11111 = 411.25   J  7010 
 
NOTE: Effective January 1, 2001, the following MSP Contractor numbers and 
nonpayment/payment denial codes will be used. 
 
MSP Contractor Numbers Effective January 1, 2001 
 
CWF  MSP Contractor Numbers  Non- CROWD Special 
Source    payment/  Project Numbers 
Codes  Payment   
  Denial Codes 
 
0  11100 = MSP Contractor  00 Effective  6000 
4/1/2020 
1  11101 = Initial Enrollment  T  6010 
Questionnaire  
2  11102 = IRS/SSA/CMS Data  Y  6020 
Match  
3  11103 = HMO Rate Cell  U  6030 
4  11104 = Litigation Settlement   V  6040 
5  11105 = Employer Voluntary  Q  6050 
Reporting  
6  11106 = Insurer Voluntary  K  6060 
Reporting  
7  11107 = First Claim  E  6070 
Development  
8  11108 = Trauma Code  F  6080 
Development 
9  11109 = Secondary Claims  G  6090 
Investigation  
10 -  11110 = Self Reports  H  7000 
Effective 
4/1/2002  CWF  MSP Contractor Numbers  Non- CROWD Special 
Source    payment/  Project Numbers 
Codes  Payment   
  Denial Codes 
 
11 -  11111 = 411.25   J  7010 
Effective 
4/1/2002 
 
11101, 11102, 11103, 11104, and 11105 use the same non-payment denial codes as 
their previous contractor numbers (i.e., 33333, 55555, 77777, 88888, 99999). Savings 
from the old and new numbers, if applicable will be reported together (e.g., 11101 
and 99999, etc). There must be a conversion of the MSP savings to the new non-
payment/payment denial codes as of January 1, 2001.  
 
Additional MSP Contractor Numbers Effective April 1, 2002  
 
Effective April 1, 2002, CWF is expanding the source code field and the 
nonpayment/ payment denial code field from 1-position fields to 2-position fields. 
 
CWF  MSP Contractor Numbers  Non- CROWD Special 
Source    payment/  Project Numbers 
Codes  Payment   
  Denial Codes 
 
12  11112 = Blue Cross-Blue Shield  12  7012 
Voluntary Data Sharing 
Agreements 
13  11113 = Office of Personnel  13  7013 
Management (OPM) Data Match  
14  11114 = State Workers'  14  7014 
Compensation (WC) Data Match  
15  11115 = WC Insurer Voluntary  15  7015 
Data Sharing Agreements (WC 
VDSA)  
16  11116 = Liability Insurer  16  7016 
Voluntary Data Sharing 
Agreements (LIAB VDSA)  
17  11117 = Voluntary Data Sharing  17  7017 
Agreements (No Fault VDSA)  
18  11118 = Pharmacy Benefit  18  7018 
Manager Data  
19  11119 = Workers Compensation  19  7019 
Medicare Set-Aside Arrangement 
20  11120 = COBA  20  N/A 
21  11121= MIR Group Health Plan   21  7021  CWF  MSP Contractor Numbers  Non- CROWD Special 
Source    payment/  Project Numbers 
Codes  Payment   
  Denial Codes 
 
22  11122= MIR Non-Group Health  22  7022 
Plan 
23  11123 = To be determined  23  7023 
24  11124 = To be determined  24  7024 
25  11125 = Recovery Audit  25  7025 
Contractor-California  
26  11126 = Recovery Audit  26  7026 
Contractor-Florida  
27  11127 = To be determined  27  7027 
       
39  11139 = GHP Recovery  39  7039 
41  11141 =NGHP Non Ongoing  41  7041 
Responsibility for Medicals 
(ORM) 
42  11142 = NGHP ORM Recovery  42  7042 
43  11143 = MSP Contractor  43  7043 
/Medicare Part C/Medicare 
Advantage 
       
99  11199 = To be determined  99  7099 
 
20 - MSP Maintenance Transaction Record Processing 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
The MSP Contractor shall submit an MSP maintenance transaction to establish an MSP 
auxiliary record within 10 calendar days of receipt of notice that another payer is primary 
to Medicare. The CWF applies extensive editing to the maintenance transaction.  If an 
MSP maintenance transaction does not meet all edit criteria, error codes specific to the 
failed edit(s) will be returned via the CWF MSP Maintenance Transaction Response. A 
complete record layout and field descriptions are contained in CWF Systems 
Documentation, Record Name: CWF, MSP Maintenance Transaction Response. For Out-
of-Service (OSA) Area transactions, the CWF OSA Maintenance Transaction Response is 
used. Its complete record layout and field descriptions are contained in CWF Systems 
Documentation, Record Name: CWF, MSP Maintenance Transaction Response. The 
consistency edit error codes and edit definitions are contained in CWF Systems 
Documentation Record Name: MSP Maintenance Transaction Error Codes. MSP 
transactions that pass all edits are applied to the CWF, MSP auxiliary file. 
 
 
  20.1 - Types of MSP Maintenance Transactions 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
The three types of maintenance transactions are add, change, and delete. 
 
The MSP Contractor shall use MSP maintenance transaction type "O" (zero) for an add 
or a change transaction. 
 
  The transaction is an add when no matching MSP occurrence - NO MATCHING 
MSP auxiliary record - is found for the beneficiary; 
 
  The transaction is a change when a matching MSP occurrence is found. 
 
After a successful MSP maintenance transaction processes through CWF, before and 
after images of the MSP auxiliary file occurrence are written to the MSP Audit File. 
 
20.1.1 - MSP Add Transaction 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
The two situations in which the "add" maintenance transaction is used are: 
  There is no MSP auxiliary file record for a beneficiary. In this case, the "add" 
transaction creates an MSP auxiliary record containing the new MSP transaction 
and sets the MSP indicator on the beneficiary's master record; or 
  There is an MSP auxiliary file record but no matching occurrence for the 
beneficiary. In this case, the "add" transaction adds the maintenance transaction as 
a new occurrence. 
The following fields are mandatory for a validity indicator of "Y" or "I" (Another insurer 
is responsible for payment): 
  Medicare beneficiary identifier; 
  MSP type (MSP code); 
  Validity indicator; 
  MSP effective date; 
  Contractor identification number; 
  Insurer name (CWF will allow a space in the second position provided the third 
position contains a valid character other than a space.); 
  Patient relationship; and 
  Insurance type. 
A "Y" or "I" record CANNOT be established without the insurer name.  Note, if the 
Insurance Company Name is blank, or contains one of the abbreviated values that should 
not be used as found in the ECRS manual, then it is considered an error. 
NOTE: Although the insurer address cannot be MANDATORY, it should be provided 
whenever possible. 
The following are to be used as default values when creating an I record: 
(1)  MSP Effective Date:  Use the Part A entitlement date. 
(2)  Patient Relationship:  Use 01 if there is no indication of other insured member, and 
use 02 if another member is shown, but uncertain of relationship.  (3)  MSP Type:  For GHP, use the current reason for entitlement: working aged (12), 
disability (43), or ESRD (13).  For NGHP, if not identified, the default to be used is No-
Fault (14). 
 
20.1.2 - MSP Change Transaction 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
An MSP change transaction occurs when the key fields on the incoming maintenance 
transaction match those on an existing MSP auxiliary occurrence. 
 
An MSP record match occurs when the following items are the same: 
 
Medicare beneficiary identifier; 
MSP type;  
MSP effective date;  
Insurance type; and  
Patient relationship  
 
When these items match, the record is overlaid. 
 
No change transactions will be permitted to records established, except for the addition of 
a termination date, by any contractor other than the MSP Contractor. 
 
20.1.3 - MSP Delete Transaction 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
The MSP maintenance type "1" is used to delete an MSP auxiliary occurrence. This 
transaction checks the beneficiary's master record for an MSP indicator. The MSP 
Contractor is responsible for submitting this transaction. A/B MACs and DME MACs 
advise the MSP Contractor, via the ECRS, of the need to process an MSP maintenance 
type 1 transaction (delete). 
 
Only certain MSP contractor numbers may delete MSP occurrences originated or last 
updated by certain other MSP contractor numbers. No contractor number may update or 
delete a MSP occurrence originated or last updated by contractor number 11100 except 
contractor number 11100. Please see the table below for the exact criteria for deletion of 
MSP occurrences last updated by MSP contractor numbers. A match shall occur in order 
to delete the MSP occurrence originated or last updated by one MSP contractor number 
with a delete transaction submitted under a certain MSP contractor number. For example, 
MSP contractor numbers 11100, 11110, 11141 and 11140 are the only contractor 
numbers that may delete a MSP occurrence originated or last updated by 11110. The 
MSP Contractor is the sole contractor that may delete MSP contractor numbers. The MSP 
Contractor shall maintain the necessary logic to control updating and deleting MSP 
occurrences based on MSP contractor numbers. A/B MACs and DME MACs shall follow 
the current restrictions regarding deletion of MSP records. 
  Originating 
or Last 
Updating  MSP Contractor Number That Can Update/Delete 
Contractor 
Number 
11100  11100 
11110  11100, 11110, 11139, 11141, 11140, 11142 
11141  11100, 11110, 11139, 11141, 11140, 11142 
11140  11100, 11110, 11139, 11141, 11140, 11142 
11121  11100, 11110, 11141, 11140, 11121, 11143, 11139, 11142 
11122  11100, 11110, 11141, 11140, 11121, 11143, 11139, 11142 
11143  11100, 11110, 11141, 11140, 11121, 11143, 11139, 11142 
11139  11100, 11110, 11141, 11140, 11121, 11143, 11139, 11142 
11142  11100, 11110, 11141, 11140, 11121, 11143, 11139, 11142 
11100, 11110, 11141, 11140, 11121, 11143, 11105, 11102, 11139, 
11105 
11142 
11100, 11110, 11141, 11140, 11121, 11143, 11105, 11102, 11139, 
11102 
11142  
All others  Any 
 
The MSP Contractor shall allow (MMSEA Section 111) GHP responsible reporting 
entities (RREs) to override this update/delete hierarchy reflected in the table above under 
certain circumstances. MIR GHP RREs must submit an override code to the MSP 
Contractor after receiving an error on an attempted update/delete. The MSP Contractor 
applies the update/delete using contractor number 11121. This override capability shall 
not apply to MSP occurrences originated or last updated by 11100. 
 
The MSP Contractor shall apply the same hierarchy rules represented in the table above 
to transactions that have the effect of adding back or reopening matching MSP 
occurrences previously deleted. 
 
20.1.4 - MSP Termination Date Transaction 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
A/B MACs and DME MACs add termination dates to MSP auxiliary records already 
established on CWF with a "Y" validity indicator, where there is no discrepancy in the 
validity of the information contained on CWF. They handle phone calls and written 
inquiries relating to simple terminations of existing MSP occurrences. Simple 
terminations are defined as terminations that can be made to an MSP auxiliary record 
without further development or investigation. They shall not transfer these calls or 
written inquiries to the MSP Contractor. In determining whether a call is to be handled 
by them or the MSP Contractor, the A/B MAC or DME MAC establishes the basis of the 
call.  The following are examples when not to transfer a termination request to the MSP 
Contractor for further action. 
 
EXAMPLE 1:   
Scenario: Mr. Doe is calling to report that his employer group health coverage has 
ended. 
 
A/B MACs and DME MAC action: The A/B MACs and DME MACs checks for 
matching auxiliary record on CWF and terminates, if no conflicting data are presented. 
The A/B MACs and DME MACs does not transfer the call to the MSP Contractor. 
 
EXAMPLE 2: 
 
Scenario: Mrs. X is calling to report that she has retired. 
 
A/B MACs and DME MACs action: The A/B MACs and DME MACs checks for 
matching auxiliary record on CWF and terminates if no conflicting data are presented. 
The A/B MACs and DME MACs does not transfer the call to the MSP Contractor. 
 
EXAMPLE 3: 
 
Scenario: The A/B MACs or DME MACs receives written correspondence that benefits 
are exhausted for an automobile case. 
 
A/B MACs and DME MACs action: The A/B MAC and DME MAC checks for matching 
auxiliary record on CWF. The MSP Contractor terminates in accordance with existing 
guidelines (e.g., accounting of monies spent).  
 
EXAMPLE 4 
 
Scenario: Union Hospital is calling to report that the MSP period contained on CWF for 
beneficiary X should be terminated. 
 
A/B MAC and DME MAC action: The A/B MAC and DME MAC checks for matching 
auxiliary record on CWF and terminates if no conflict in evidence is presented. It does 
not transfer the call to the MSP Contractor. 
 
MSP Contractor Role 
 
The MSP Contractor adds termination dates to records not covered in A, above. In 
addition, the MSP Contractor updates MSP occurrences as a result of a request from an 
A/B MAC or DME MAC, or as a result of the MSP Contractor development and 
investigation. The following are examples of when to transfer a termination request to the 
MSP Contractor for further action. 
 
EXAMPLE 1: 
 
Scenario: The termination date is greater than six months prior to the date of accretion 
(i.e., SP 57 error code) for all MSP Contractor numbers (e.g., 11100-11145, 33333,  77777, 88888, or 99999).  (All MSP Contractor numbers follow the old data match 6-
month termination rule.) 
 
A/B MAC and DME MAC action: The A/B MAC and DME MAC sends a CWF 
assistance request to the MSP Contractor. 
 
MSP Contractor action: The MSP Contractor checks for matching record on CWF and 
terminates. In cases where discrepant information exists, the MSP Contractor investigates 
to determine the proper course of action. 
 
EXAMPLE 2: 
 
Scenario: The A/B MAC and DME MAC receives information with regard to 
termination that is discrepant with the information contained on CWF. 
 
A/B MAC and DME MAC action: The A/B MAC and DME MAC forwards to the MSP 
Contractor for investigation via ECRS. 
 
MSP Contractor action: The MSP Contractor checks for matching record on CWF, 
investigates, and terminates if appropriate. 
 
20.2 - MSP Maintenance Transaction Record A/B MAC and DME MAC 
MSP Auxiliary File Update Responsibility  
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
The capability to update the CWF MSP auxiliary file is essentially a function of only the 
MSP Contractor.  The A/B MAC and DME MACs do not have the capability to delete 
any MSP auxiliary file records, including those that a specific A/B MAC or DME MAC 
established. If it is believed that a record should be changed or deleted, A/B MACs and 
DME MACs use the MSP Contractor via the ECRS (discussed in Pub. 100-05, Chapter 5, 
CWF Assistance Request option, to notify the MSP Contractor of the needed revision. 
A/B MACs and DME MACs process claims in accordance with existing claims 
processing guidelines. 
There are only two instances in which A/B MACs and DME MACs retain the capability 
to update CWF. They are:  
A.  A claim is received for secondary benefits and the contractor could, without further 
development (for example, the EOB from another insurer or third-party payer contains all 
necessary data), add an MSP occurrence and pay the secondary claim. A/B MACs must 
use a validity indicator of "I" to add new MSP occurrences and update CWF. An I 
record is to be added to the CWF within 10 calendar days when the claim is suspended 
for MSP (internal system or CWF, whichever suspends first) if no MSP record with the 
same MSP type already exists in CWF. Note: Effective October 1, 2021, DME MACs no 
longer submitIrecords and instead submit an Electronic Correspondence Referral 
System (ECRS) Inquiry to create an MSP record. A/B MACs cannot submit a new record 
with a "Y" or any record with an "N" validity indicator.   B.  A claim is received for conditional payment, and the claim contains sufficient 
information to create an "I" record without further development. A/B MACs add the MSP 
occurrence using an "I" validity indicator. An I record is to be added to the CWF within 
10 calendar days when the claim is suspended for MSP (internal system or CWF, 
whichever suspends first) if no MSP record with the same MSP type already exists in 
CWF. 
A/B MACs will transmit "I" records to CWF via the current HUSP transaction. The CWF 
will treat the "I" validity indicator the same as a "Y" validity indicator when processing 
claims. Receipt of an "I" validity indicator will result in a CWF trigger to the MSP 
Contractor.  The MSP contractor will develop and confirm all "I" maintenance 
transactions established by the A/B MAC.  If the MSP contractor receives an affirmative 
confirmation of MSP through its development efforts within 45 calendar days, the MSP 
contractor will convert the I to a Y validity indicator. If the MSP contractor has not 
received confirmation of MSP through its development efforts within 45 calendar days, 
the MSP contractor will automatically delete the "I" validity indicator.  Also, if the MSP 
contractor develops and determines there is no MSP, the MSP Contractor will delete the 
"I" record.  An "I" record should never be established when the mandatory fields of 
information are not readily available to an A/B MAC on a claim attachment. If the A/B 
MAC has the actual date that Medicare became secondary payer, they use that as the 
MSP effective date. If that information is not available, the A/B MAC shall use the Part 
A entitlement date as the GHP MSP effective date. A/B MACs may include a termination 
date when they initially establish an "I" record.  However, they may not add a termination 
date to an already established "I" record. 
CWF accepts an "I" record only if no MSP record (validity indicator of either "I" or "Y," 
open, closed, or deleted status) with the same MSP type already exists on CWF with an 
effective date within 45 calendar days of the effective date of the incoming "I" record. 
Therefore, "I" records submitted to CWF before 45 calendar days have elapsed will reject 
with an SP 20 error code. The resolution for these cases is to transfer all available 
information to the MSP contractor via the Electronic Correspondence Referral System 
(ECRS) CWF assistance request screen. It will be the responsibility of the MSP 
contractor to reconcile the discrepancy and make any necessary modifications to the 
CWF auxiliary file record.  
A refund or returned check is no longer a justification for submission of an "I" record. 
Since an "I" record does not contain the source (name and address) of the entity that 
returned the funds, the MSP contractor lacks the information necessary to develop to that 
source. Follow the examples below to determine which ECRS transaction to submit. 
1. An MSP inquiry should be submitted when there is no existing or related MSP record 
on the CWF. A related record means if an MSP record on CWF matches and has the 
same HICN/MBI, MSP type, MSP effective date, Insurance type, patient relationship 
code, and validity indicator.  
2. The CWF assistance request should be submitted when the information on the CWF is 
incorrect or the MSP record has been deleted. 
3. The check or voluntary refund either opens and/or closes the MSP case or MSP issue. 
Under these circumstances, the A/B MACs or DME MACs shall submit an MSP inquiry 
to open or close the MSP record.  Note: The A/B MACs or DME MACs should refer to 
the ECRS manual for more information regarding closed cases.  The check should be deposited to unapplied cash until the MSP contractor makes an MSP 
determination. 
 
30 - CWF, MSP Auxiliary File 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
A maximum number of 17 MSP auxiliary records may be stored in CWF for each 
beneficiary. The MSP Contractor is responsible for deletion of a record when the 
maximum storage is exceeded using the following priority: 
 
  Oldest "deleted" (flagged for deletion) occurrence; 
  Oldest "confirmed no" occurrence; 
 
  Oldest termination date; or 
 
  Oldest maintenance date for the MSP type to be added. 
 
30.1 - Integrity of MSP Data 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
30.1.1 - MSP Effective Date Change Procedure 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
When the MSP Contractor becomes aware that an MSP effective date is incorrect, it shall 
perform the following functions: 
 
  Delete the auxiliary record containing the incorrect MSP effective date using an 
MSP delete transaction; and 
 
  Submit a CWF, MSP maintenance transaction with the correct MSP effective date 
to establish a new auxiliary record. 
 
NOTE: When the beneficiary is entitled to both Parts A and B, the MSP Contractor shall 
use the Part A entitlement date, if the insurance effective date is prior to entitlement to 
Medicare. 
 
30.1.2 - CWF/MSP Transaction Request for Contractor Assistance 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
Instances occur when the A/B MAC or DME MAC determines that the MSP effective date 
is not correct.  When this happens, the contractor shall advise the MSP Contractor, via 
ECRS, of the need to change the MSP effective date and shall provide the MSP 
Contractor with documentation to substantiate the change. 
 
  30.1.3 - CWF/MSP Transaction Request for Contractor Assistance 
(Rev. 1, 10-01-03) 
 
Instances occur when the intermediary or carrier determines that the MSP effective date 
is not correct.  When this happens, the contractor shall advise the COB, via ECRS, of the 
need to change the MSP effective date and shall provide the COBC with documentation 
to substantiate the change. 
 
30.2 - MSP Termination Date Procedure 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
A.  Future Termination Dates 
For Non-GHP records, the termination date edits identified for GHP do not apply 
as the termination date may be more than 6-months from the MSP effective date.  
For GHP records, the termination date cannot be greater than the current date plus 6 
months, except for MSP code = B; and for GHP records, the termination date cannot be 
greater than the first day the beneficiary turned 65 if the MSP code is B or G.  For 
ESRD, CWF uses the following criteria: 
 
  MSP effective date prior to February 1, 1990, allows for termination date up to 12 
months after the effective date; 
 
  MSP effective date February 1, 1990, through February 29, 1996, allows for 
termination date up to 18 months after the effective date; or 
 
  MSP effective date March 1, 1996, and later allows for termination date up to 30 
months after the effective date. 
 
B.  Termination for "Y" Validity Indicator 
 
A CWF MSP auxiliary record with a "Y" validity indicator establishes Medicare as the 
secondary payer. When posting a termination date to this record, the "Y" validity 
indicator should not be changed. The record indicates a valid MSP occurrence and all 
future claims submitted will edit against the time frame posted. The A/B MAC or DME 
MAC shall advise the MSP Contractor via ECRS when MSP no longer applies, and the 
MSP Contractor shall enter the termination date. 
 
30.3 - MSP Auxiliary File Errors 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition  period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
Maintenance transactions to the MSP Auxiliary file reject invalid data with errors 
identified by a value of "SP" in the disposition field on the Reply Record. A trailer of 
"08" containing up to four error codes will always follow. Listed below are the possible 
MSP Maintenance Transaction error codes with a general description. 
 
Error  Definition  Valid Values 
Code 
SP11  Invalid MSP transaction record type  "HUSP," "HISP," or "HBSP"  
SP12   Invalid  Medicare beneficiary identifier   Valid Medicare beneficiary 
identifier  
SP13   Invalid Beneficiary Surname   Valid Surname  
SP14   Invalid Beneficiary First Name Initial   Valid Initial  
SP15   Invalid Beneficiary Date of Birth   Valid Date of Birth  
SP16   Invalid Beneficiary Sex Code   0=Unknown, 1=Male, 
2=Female  
SP17   Invalid Contractor Number   CMS Assigned Contractor 
Number  
SP18   Invalid Document Control Number   Valid Document Control 
Number  
SP19   Invalid Maintenance Transaction Type  0=Add/Change MSP Data 
transaction, 1=Delete MSP 
Data Transaction  
SP20   Invalid Validity Indicator   Y= Beneficiary has MSP 
Coverage,  
I= Entered by the A/B MAC or 
DME MAC  MSP Contractor 
investigate,  
N -No MSP coverage  
SP21   Invalid MSP Code   A=Working Aged  
B=ESRD  
C= Conditional Payment  
D= No Fault  
E= Workers' Compensation  
F= Federal  
G= Disabled  
H= Black Lung  
L= Liability  
SP22   Invalid Diagnosis Code 1-5   Valid Diagnosis Code  
SP23   Invalid Remarks Code 1-3   See the Valid Remarks Codes 
Below  
SP24  Invalid Insurer Type  See definitions of Insurer 
Type codes below  Error  Definition  Valid Values 
Code 
SP25   Invalid Insurer Name   Alphabetic, Numeric, Space, 
  Comma, & - ' . @ # / ; : 
An SP25 error is returned when the MSP  Insurer Name must be present 
Insurer Name is equal to one of the  if Validity Indicator = Y  
following:    
Supplement  
Supplemental  
Insurer  
Miscellaneous  
CMS  
Attorney  
Unknown  
None  
N/A  
Un  
Misc  
NA  
NO  
BC  
BX  
BS  
BCBX  
Blue Cross  
Blue Shield  
Medicare 
Medicaid 
 
SP26   Invalid Insurer Address 1 and/or Address  Alphabetic, Numeric, Space, 
2   Comma, & - ' . @ # / ; :  
SP27   Invalid Insurer City   Alphabetic, Numeric, Space, 
Comma, & - ' . @ # / ; :  
SP28   Invalid Insurer State   Must match U.S. Postal 
Service state abbreviation 
table.  
SP29   Invalid Insurer Zip Code   If present, 1st 5 digits must be 
numeric. If foreign country 
"FC" state code, the nine 
positions may be spaces.   Error  Definition  Valid Values 
Code 
SP30   Invalid Policy Number   Alphabetic, Numeric, Space, 
Comma, & - ' . @ # / ; :  
SP31   Invalid MSP Effective Date (Mandatory)   Non-blank, non-zero, numeric, 
number of days must 
correspond with the particular 
month. MSP Effective Date 
must be no more than 3 
months in the future from the 
current date. 
SP32   Invalid MSP Termination Date   Must be numeric; may be all 
zeroes if not used; if used, date 
must correspond with the 
particular month for GHP 
records. The MSP 
Termination Date is Greater 
than Six Months from the 
current date for non-Group 
Health Plan MSP Auxiliary 
Records. 
SP33   Invalid Patient Relationship   The following codes are valid 
for all MSP Auxiliary 
occurrences regardless of 
accretion date: 
 
01 = Self; the beneficiary is 
the policy holder or subscriber 
for the other GHP insurance 
reflected by the MSP 
occurrence or- Beneficiary is 
the injured party on the 
Workers Compensation, No-
Fault, or Liability claim 
 
02 =Spouse or Common Law 
Spouse 
 
03 = Child 
 
04 = Other Family Member 
 
20 = Life Partner or Domestic 
Partner 
  Error  Definition  Valid Values 
Code 
The following codes are only 
valid on MSP Auxiliary 
occurrences with accretion 
dates PRIOR TO 4/4/2011: 
 
05 =  Step Child 
06 =  Foster Child 
07 =  Ward of the Court 
08 =  Employee 
09 =  Unknown 
10 =  Handicapped 
Dependent 
11 =  Organ donor 
12 =  Cadaver Donor 
13 =  Grandchild 
14 =  Niece/Nephew 
15 =  Injured Plaintiff 
16 =  Sponsored Dependent 
17 =  Minor Dependent of a 
Minor Dependent 
18 =  Parent 
19 =  Grandparent                    
20 = Life Partner or Domestic 
Partner 
 
SP34   Invalid subscriber First Name   Alphabetic, Numeric, Space, 
Comma, & - ' . @ # / ; : 
SP35   Invalid Subscriber Last Name   Alphabetic, Numeric, Space, 
Comma, & - ' . @ # / ; : 
SP36   Invalid Employee ID Number   Alphabetic, Numeric, Space, 
Comma, & - ' . @ # / ; : 
SP37   Invalid Source Code   Spaces, A through W, 0  19, 
21, 22, 25, 26, 39, 41, 42, 43. 
See 10.2 for definitions of 
valid CWF Source Codes.  
SP38   Invalid Employee Information Data Code   Spaces if not used, alphabetic 
values P, S, M, F. See 30.3.4 
for definition of each code.  
SP39   Invalid Employer Name   Spaces if not used. Valid 
Values:  
Alphabetic, Numeric, Space, 
Comma, & - ' . @ # / ; : 
SP40   Invalid Employer Address   Spaces if not used. Valid 
Values:   Error  Definition  Valid Values 
Code 
Alphabetic, Numeric, Space, 
Comma, & - ' . @ # / ; : 
SP41   Invalid Employer City   Spaces if not used. Valid 
Values:  
Alphabetic, Numeric, Space, 
Comma, & - ' . @ # / ; : 
SP42   Invalid Employer State   Must match U.S. Postal 
Service state abbreviations.  
SP43   Invalid Employer ZIP Code   If present, 1st 5 digits must be 
numeric. If foreign country 
FC is entered as the state 
code, and the nine positions 
may be spaces.  
SP44   Invalid Insurance Group Number   Spaces if not used. Valid 
Values:  
Alphabetic, Numeric, Space, 
Comma, & - ' . @ # / ; : 
SP45   Invalid Insurance Group Name   Spaces if not used. Valid 
Values:  
Alphabetic, Numeric, Space, 
Comma, & - ' . @ # / ; : 
SP46   Invalid Pre-paid Health Plan Date   Numeric; number of days 
must correspond with the 
particular month.  
SP47  Beneficiary MSP indicator not on for  Occurs when the code 
delete transaction.  indicating the existence of 
MSP auxiliary record is not 
equal to "1" and the MSP 
maintenance transaction type 
is equal to 1.  
SP48   MSP auxiliary record not found for delete  See MSP Auxiliary Record 
data transaction   add/update and delete function 
procedures above.  
SP49   MSP auxiliary occurrence not found for  See MSP Auxiliary Record 
delete data transaction   add/update and delete function 
procedures above.  
SP50   Invalid function for update or delete  See MSP Auxiliary Record 
Contractor number unauthorized   add/update and delete function 
procedures above  
SP51   MSP Auxiliary record has 17 occurrences   
and none can be replaced  
SP52   Invalid Patient Relationship Code which  Accretion Dates prior to 
is mandatory for MSP Codes A, B and G  4/4/2011: 
when the Validity Indicator is "Y"   Error  Definition  Valid Values 
Code 
Patient Relationship must be 
01 or 02 for MSP Code A 
(Working Aged). 
Patient Relationship must be 
01, 02, 03, 04, 05, 18 or 20 for 
MSP Codes B (ESRD) and G 
(Disabled).  
 
Accretion Dates 4/4/2011 and 
subsequent: 
Patient Relationship must be 
01 or 02 for MSP Code A 
(Working Aged). 
Patient Relationship must be 
01, 02, 03, 04, or 20 for MSP 
Codes B (ESRD) and G 
(Disabled).  
SP53   The maintenance transaction was for   
Working Aged EGHP and there is either a 
ESRD EGHP or Disability EGHP entry 
on file that has a termination date after the 
Effective date on the incoming transaction 
or is not terminated, and the contract 
number on the maintenance transaction is 
not equal to "11102," "11104," 11105," 
"11106," "33333," "66666,", "77777," 
"88888," or "99999." 
SP54   MSP Code A, B or G has an Effective  For MSP Code A, the 
date that is in conflict with the calculated  Effective date must not be less 
age 65 date of the Bene.   than the date at age 65. For 
MSP Code G, the Effective 
date must not be greater than 
the date at age 65.  
SP55   MSP Effective date is less than the earliest   
Bene Part A or Part B Entitlement Date. 
SP56   MSP Prepaid Health Plan Date must be =   
to or greater than MSP Effective date or 
less than MSP Termination date.  
SP57   Termination Date Greater than 6 months   
prior to date added for Contractor 
numbers other than 11100  11119, 
11121, 11122, 11126, 11139, 11141, 
11142, 11143, 33333, 55555, 77777, 
88888, and 99999.   Error  Definition  Valid Values 
Code 
SP58   Invalid Insurer type, MSP code, and  If MSP code is equal to "A" or 
validity indicator combination.   "B" or "G" and validity 
indicator is equal to "I" or "Y" 
then insurer type must not be 
equal to spaces. Mapped 
coverage type must equal J, 
K, or A. 
SP59   Invalid Insurer type, and validity indicator  If validity indicator is equal to 
combination   "N" then insurer type must be 
equal to spaces.  
SP60   Other Insurer type for same period on file  Edit applies only to MSP 
(Non "J" or "K") Insurer type on incoming  codes:  
maintenance record is equal to "J" or "K"  A - Working Aged,  
and Insurer type on matching aux record  B - ESRD EGHP,  
is not equal to "J" or "K."   G - Disability EGHP  
SP61   Other Insurer type for same period on file  Edit applies only to MSP 
("J" or "K") Insurer type on incoming  codes:  
maintenance record is not equal to "J" or  A - Working Aged,  
"K" and Insurer type on matching aux  B - ESRD EGHP,  
record is equal to "J" or "K."   G - Disability EGHP  
SP62   Incoming term date is less than MSP   
Effective date.  
SP66   MSP Effective date is greater than the   
Effective date on matching occurrence on 
auxiliary file  
SP67   Incoming term date is less than posted   
term date for Provident  
SP72   Invalid Transaction attempted   A HUSP add transaction is 
received from a A/B MAC and 
DME MAC (non-MSP 
Contractor) with a validity 
indicator other than "I."  
SP73   Invalid Term Date/Delete Transaction   A MAC attempts to change a 
Term Date on an MSP 
Auxiliary record with a "I" or 
"Y" Validity Indicator that is 
already terminated, or trying 
to add Term Date to "N" 
record.  
SP74   Invalid cannot update "I" record.   A MAC submits a HUSP 
transaction to update/change 
an "I" record or to add an "I" 
record and a match MSP  Error  Definition  Valid Values 
Code 
Auxiliary occurrence exists 
with a "I" validity indicator.  
SP75   Invalid transaction, no Medicare Part A  A HUSP transaction to add a 
benefits   record with a Validity 
Indicator equal to "I" (from an 
A/B MAC or DME MAC) or 
"Y" (from the MSP 
Contractor) with an MSP 
Type equal to "A," "B," "C," 
or "G" and the effective date 
of the transaction is not within 
a current or prior Medicare 
Part A entitlement period, or 
the transaction is greater than 
the termination date of a 
Medicare entitlement period.  
SP76  MSP Type is equal to W (Workers   
Compensation Medicare Set-Aside) and 
there is an open MSP Type E (Workers 
Compensation) record.  
SP77  A diagnosis cannot be added to this   
occurrence by a Part A/Part B/DME 
MAC. 
SP78  The diagnosis code submitted is not  When an incoming HUSP 
allowed on an MSP Type 'D' record.  transaction with a Validity 
Indicator equal to 'I' or 'Y' is 
received from an 
A/B, DME MAC or the MSP 
Contractor for an MSP Type 
'D' 
record, and the transaction 
contains one of the CMS  
identified ICD 9 or ICD 10 
diagnosis codes. 
SP79  A MAC attempts to create/enter a value in  Valid Values for the 1-byte 
the ORM field on the incoming I HUSP  ORM indicator on the CWF 
record (makes sure that a MAC cannot  MSP Detail screen (MSPD) 
update or overlay an ORM value in the  are:  Y (Yes) or a space. 
ORM field).   
A Y ORM indicator value 
denotes that the ORM existed 
for a period of time, not 
necessarily that it currently 
exists. An ORM indicator of a  Error  Definition  Valid Values 
Code 
space implies that an RRE 
has not assumed ORM. 
SP80  A MAC attempted to create/enter an  The 1- byte ORM indicator 
ORM indicator on an MSP record other  (valid values = Y or a space) 
than a D, E, and L.   shall only be received on 
HUSP transactions with MSP 
Codes D, E, and L.  
SP81   A contractor, other than the following  To ensure that no other entity 
contractor numbers of 11100, 11110,  than the following contractor 
11122, 11141, and 11142, attempts to  numbers (11100, 11110, 
update, remove or set the existing ORM  11122, 11142, and 11142) can 
record indicator of a Y to a space.   modify an existing records 
ORM indicator to equal a 
space, if originally it was a 
Y. 
SP82  MSP Type 'L' or 'D' does not exist.  When an incoming HUSP 
transaction is submitted for 
LMSA (MSP Type S) and no 
Liability (MSP Type L) MSP 
Auxiliary record exists; or  
when an incoming HUSP 
transaction is submitted for 
NFMSA (MSP Type T) and 
no No-Fault Auto (MSP Type 
D) MSP Auxiliary record 
exists. 
SP83  No Termination Date present for a  When an incoming HUSP 
Liability or No-Fault Auto occurrence.  transaction is submitted for 
LMSA (MSP Type S) and the 
Liability (MSP Type L) record 
on the MSP Auxiliary File 
does not have a Termination 
Date; or when an incoming 
HUSP transaction is submitted 
for NFMSA (MSP Type T) 
and the No-Fault Auto (MSP 
Type D) record on the MSP 
Auxiliary File does not have 
Termination Date. 
SP84  Invalid Effective date for LMSA or  An HUSP transaction is 
NFMSA or open record.  submitted by contractor 
'11144'  Error  Definition  Valid Values 
Code 
or '11100' for LMSA (MSP 
Type S) and posted to the 
MSP Aux 
file is a Liability (MSP Type 
L) with a Termination Date. 
If the Effective Date of the 
LMSA (MSP Type S) is not 
one day after the Termination 
Date of the Liability 
(MSP Type L). 
If the Effective Date of the 
LMSA (MSP Type S) is 
one day after the Termination 
Date of the Liability (MSP 
Type L), and the diagnosis 
codes on the LMSA (MSP 
Type S) 
are not an Exact or not a 
Family Match with the 
Liability 
(MSP Type L) diagnosis 
codes. 
AND/OR 
An HUSP transaction is 
submitted by contractor 
'11145' 
or '11100' for NFMSA (MSP 
Type T) and posted to the 
MSP Aux 
file is a No-Fault (MSP Type 
D) with a Termination Date. 
If the Effective Date of the 
NFMSA (MSP Type T) is not 
one day after the Termination 
Date of the No-Fault (MSP 
Type D). 
If the Effective Date of the 
NFMSA (MSP Type T) is 
one day after the Termination 
Date of the No-Fault (MSP 
Type D), and the diagnosis 
codes on the NFMSA (MSP 
Type T)  Error  Definition  Valid Values 
Code 
are not an Exact or not a 
Family Match with the No-
Fault 
(MSP Type D). 
SP91  Invalid Employer Size (Mandatory). Field   
must contain a numeric     
character. 
SP99  Medicare ID (HICN or MBI) required if   
individual is less than 45   
years of age.                                                       
 
 
30.3.1 - Valid MSP Remarks Codes 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
MSP 
Remark 
Code  Definition 
01  Beneficiary retired as of termination date. 
02  Beneficiary's employer has less than 20 employees. 
03  Beneficiary's employer has less than 100 employees 
04  Beneficiary is dually entitled to Medicare, based on ESRD and Age or ESRD 
and disability 
05  Beneficiary is not married. 
06  The Beneficiary is covered under the group health plan of a family member 
whose employer has less than 100 employees. 
07  Beneficiary's employer has less than 20 employees and is in a multiple or 
multi-employer plan that has elected the working aged exception. 
08  Beneficiary's employer has less than 20 employees and is in a multiple or 
multi-employer plan that has not elected the working aged exception. 
09  Beneficiary is self-employed. 
10  A family member of the Beneficiary is self-employed. 
20  Spouse retired as of termination date. 
21  Spouse's employer has less than 20 employees. 
22  Spouse's employer has less than 100 employees. 
23  Spouse's employer has less than 100 employees but is in a qualifying multiple 
or multi-employer plan. 
24  Spouse's employer has less than 20 employees and is multiple or multi-
employer plan that has elected the working aged exception. 
25  Spouse's employer has less than 20 employees and is multiple or multi-
employer plan that has not elected the working aged exception. 
26  Beneficiary's spouse is self-employed 
30  Exhausted benefits under the plan 
31  Preexisting condition exclusions exist  MSP 
Remark 
Code  Definition 
32  Conditional payment criteria met 
33  Multiple primary payers, Medicare is tertiary payer 
34  Information has been collected indicating that there is not a parallel plan that 
covers medical services 
35  Information has been collected indicating that there is not a parallel plan that 
covers hospital services 
36  Denial sent by EGHP, claims paid meeting conditional payment criteria. 
37  Beneficiary deceased. 
38  Employer certification on file. 
39  Health plan is in bankruptcy or insolvency proceedings. 
40  The termination date is the Beneficiary's retirement date. 
41  The termination date is the spouse's retirement date. 
42  Potential non-compliance case, Beneficiary enrolled is supplemental plan. 
43  GHP coverage is a legitimate supplemental plan. 
44  Termination date equals transplant date 
50  Employment related accident 
51  Claim denied by workers comp 
52  Contested denial 
53  Workers compensation settlement funds exhausted 
54  Auto accident - no coverage 
55  Not payable by black lung 
56  Other accident - no liability 
57  Slipped and fell at home 
58  Lawsuit filed - decision pending 
59  Lawsuit filed - settlement received 
60  Medical malpractice lawsuit filed 
61  Product liability lawsuit filed 
62  Request for waiver filed 
70  Data match correction sheet sent 
71  Data match record updated 
72  Vow of Poverty correction 
 
30.3.2 - Valid MSP Insurance Type Codes 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
MSP  Definition  
Insurer 
Type Code  
A   GHP Hospital and Medical Coverage -or- Other Non-GHP 
B   GHO  
C   Preferred Provider Organization (PPO)  
D   Third Party Administrator arrangement under an Administrative Service Only (ASO) 
contract without stop loss from any entity.   E   Third Party Administrator arrangement with stop loss insurance issued from any entity.  
F   Self-Insured/Self-Administered.  
G   Collectively-Bargained Health and Welfare Fund.  
H   Multiple Employer Health Plan with at least one employer who has more than 100 full 
and/or part-time employees.  
I   Multiple Employer Health Plan with at least one employer who has more than 20 full 
and/or part-time employees.  
J   GHP Hospitalization Only Plan - A plan that covers only Inpatient hospital services.  
K   GHP Medical Services Only Plan - A plan that covers only non-inpatient medical 
services.   
M   Medicare Supplemental Plan, Medigap, Medicare Wraparound Plan or Medicare Carve 
Out Plan.  
R  GHP Health Reimbursement Arrangement 
S  GHP Health Savings Account 
SPACES   Unknown  
 
NOTE: For MSP occurrences with accretion dates of 4/4/2011 and subsequent, the 
only valid Insurer Type Codes are A, J, K, R, S, and spaces. 
 
30.3.3 - Other Effective Date and Termination Date Coverage Edits 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
If MSP Code:  MSP Effective Date Must Be Greater 
Than 
A - Working Aged  January 1, 1983 (830101) 
A - Working Aged  Calculated Date beneficiary turned 65 (first 
day of month). 
B  ESRD  October 1, 1981 
D - No Fault  December 1, 1980 
E - Workers' Compensation  July 1, 1966 
F - Federal/Public Health  July 1, 1966 
H - Black Lung  July 1, 1973 
   
G - Disabled (43)  January 1, 1987 
G  Disabled  Prior to the first day of the month the 
Beneficiary turns 65. 
L  Liability  December 1, 1980 
 
Other Termination date coverage edits are: 
 
 
  For Group Health Plan (GHP) records the termination date cannot be greater than 
the current date plus six months, except for MSP code = B, and   
  For GHP records the termination date cannot be greater than the first day the 
beneficiary turned 65 if the MSP code is B or G. 
 
Note: For Non-GHP records the termination date edits identified above do not 
apply as the termination date may be more than 6-months from the MSP effective 
date. 
 
30.3.4 - MSP Employee Information Data Code 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
MSP Employee Information Data Code  Valid Values 
P  Patient 
S  Spouse 
M  Mother 
F  Father 
 
30.4 - Automatic Notice of Change to MSP Auxiliary File 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
The Common Working File (CWF) sends MSP transactions to all contractors of record 
when an MSP auxiliary record is created or changed for any beneficiary.  
 
Alerts are sent to the A/B MACs and DME MACs when an update is made to an MSP 
record.   
 
40 - MSP Claim Processing 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
The CWF performs consistency edit checks on claims submitted to it. Refer to CWF 
Systems Documentation for the complete record layout and field descriptions. Record 
names are: 
 
  CWF Part B Claim Record, and  
 
  CWF Inpatient/SNF Bill Record. 
 
The MSP claims failing the consistency edits shall receive a reject with the appropriate 
disposition code, reject code, and MSP trailer data. Refer to CWF Systems 
Documentation, Record Name: CWF, MSP Basic Reply Trailer Data for the complete 
record layout and field descriptions. Claims passing the consistency edit process are 
reviewed for utilization compliance. Claims rejected by the utilization review process are 
rejected with the appropriate disposition code, reject code and MSP trailer data. 
 
 
  40.1 - CWF, MSP Claim Validation 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
There are four conditions that may occur when an A/B MAC and DME MAC validates 
claims against the CWF, MSP auxiliary file: 
 
  MSP is indicated on the claim and there is matching data on the CWF, MSP 
auxiliary record. The claim is accepted and all CWF, MSP auxiliary occurrences 
are returned, 
 
  MSP is indicated on the claim and there is no matching data on an MSP auxiliary 
record. The claim is rejected and all CWF, MSP occurrences that apply are 
returned. Section 40.8 describes the CWF, MSP Utilization Error Codes, and the 
appropriate resolution for those codes, 
 
  MSP is not indicated on the claim and the MSP auxiliary file has an occurrence 
that indicates there is MSP involvement for the time period affected. The claim is 
rejected and all occurrences that apply are returned, and 
 
  MSP is not indicated on the claim and there are no matching occurrences on the 
CWF, MSP auxiliary file that indicate MSP involvement. The claim is accepted 
for payment. 
 
NOTE: An occurrence applies if the claim service dates are equal to, or greater than, the 
effective date of the occurrence and less than, or equal to, the termination date of that 
occurrence, if there is a termination date. 
 
 
40.2 - CWF Claim Matching Criteria Against MSP Records 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
The matching criteria between the claim and the MSP auxiliary occurrence in CWF is as 
follows: 
 
HICN/MBI, MSP type, MSP effective date and termination date, insurance type, patient 
relationship code and validity indicator for the same insurer. Note, NGHP records 
includes matching on the family of diagnosis codes. 
 
40.3 - Conditional Payment 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
To make a conditional payment, A/B MACs and DME MACs indicate conditional 
payment on the CWF, Part B Claim by placing a "C" in the "MSP code" field (field 97 of 
the CWF Part B Claim record.). Intermediaries indicate conditional payment on the CWF 
Inpatient/SNF Bill by placing zeros (0) in the "value amount" field (position 77b) 
along with the appropriate "value code." An MSP auxiliary record for the beneficiary  with a "Y" validity indicator must be present. The CWF will reject the claim with error 
code 6805 when a claim for conditional payment is submitted and there is no matching 
MSP auxiliary record present. 
 
40.4 - Override Codes 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
The CWF will accept MSP override codes. A/B MACs or DME MACs must place the 
appropriate override code in the "MSP code" field (field 97) of the CWF Part B Claim 
record. Intermediaries must place the appropriate override code in the CWF 
(Inpatient/SNF Bill or Outpatient/Home Health/Hospice), "Special Action Code/Override 
Code, field 90." Override codes must be used only as described below. 
 
The CWF employs the following matching criteria for override codes "M" and "N": 
 
  Dates of service on the claim fall within the effective and termination dates on 
auxiliary record; and 
 
  Validity indicator is equal to "Y." 
 
The correct use of override codes is as follows: 
 
A.   Override code "M" is used where GHP, LGHP and ESRD services are involved 
and the service provided is either: 
 
  Not a covered service under the primary payer's plan; 
 
  Not a covered diagnosis under the primary payer's plan; or 
 
  Benefits have been exhausted under the primary payer's plan. 
 
B.   Override code "N" is used where non-GHP (auto medical, no-fault, liability, 
Black Lung, and workers' compensation) services are involved and the service is 
either: 
 
  Not a covered service under the primary payer's plan; 
 
  Not a covered diagnosis under the primary payer's plan; or 
 
  Benefits have been exhausted under the primary payer's plan. 
 
Contractors receive error code 6806 when the MSP override code equals "M" or "N" and 
no MSP record is found with overlapping dates of service.  
 
 
  40.5 - MSP Cost Avoided Claims 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
A/B MACs and DME MACs shall follow the instructions cited in Pub. 100-05, Chapter 5 
for counting savings on MSP cost avoided claims.  
 
They shall submit ALL MSP cost avoided claims to CWF. 
 
Payment/Denial codes are used to identify the reason a claim was denied. Specific codes 
for MSP are listed and defined in 10.2 under the MSP/ Contractor Number chart in 
that section. A/B MACs (Part B) and DME MACs submit the appropriate code to CWF in 
the Health Utilization Part B Claim ("HUBC") claim record in field 63 "Payment/Denial 
Code" for line item denials.  They complete the appropriate code for full claim denials in 
the "HUBC" claim record, field 16 "Payment/Denial". A/B MACs (Part A) submit the 
appropriate code in the Health Utilization Inpatient Claim (HUIP) CWF record field 58 
"Nonpayment" code for inpatient hospital and SNF claim denials. They submit the 
appropriate code in field 59 "No Pay Code" of the CWF record for the specific type of 
claim identified in the chart below. 
 
PAYMENT/DENIAL CODE FIELDS IN CWF CLAIM RECORD 
 
Contractor  Type of Claim  CWF  Field 
Record 
A/B MAC (Part B)  Full Claim Denial   HUBC  16 Payment/Denial  
and DME MAC 
A/B MAC (Part B)  Full Line Item  HUBC  63 Payment/Denial Code 
and DME MAC  Denial 
A/B MAC (Part A)  Inpatient hospital  HUIP  58 Nonpayment Code 
and DME MAC  and inpatient SNF 
Denial 
A/B MAC (Part A)  Health Utilization  HUOP  59 No Pay Code 
and DME MAC  Outpatient (HUOP) 
A/B MAC (HH&H)  Health Utilization  HUHH  59 No Pay Code 
Home Health 
(HUHH) 
A/B MAC (HH&H)  Health Utilization  HUHC  59 No Pay Code 
Hospice Claim 
(HUHC) 
 
If a denial indicator is incorrect, the CWF software will correct the denial indicator based 
on the matching MSP auxiliary record and send the correct value back to the contractor 
on the response record header. It is not necessary for an MSP auxiliary record to be 
present in order to post MSP cost avoided savings. If one is present, the A/B MAC or 
DME MAC uses the "X" or "Y" override code as appropriate. 
 
  40.6 - Online Inquiry to MSP Data 
(Rev. 125, Issued: 03-22-19, Effective: 04-22-19, Implementation: 04-22-19) 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
The MSP data may be viewed online in CWF via the HIMR access. The user enters the 
transaction HIMR, which displays the HIMR Main Menu, and enters the MSPA 
selection. (A complete record layout and field descriptions can be found in the CWF 
Systems Documentation at  http://cms.csc.com/cwf/, Record Name: MSP Auxiliary File 
and MSP Audit History File.) 
 
A user can view a selected CWF, MSP auxiliary record by following the steps outlined 
below: 
 
A.  Enter the Medicare beneficiary identifier and MSP record type. 
 
If the data entered is invalid, an error message is displayed with the field in error 
highlighted. If the data entries are valid, a search is done of the beneficiary master file for 
an MSP indicator. The search of the master file will show one of the following: 
 
  The MSP indicator on the beneficiary file is not set. In this case the message 
"MSP not indicated" is displayed; 
 
  No record is found. In this case, a message "MSP auxiliary file not found" is 
displayed; or 
 
  MSP is indicated. In this case, the MSP auxiliary file is read and the screen will 
display an MSP Record. 
 
A successful reading of the MSP file, as noted in the third bullet above, will display an 
MSP occurrence summary screen that includes: 
 
  Summary selection number; 
 
  MSP code; 
 
  MSP code description; 
 
  Validity indicator; 
 
  Delete indicator; 
    Effective date; and  
 
  Termination date, if applicable. 
 
B.  Enter the summary selection number on the MSP occurrence summary screen. 
 
This results in a display of the MSP occurrence detail screen for the selected MSP 
occurrence. The MSP occurrence detail screen is a full display of the information on the 
MSP auxiliary file for the particular MSP occurrence. 
 
40.7 - MSP Purge Process 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
The CWF process includes an MSP purge process. The CMS will determine when the 
purge process will be employed. The criteria for deletion of MSP data from the CWF 
MSP auxiliary file will be a predetermined number of years from the following dates: 
 
  Date of death; 
 
  Termination date and last maintenance date; or 
 
  Last maintenance date and delete indicator equal to "D." 
 
The MSP purge criteria will be parameter driven. All occurrences of MSP data for a 
beneficiary will be copied to the MSP history audit file, and the MSP indicator on the 
beneficiary file will be disengaged (turned off) if no other occurrences are present on the 
file. 
 
A Summary report, by originating contractor identification number, will contain the total 
number of MSP records affected by the purge and the total of each type of MSP 
occurrence deleted from the MSP auxiliary file. 
 
40.8 - MSP Utilization Edits and Resolution for Claims Submitted to 
CWF 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
 
Error 
Code  Error Description  Resolution 
6801  GHP MSP indicated on claim - no  Prepare an "I" MSP maintenance 
MSP auxiliary record exists on CWF  transaction and resubmit claim to 
data base.  CWF. See 10.1 for criteria to submit 
"I". If "I" criteria is not met, submit an 
MSP inquiry via ECRS. 
6802  GHP MSP indicated on claim - no  (1) Analyze CWF auxiliary file. 
match on MSP auxiliary file.  Error 
Code  Error Description  Resolution 
(2) Create a new "I" MSP auxiliary 
record, or if "I" record criteria is not 
met, submit an MSP inquiry or CWF 
assistance request via ECRS; and 
(3) Resubmit claim. 
NOTE: Match criteria: MSP types are equal, validity indicator equals "Y," dates of 
service are within MSP period and NO override code is indicated on claim. 
6803  GHP MSP auxiliary record exists - no  (1) Deny claim. Advise 
GHP MSP indicated on claim but dates beneficiary/provider:  "Resubmit 
of service match a GHP occurrence.  claim with other payer's Explanation 
of Benefits for possible secondary 
payment. If other insurance has 
terminated, resubmit with 
documentation showing termination 
dates of other insurance." If you have 
documentation showing termination 
of the insurance coverage indicated in 
the CWF, MSP occurrence, process 
as follows: 
(2) Post a termination date; or 
(3) Resubmit claim as MSP. 
If the termination date is incorrect, 
submit a CWF assistance request via 
ECRS. 
6805  GHP MSP conditional payment claim  (1) A/ B MACs only:  Create an "I" 
and matching MSP record with Ior  MSP Auxiliary Record when it fits 
"Y" validity indicator not found for  the criteria for adding an "I" record. 
these dates of service.  (2) Submit MSP inquiry or CWF 
assistance request via ECRS. 
(3) Resubmit claim. 
6806  MSP override code equals "M" and no  If record was deleted in error, request 
GHP MSP record found with  CWF assistance request.  Do not 
overlapping dates of service.  recreate record with "I" validity 
indicator. 
6810  Part A claim was processed and only a Part B (Insurer type = "K") matching 
record was found. 
6811  Part B claim was processed and only a Part A (Insurer type = "J") matching 
record was found. 
6815  WC Medicare Set-Aside exists (Insurer type= W). Medicare contractor 
payment not allowed.  Error 
Code  Error Description  Resolution 
6816  No-Fault over-rideable utilization error code to be used when a valid (Y) 
ORM indicator is on the MSP CWF auxiliary file and the diagnosis codes on 
the claim match the diagnosis codes (or match within the family of diagnosis 
codes) on the open MSP ORM record on CWF.  MACs shall deny the 
claim(s) as a Medicare payment is not allowed. 
6817  Workers Compensation over-rideable utilization error code to be used when 
a valid (Y) ORM indicator is on the MSP CWF auxiliary file and the 
diagnosis codes on the claim match the diagnosis codes (or match within the 
family of diagnosis codes) on the open MSP ORM record on CWF.  MACs 
shall deny the claim(s) as a Medicare payment is not allowed. 
6818  Liability over-rideable utilization error code to be used when a valid (Y) 
ORM indicator is on the MSP CWF auxiliary file and the diagnosis codes on 
the claim match the diagnosis codes (or match within the family of diagnosis 
codes) on the open MSP ORM record on CWF.  MACs shall deny the 
claim(s) as a Medicare payment is not allowed. 
 
6819   A non-GHP ('D', 'H' or 'L') MSP auxiliary record exists, and no non-GHP 
MSP is indicated on the claim, but the Dates of Service match, the diagnosis 
on the claim is a match within the family of diagnosis codes OR a non-GHP 
('E') MSP auxiliary record exists, and no non-GHP MSP is indicated on the 
claim, but the Dates of Service match, the diagnosis on the claim is an exact 
match or a match within the family of diagnosis codes. 
 
6821   Non-GHP MSP indicated on claim; no MSP Auxiliary file exists. This 
indicates no Non-GHP MSP file found. 
 
6822  Non-GHP MSP indicated on the claim; a Non-GHP match does not exist on 
MSP Auxiliary file. 
 
6823  Beneficiary has a non-GHP MSP Type record 'S' on the Auxiliary file; there is 
a matching diagnosis on the claim and auxiliary file, and the claim contains 
payment (full or conditional). 
 
6824  Beneficiary has a non-GHP MSP Type record 'T' on the Auxiliary file; there is 
a matching diagnosis on the claim and auxiliary file, and the claim contains 
payment (full or conditional). 
 
6825  Non-GHP MSP conditional payment claim, but a non-GHP MSP record with 
a Validity Indicator equal to 'I' or 'Y' is not present for these Dates of Service. 
 
6826  MSP Override Code is 'N' or Cost Avoid and no non-GHP MSP record is 
found with overlapping Date of Service. 
6830  Part A claim was processed and only a Part B (Insurer Type 'K') matching 
non-GHP record was found.  6832  The non-GHP MSP occurrence ('D', 'E', 'H', 'L', 'S', 'T', or 'W') does not 
contain a diagnosis code. 
6833  The ICD-9 diagnosis on the claim is not an exact or Family match to the ICD-
10 diagnosis on the open non-GHP MSP Aux record (Value Code '14' (MSP 
Codes 'D' or 'T'), Value Code '15' (MSP Codes 'E' or 'W'), Value Codes '47' 
(MSP Codes 'L' or 'S'), or 
the ICD-10 diagnosis on the claim is not an exact or Family match to the 
ICD-9 diagnosis on the open non-GHP MSP Aux record (Value Code '14' 
(MSP Codes 'D' or 'T'), Value Code '15' (MSP Codes 'E' or 'W'), Value Codes 
'47' (MSP Codes 'L' or 'S'). 
 
6834  When the claim is secondary and it shows there is a GHP insurer, but the MSP 
record on CWF has only a non-GHP MSP occurrence. 
 
6835  When the claim is secondary and it shows there is a non-GHP insurer, but the 
MSP record on CWF has only a GHP MSP occurrence. 
 
See discussion in 40.4 above for proper use of override codes. 
 
40.9 - CWF MSP Reject for A Beneficiary Entitled to Medicare Part B 
Only and A GHP 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
An MSP situation cannot exist when a beneficiary has GHP coverage (i.e., working aged, 
disability and ESRD) and is entitled to Part B only.  CWF will edit to prevent the posting 
of these MSP records to CWF when there is no Part A entitlement date.  Currently, if a 
contractor submits an ECRS transaction to the MSP Contractor to add a GHP MSP 
record where there is no Part A entitlement, the A/B MAC and DME MAC will receive a 
reason code of 61, MSP cannot exist without Part A entitlement.   
 
A/B MACs and DME MACs shall not submit an ECRS request to the MSP Contractor to 
establish a GHP MSP record when there is no Part A entitlement. A/B MACs and DME 
MACs that attempt to establish an I record will receive a CWF error. 
 
The CWF shall continue to allow the posting of Part B MSP records where there is no 
Part A entitlement when NGHP situations exists, such as automobile, liability, and 
workers compensation.  Where an NGHP situation exists, the A/B MAC and DME MAC 
shall continue to submit ECRS transactions and establish I records, as necessary. 
 
40.10  ICD-10 and ICD 9-CM Diagnosis Code Tables Involving Non-
GHP MSP Claims  
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
In accordance with The Health Insurance Portability and Accountability Act of 1996 
(HIPAA), the Secretary of the Department of Health and Human Services adopts  standard medical data code sets for use in standard transactions. According to the ICD-
10 final rule, published in the Federal Register on January 16, 2009, the Secretary 
adopted the ICD-10-CM and ICD-10- PCS code sets for use in appropriate HIPAA 
standard transactions, including those for submitting health care claims electronically. 
Entities covered under HIPAA, which includes Medicare and its providers submitting 
claims electronically, are bound by these requirements and must comply. Medicare also 
requires submitters of paper claims to use ICD-10 codes on their claims according to the 
same compliance date. 
 
CMS annually instructs CWF to upload and implement the ICD-10 tables in CWF for 
NGHP MSP claims transactions. In order to be prepared to meet the time line to 
implement the annually updated ICD-10 diagnosis codes by the mandated time frame of 
October, CWF implements the ICD-10 updates effective with each October release. CMS 
also provides CWF with the Diagnosis and Procedure Codes Conversion Tables that are 
used to associate ICD-10 codes to ICD-9 codes found in CWF MSP records. CWF loads 
and converts ICD-10 to ICD-9 diagnosis codes for purposes of determining whether ICD 
10 diagnosis codes on incoming MSP claim are related to the NGHP MSP record in 
CWF. 
 
40.10. 1 - Certain Diagnosis Codes Not Allowed on NGHP MSP Records  
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
There are certain diagnosis codes that systems must not apply to MSP Type 14, CWF 
MSP Type D No-Fault records and MSP Type 14, CWF MSP Type L Liability records 
and MSP Type 15, CWF Type E or W, Workers Compensation records.  In order for 
these MSP claims not to deny and process correctly, the CWF must only allow those 
diagnosis codes related to the accident or injury.  CMS has provided a comprehensive list 
of diagnosis codes that apply and do not apply to NF, L or WC MSP records. The list of 
diagnosis codes and excluded diagnosis codes may be found at the Coordination of 
Benefits Overview website at https://www.cms.gov/medicare/coordination-benefits-
recovery-overview/icd-code-lists.    
 
50 - Special CWF Processes 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
Special CWF MSP Processes are identified below. 
 
50.1 - Extension of MSP-ESRD Coordination Period 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
Section 4631(b), of the Balanced Budget Act (BBA) of 1997, permanently extends the 
coordination period to 30 months for any individual whose coordination period began on 
or after March 1, 1996. Therefore, individuals who have not completed an 18-month 
coordination period by July 31, 1997, will have a 30-month coordination period under the 
new law. The Common Working File (CWF) will deny claims for primary payment that  are submitted for applicable individuals during the 30-month coordination period. This 
provision does not apply to individuals who would reach the 18-month point on or before 
July 31, 1997. These individuals would continue to have an 18-month coordination 
period. 
 
A one-time utility program was executed in CWF to extend the ESRD coordination 
period for applicable individuals (those records with a Medicare Secondary Payer (MSP) 
code of "B" and a coordination period termination date of August 1997, or later) to 30 
months. This was done by adding 12 months to all coordination periods with a 
termination date on or after August 1997. All applicable records were changed by 
September 1, 1997. Any open records (those which do not have a termination date) 
remained open until they closed using the existing mechanisms, but following the time 
guidelines outlined above. That is, any ESRD, MSP termination dates, which were added 
to CWF where the coordination period ended in August 1997 or later, now reflect the 
new 30-month period. Claims erroneously submitted for primary payment are rejected 
with CWF Utilization Error Code 6803. 
 
50.2 - MSP W Record and Accompanying Processes                          
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
I. Common Working File Requirements (CWF) 
 
CWF accepts an MSP code of W for Workers Compensation Medicare Set-Aside 
Arrangements (WCMSA) for use on the HUSP records for application on the HUSP 
Auxiliary File.  The CWF indicates the description name for an MSP code W record as 
WC Medicare Set-Aside. 
 
The CWF accepts a contractor number 11119 on incoming MSP W HUSP records for 
application on the MSP Auxiliary file.  The CWF accepts a 19 in the source code field 
on both the HUSP, and HUST transactions for contractor 11119.  The CWF shall accept 
the Y validity indicator for HUSP transactions created by contractor 11119.  The CWF 
returns a 19 in the Source Code field of the 03 response trailer. 
 
The CWF allows contractors 11100, 11101, 11102, 11103, 11104, 11105, 11106, 11107, 
11108, 11109, 11110, 11111, 11112, 11113, 11114, 11115, 11116, 11117, 11118, 11119, 
11122, 11125, 11126, 11139, 11140,11141, 11142, 11143, 33333, 55555, 77777, 88888, 
99999, to update, delete, change records originated or updated by contractor 11119. 
 
CWF will create and send a transaction to the contractors shared systems that have 
processed claims for each beneficiary when an add or change transaction is received for 
contractor 11119 or from contractor 11119.  The CWF uses the following address for 
contractor number 11119: 
 
WCMSA Proposal/Final Settlement 
P.O. Box 138899   Oklahoma City, OK 73113-8899 
 
The CWF applies the same MSP consistency edits for Workers Compensation (WC) 
code E to MSP code W. 
 
The CWF maintainer creates error code (6815).  The message for this new error code 
(6815) reads WC Set-Aside exists. Medicare contractor payment not allowed. CWF 
activates this error under the following conditions: 
 
  A MSP code W record is present.  
 
  The record contains a diagnosis code related to the MSP code W occurrence. 
 
The CWF ensures that error code 6815 is overridden by MACS (A/B) and MACs 
(DME) with a code N or M, for claim lines or claims on which workers compensation 
set-aside diagnosis do not apply.  CWF accepts the new error code (6815) as returned on 
the 08 trailer. 
 
The CWF creates a HUSP transaction error code, SP76, to set when an incoming HUSP 
transaction with MSP Code W is submitted and the beneficiary MSP Auxiliary file 
contains an open MSP occurrence with MSP code E with the same effective date and 
diagnosis code(s). 
 
II.  Shared Systems and MACs (A/B) and MACS (DME) 
 
A/B MACs and DME MACs shared systems accepts MSP Code W to identify a 
Workers Compensation Medicare Set-Aside Arrangement (WCMSA) for use on HUSP 
records for application on the HUSP Auxiliary file.  The Medicare shared systems utilizes 
the description name of WC Medicare Set-Aside for MSP code W records. 
 
The shared systems:  
  Utilizes contractor number 11119 on incoming MSP W HUSP records for 
application on the MSP Auxiliary file. 
 
  Accepts contractor number 11119 and MSP code W and source code 19 on 
the returned 03 CWF trailer. 
 
  Accepts 19 in the source code field on the HUSP, and HUST transactions for 
contractor 11119.   
 
  Accepts a Y validity indicator, as well as, MSP code W for transactions created 
by contractor 11119. 
 
  Accepts and processes HUST transactions when an add, change or delete 
transaction is received for contractor 11119 or from contractor 11119. 
    Reflects CROWD/ report special project number 7019 as Workers 
Compensation Set-Aside Arrangements. 
 
  Accepts 19 in the header Payment Indicator field and in the detail Payment 
Process Indicator field for Contractor 11119. 
 
The MACS (A/B) and MACS (DME) and their systems continue to accept claims with 
value code 15 for Part A and Insurance Code (15) for Part B and DME MAC against an 
open W MSP Auxiliary file. 
 
The shared systems accepts error code (6815) as returned with the 08 trailer.  Following 
receipt of the utilization error code 6815, the A/B MACs and DME MACs systems deny 
all claims (including conditional payment claims) related to the diagnosis codes on the 
CWF MSP code W, when there is no termination date entered for the W code. 
 
Upon denying the claim, all contractor shared systems create a 19 Payment Denial 
Indicator in the header of its HUIP, HUOP, HUHH, HUHC, HUBC, HUDC claims. 
 
Upon denying the claim the MACs (B) and MACS (DME), MCS and VMS 
 
  Populate a W in the MSP code field and  
 
  Create a 19 in the HUBC and HUDC claim header transaction and a 19 in the 
claim detail process.  
 
Upon denying the claim MACs (A) and the FISS system  
 
  Populate a 15 in the value code field, in addition to the requirements referenced 
above. 
 
For MSP verification purposes, and prior to overriding claims on which the A/B MAC or 
DME MAC contractor received error code 6815, it shall: 
 
  check CWF to confirm that the date of service of the claim is after the termination 
date of the MSP W record. 
 
  and confirm the diagnosis code on the claim is related to the diagnosis codes on 
the MSP W record. 
 
MACs (B) and MACs (DME) overrides the payable lines with override code N. 
 
The MACs (A) override the payable claims with override code N.  If a claim is to be 
allowed, an N is placed on the 001 Total revenue charge line of the claim. 
 
The shared systems allows for an override of new error code 6815 with the code N. 
  The Comprehensive Error Rate Testing (CERT) contractor accepts the MSP code W in 
the claim resolution field. 
 
The shared systems bypasses the MSPPAY module if there is an open MSP code W. 
 
The shared systems does not make payment for those services related to diagnosis codes 
associated with the W Auxiliary record when the claims date of service is on or after 
the effective date and before or on the termination date of the record. 
 
The shared systems makes payment for those services related to the diagnosis codes 
associated with the W auxiliary record when a terminate date is entered and the claims 
date for service is after the termination date. 
 
The shared systems includes Reason Code 201, Group Code PR, Remark Code N722 
and Alert Remark Code MA01, when denying claims based on a W MSP auxiliary 
record on outbound 837 claims. 
 
The shared systems utilize Group Code PR; Remark Code N722 and Alert Remark 
Code MA01, Reason Code 201, when denying claims based on a W MSP auxiliary 
record for 835 ERA and SPR messages. 
 
The shared system will afford appeal rights for denied MSP code W claims. 
 
III.  The MACS (A/B) and MACs (DME): 
 
  Shall not make payment for those services related to diagnosis codes associated 
with an open W auxiliary record (not termed). 
 
  Shall make payment for those services related to diagnosis codes associated with 
a termed auxiliary W record when the claims date of service is after the 
termination date. 
 
The MACS (A/B) and MACs (DME) will include Reason Code 201, Group Code PR, 
Remark Code N722 and Alert Remark Code MA01, when denying claims based on a 
W MSP auxiliary record on outbound 837 claims. 
 
The MACS (A/B) and MACs (DME) utilize Group Code PR; Remark Code N722 and 
Alert Remark Code MA01, Reason Code 201, when denying claims based on a W 
MSP auxiliary record for 835 ERA and SPR messages. 
 
The MACS (A/B) and MACs (DME) and share systems shall afford appeal rights for 
denied MSP code W claims. 
 
Those systems responsible for the HETS 270/271 transaction shall ensure that 
documentation concerning the EB value and qualifier WC is updated. 
  The CROWD/MDX reflects special project number 7019 as Workers Compensation 
Medicare Set-Aside Arrangements. 
 
IV.  Medicare Residual Payment When WCMSA benefits terminate, or deplete, 
during a beneficiarys provider facility stay or upon a physicians visit. 
 
There are situations where WCMSA benefits may terminate, or deplete, during a 
beneficiarys provider facility stay or upon a physicians visit and a residual Medicare 
secondary payment is due.  Under these circumstances Medicare may make a residual 
secondary payment.  The term residual payment is defined as: a payment Medicare 
makes on a claim where available funds have been exhausted from the WCMSA benefit 
or responsibility for payment terminates mid-service.  The A/B MACs (A/B), DME 
MACs and shared systems may pay this residual secondary payment by sending the 
primary payer amounts to the MSPPAY module and calculate Medicares payment if 
such services are covered and reimbursable by Medicare. 
 
The MACs (A/B), MACs (DME), and shared systems, receive, accept, and make a 
residual payment on MSP Type 15 (MSP Code E) WCMSA electronic claims when the 
CAS segment shows one of the following CARCs and primary payer benefits are 
terminated, exhausted or the claim contains a partial or zero payment: 
 
27  Expenses occurred after coverage terminated. 
35  Lifetime benefit maximum has been reached. 
119  Benefit maximum for this time period, or occurrence, has been reached. 
149  Lifetime benefit maximum has been reached for this source/benefit category. 
 
The MACs (A/B), MACs (DME), and shared systems receive, accept, and make payment 
on MSP Type 15, WCMSA paper (hard copy) claims when the claim includes an 
attached remittance advice (RA)/Explanation of Benefits (EOB) that: 
 
1)  Shows the claim with a zero payment or was not paid in full by the primary 
payer and a residual payment is due;  
 
2)  Is a Medicare covered and reimbursable service; and  
 
3)  Contains a reason code for denial or similar verbiage if a reason code is not 
indicated: 
 
  Expenses occurred after the coverage terminated; 
  Lifetime benefit maximum has been reached; 
  Benefit maximum for this time period, or occurrence, has been reached; or  
  Lifetime benefit maximum has been reached for this source/benefit 
category. 
 
NOTE:  If an MSP Type 15, WCMSA electronic, or hard copy claim, is received and 
there is a corresponding WCMSA record on CWF and the claim contains a partial, or  zero, payment from a primary insurer and the claim, or attached primary payer remittance 
advice/EOB, does not include a reason code for denial or similar verbiage if a reason 
code is not indicated, the A/B MACs, DME MACs and shared system deny the claim 
based on the CWF utilization 6815. 
 
In order for the residual payment to occur, CWF performs the following functions: 
 
CWF HUIP, HUOP, HUHH, HUHC (HBIP, HBOP, HBHH, and HBHC for BDS) claims 
allow for a 1-byte field (Residual Payment Indicator) at the claim header level. Valid 
values for the field = X or space. 
 
CWF HUBC and HUDC (HBBC and HBDC for BDS) claims allow for a 1-byte field 
(Residual Payment Indicator) at the claim header level and at the detail level. Valid 
values for the field = X or space. 
 
NOTE:  The shared systems must ensure that the MACs are able to input an X in the 
header of their claims, and at the service line level, when applicable, that are sent to 
CWF, for situations when the claim is not paid, or not paid in in full, by the primary 
payer. 
 
CWF shall override the 6815 WCMSA utilization error code when the MACs determine 
a residual payment should be made on the claim. 
 
The MACs make a residual payment by placing the X at the header for the Part A 
claims, or an X at either the header or detail line for Part B Professional and DME 
MAC claims. 
 
The A/B MACs, DME MACs and shared systems must send the primary payers MSP 
amounts, found on the incoming WCMSA claim, to MSPPAY for Medicares Secondary 
Payment calculation when a residual payment is expected to be made by Medicare. 
 
NOTE:  When applicable, the A/B MACs and DME MACs send the attestation 
form/letter, it received from the reporting entity indicating WCMSA benefits are 
exhausted, to the MSP Contractor.  For ORM, the Section 111 reporting entity shall 
report that benefits are exhausted via the normal quarterly data file process. 
 
50.3 - MSP W Record and Accompanying Processes 
(Rev. 113, Issued: 08-06-15, Effective: 01-01-16, Implementation: 01-04-16) 
 
I. Common Working File Requirements (CWF) 
 
Effective July 1, 2009, the Common Working File (CWF) shall accept a new Medicare 
Secondary Payer (MSP) code W for Workers Compensation Medicare Set-Aside 
Arrangements (WCMSA) for use on the HUSP records for application on the HUSP 
Auxiliary File.  The CWF shall indicate the description name for a MSP code W record 
as WC Medicare Set-Aside.   
The CWF shall accept a new contractor number 11119 on incoming MSP W HUSP 
records for application on the MSP Auxiliary file.  The CWF shall accept a 19 in the 
source code field on both the HUSP, HUSC and HUST transactions for contractor 11119.  
The CWF shall accept the Y validity indicator for HUSP and HUSC transactions 
created by contractor 11119.  The CWF shall return a 19 in the Source Code field of 
the 03 response trailer. 
 
The CWF shall allow contractors 11100, 11101, 11102, 11103, 11104, 11105, 11106, 
11107, 11108, 11109, 11110, 11111, 11112, 11113, 11114, 11115, 11116, 11117, 11118, 
11119, 11122, 11125, 11126, 11139, 11140,11141, 11142, 11143, 33333, 55555, 77777, 
88888, 99999, to update, delete, change records originated or updated by contractor 
11119. 
 
CWF will create and send a HUSC transaction to the contractors shared systems that 
have processed claims for each beneficiary when an add or change transaction is received 
for contractor 11119 or from contractor 11119.  The CWF shall use the following address 
for contractor number 11119: 
 
WCMSA Proposal/Final Settlement 
P.O. Box 138899  
Oklahoma City, OK 73113-8899 
 
The CWF shall apply the same MSP consistency edits for Workers Compensation (WC) 
code E to MSP code W. 
 
The CWF maintainer shall create a new error code (6815).  The message for this new 
error code (6815) shall read WC Set-Aside exists. Medicare contractor payment not 
allowed. CWF shall activate this error under the following conditions: 
 
  A MSP code W record is present.  
 
  The record contains a diagnosis code related to the MSP code W occurrence. 
 
The CWF shall ensure that error code 6815 may be overridden by MACS (A/B) and 
MACs (DME) with a code N or M, for claim lines or claims on which workers 
compensation set-aside diagnosis do not apply.  CWF shall accept the new error code 
(6815) as returned on the 08 trailer. 
 
The CWF will create a new HUSP transaction error code, SP76, to set when an incoming 
HUSP transaction with MSP Code W is submitted and the beneficiary MSP Auxiliary 
file contains an open MSP occurrence with MSP code E with the same effective date 
and diagnosis code(s). 
 
II.  Shared Systems and MACs (A/B) and MACS (DME) 
  Effective July 1, 2009, contractor shared systems shall accept a new MSP Code W to 
identify a Workers Compensation Medicare Set-Aside Arrangement (WCMSA) for use 
on HUSP records for application on the HUSP Auxiliary file.  The Medicare shared 
systems shall accept the description name of WC Medicare Set-Aside for MSP code 
W records. 
 
The shared system shall accept a new contractor number 11119 on incoming MSP W 
HUSP records for application on the MSP Auxiliary file. 
 
The shared systems shall accept contractor number 11119 and MSP code  W and 
source code 19 on the returned 03 CWF trailer. 
 
The contractor shared systems shall accept 19 in the source code field on the HUSP, 
HUSC, and HUST transactions for contractor 11119.  The shared systems shall accept a 
Y validity indicator, as well as, MSP code W for HUSC transactions created by 
contractor 11119. 
 
The contractor shared systems shall accept and process HUSC and HUST transactions 
when an add, change or delete transaction is received for contractor 11119 or from 
contractor 11119. 
 
The CROWD report shall be updated to reflect special project number 7019 as 
Workers Compensation Set-Aside Arrangements. 
 
Shared systems shall accept 19 in the header Payment Indicator field and in the detail 
Payment Process Indicator field for Contractor 11119. 
 
The MACS (A/B) and MACS (DME) and their systems shall continue to accept claims 
with value code 15 for Part A and Insurance Code (15) for Part B and DME MAC against 
an open W MSP Auxiliary file. 
 
The shared systems shall accept new error code (6815) as returned with the 08 trailer.  
Following receipt of the utilization error code 6815, the Medicare contractors systems 
shall deny all claims (including conditional payment claims) related to the diagnosis 
codes on the CWF MSP code W, when there is no termination date entered for the W 
code. 
 
Upon denying the claim, all contractor shared systems shall create a 19 Payment Denial 
Indicator in the header of its HUIP, HUOP, HUHH, HUHC, HUBC, HUDC claims. 
 
Upon denying the claim the MACs (B) and MACS (DME), MCS and VMS shall... 
 
  Populate a W in the MSP code field and  
 
  Create a 19 in the HUBC and HUDC claim header transaction and a 19 in the 
claim detail process.    
Upon denying the claim MACs (A) and the FISS system shall...  
 
  Populate a 15 in the value code field, in addition to the requirements referenced 
above. 
 
For MSP verification purposes, and prior to overriding claims on which the contractor 
received error code 6815, the contractor shall: 
 
  check CWF to confirm that the date of service of the claim is after the termination 
date of the MSP W record. 
 
  and confirm the diagnosis code on the claim is related to the diagnosis codes on 
the MSP W record. 
 
MACs (B) and MACs (DME) shall override the payable lines with override code N. 
 
The MACs (A) shall override the payable claims with override code N.  If a claim is to be 
allowed, an N shall be placed on the 001 Total revenue charge line of the claim. 
 
The contractor shared systems shall allow an override of new error code 6815 with the 
code N. 
 
The Comprehensive Error Rate Testing (CERT) contractor shall accept the MSP code 
W in the claim resolution field. 
 
The shared systems shall bypass the MSPPAY module if there is an open MSP code 
W. 
 
The shared systems shall not make payment for those services related to diagnosis codes 
associated with the W Auxiliary record when the claims date of service is on or after 
the effective date and before or on the termination date of the record. 
 
The shared systems shall make payment for those services related to the diagnosis codes 
associated with the W auxiliary record when a terminate date is entered and the claims 
date for service is after the termination date. 
 
The shared systems shall include Reason Code 201, Group Code PR, Remark Code 
N722 and Alert Remark Code MA01, when denying claims based on a W MSP 
auxiliary record on outbound 837 claims. 
 
The shared systems shall utilize Group Code PR; Remark Code N722 and Alert 
Remark Code MA01, Reason Code 201, when denying claims based on a W MSP 
auxiliary record for 835 ERA and SPR messages. 
 
The shared system shall afford appeal rights for denied MSP code W claims.   
III.  The MACS (A/B) and MACs (DME): 
 
  Shall not make payment for those services related to diagnosis codes associated 
with an open W auxiliary record (not termed). 
 
  Shall make payment for those services related to diagnosis codes associated with 
a termed auxiliary W record when the claims date of service is after the 
termination date. 
 
The MACS (A/B) and MACs (DME)shall include Reason Code 201, Group Code PR, 
Remark Code N722 and Alert Remark Code MA01, when denying claims based on a 
W MSP auxiliary record on outbound 837 claims. 
 
The MACS (A/B) and MACs (DME) shall utilize Group Code PR; Remark Code 
N722 and Alert Remark Code MA01, Reason Code 201, when denying claims based 
on a W MSP auxiliary record for 835 ERA and SPR messages. 
 
The MACS (A/B) and MACs (DME) and share systems shall afford appeal rights for 
denied MSP code W claims. 
 
Those systems responsible for the 270/271 transaction shall ensure that documentation 
concerning the EB value and qualifier WC is updated. 
 
The CROWD report shall be updated to reflect special project number 7019 as 
Workers Compensation Medicare Set-Aside Arrangements. 
 
IV.  Medicare Residual Payment When WCMSA benefits terminate, or deplete, 
during a beneficiarys provider facility stay or upon a physicians visit. 
 
There are situations where WCMSA benefits may terminate, or deplete, during a 
beneficiarys provider facility stay or upon a physicians visit and a residual Medicare 
secondary payment is due.  Under these circumstances Medicare may make a residual 
secondary payment.  The term residual payment is defined as: a payment Medicare 
makes on a claim where available funds have been exhausted from the WCMSA benefit 
or responsibility for payment terminates mid-service.  The A/B MACs (A/B), DME 
MACs and shared systems may pay this residual secondary payment by sending the 
primary payer amounts to the MSPPAY module and calculate Medicares payment if 
such services are covered and reimbursable by Medicare. 
 
The MACs (A/B), MACs (DME), and shared systems, shall receive, accept, and make a 
residual payment on MSP Type 15 (MSP Code E) WCMSA electronic claims when the 
CAS segment shows one of the following CARCs and  primary payer benefits are 
terminated, exhausted or the claim contains a partial or zero payment: 
 
27  Expenses occurred after coverage terminated.  35  Lifetime benefit maximum has been reached. 
119  Benefit maximum for this time period, or occurrence, has been reached. 
149  Lifetime benefit maximum has been reached for this source/benefit category. 
 
The MACs (A/B), MACs (DME), and shared systems shall receive, accept, and make 
payment on MSP Type 15, WCMSA paper (hard copy) claims when the claim includes 
an attached remittance advice (RA)/Explanation of Benefits (EOB) that: 
 
4)  Shows the claim with a zero payment or was not paid in full by the primary 
payer and a residual payment is due;  
 
5)  Is a Medicare covered and reimbursable service; and  
 
6)  Contains a reason code for denial or similar verbiage if a reason code is not 
indicated: 
 
  Expenses occurred after the coverage terminated; 
  Lifetime benefit maximum has been reached; 
  Benefit maximum for this time period, or occurrence, has been reached; or  
  Lifetime benefit maximum has been reached for this source/benefit 
category. 
 
NOTE:  If an MSP Type 15, WCMSA electronic, or hard copy claim, is received and 
there is a corresponding WCMSA record on CWF and the claim contains a partial, or 
zero, payment from a primary insurer and the claim, or attached primary payer remittance 
advice/EOB, does not include a reason code for denial or similar verbiage if a reason 
code is not indicated, the MACs and shared system shall deny the claim based on the 
CWF utilization 6815. 
 
In order for the residual payment to occur, CWF performs the following functions: 
 
CWF HUIP, HUOP, HUHH, HUHC (HBIP, HBOP, HBHH, and HBHC for BDS) claims 
allow for a 1-byte field (Residual Payment Indicator) at the claim header level. Valid 
values for the field = X or space. 
 
CWF HUBC and HUDC (HBBC and HBDC for BDS) claims allow for a 1-byte field 
(Residual Payment Indicator) at the claim header level and at the detail level. Valid 
values for the field = X or space. 
 
NOTE:  The shared systems must ensure that the MACs are able to input an X in the 
header of their claims, and at the service line level, when applicable, that are sent to 
CWF, for situations when the claim is not paid, or not paid in in full, by the primary 
payer. 
 
CWF shall override the 6815 WCMSA utilization error code when the MACs determine 
a residual payment should be made on the claim.   
The MACs make a residual payment by placing the X at the header for the Part A 
claims, or an X at either the header or detail line for Part B Professional and DME 
MAC claims. 
 
The A/B MACs, DME MACs and shared systems must send the primary payers MSP 
amounts, found on the incoming WCMSA claim, to MSPPAY for Medicares Secondary 
Payment calculation when a residual payment is expected to be made by Medicare. 
 
NOTE:  When applicable, the MAC shall send the attestation form/letter, it received 
from the reporting entity indicating WCMSA benefits are exhausted, to the BCRC.  For 
ORM, the Section 111 reporting entity shall report that benefits are exhausted via the 
normal quarterly data file process. 
 
60 - Converting Health Insurance Portability and Accountability Act 
(HIPAA) Individual Relationship Codes to Common Working File 
(CWF) Medicare Secondary Payer (MSP) Patient Relationship Codes 
(Rev. 11996, Issued:04-27-23; Effective: 05-29-23; Implementation: 05-29-23) 
 
CMS has realized that its Common Working File (CWF) HUSP transaction does not 
allow for the correct association of HIPAA individual relationship codes, as found in the 
HIPAA 837 institutional and professional claims implementation guides, with 
corresponding MSP Type Codes, such as working aged (A), end-stage renal disease (B), 
and disability (G).  Therefore, effective July 6, 2004, all A/B MACs (A) that receive 
incoming electronic HIPAA, DDE, or hard copy claims that are in the HIPAA ASC X12 
837 format shall convert the incoming individual relationship codes to their equivalent 
CWF patient relationship codes.  Until further notice, A/B MACs (A) shall continue to 
operate under the working assumption that all providers will be including HIPAA 
individual relationship codes on incoming claims. 
  
Before CMS systems changes are effectuated, A/B MACs (A) may receive SP edits (i.e., 
SP-33 and SP-52) that indicate that an invalid patient relationship code was applied.  A/B 
MACs (A) are to resolve those edits by manually converting the HIPAA individual 
relationship code to the CWF patient relationship code, as specified in the conversion 
chart below.  If the A/B MAC (A) receives MSP edits and can determine that the HIPAA 
individual relationship code rather than the CWF patient relationship code was submitted 
on the incoming claim, it shall manually work the MSP edits incurred by converting the 
HIPAA individual relationship code to the appropriate CWF patient relationship code. 
 
Until Part A shared system changes are effectuated to convert HIPAA individual 
relationship codes to CWF patient relationship codes, A/B MACs (A) may move claims 
with a systems age of 30 days or older that have suspended for resolution of patient 
relationship code, including SP-33 or SP-52 edits, to condition code 15 (CC-15). 
  The A/B MAC (A) contractor system shall utilize the conversion charts, found below, to 
cross-walk incoming HIPAA individual relationship codes to the CWF patient 
relationship code values. 
 
For MSP Occurrences with accretion dates PRIOR to 4/4/2011: 
 
HIPAA  Convert To CWF  Valid Values  
Individual  Patient Relationship 
Relationship  Codes  
Codes  
18   01   Patient is Insured  
01   02   Spouse  
19   03   Natural Child, Insured has financial 
responsibility  
43   04   Natural Child, insured does not have 
financial responsibility  
17   05   Step Child  
10   06   Foster Child  
15   07   Ward of the Court  
20   08   Employee  
21   09   Unknown  
22   10   Handicapped Dependent  
39   11   Organ donor  
40   12   Cadaver donor  
05   13   Grandchild  
07   14   Niece/Nephew  
41   15   Injured Plaintiff  
23   16   Sponsored Dependent  
24   17   Minor Dependent of a Minor 
Dependent  
32,33   18   Parent  
04   19   Grandparent  
53   20   Life Partner  
29   N/A   Significant Other  
30   N/A   ?  
31   N/A   ?  
36   N/A   ?  
G8   N/A   ?  
Other HIPAA  N/A   ?  
Individual 
Relationship Codes  
 
For MSP Occurrences with accretion dates 4/4/2011 AND SUBSEQUENT: 
  HIPAA  Convert To CWF  Description 
Individual  Patient Relationship 
Relationship  Codes 
Codes 
18   01   Self; Beneficiary is the policy holder 
or subscriber for the other GHP 
insurance reflected by the MSP 
occurrence or- Beneficiary is the 
injured party on the Workers 
Compensation, No-Fault, or Liability 
claim 
01   02   Spouse  
19   03   Child  
43   03  Child 
17   03  Child 
10   03   Child 
15   04   Other 
20   04   Other  
21   04   Other  
22   04  Other  
39   04   Other  
40   04   Other  
05   04   Other  
07   04  Other  
41   01  Self; Beneficiary is the policy holder 
or subscriber for the other GHP 
insurance reflected by the MSP 
occurrence or- Beneficiary is the 
injured party on the Workers 
Compensation, No-Fault, or Liability 
claim 
23   04   Other  
24   04   Other  
32,33   04  Other  
04   04   Other  
53   20   Life Partner  
29   N/A   Significant Other  
30   N/A   ?  
31   N/A   ?  
36   N/A   ?  
G8   N/A   ?  
Other HIPAA  N/A   ?  
Individual 
Relationship Codes    
A/B MACs (A) allow CWF patient relationship codes, since these files should be 
populated with information sent back to the A/B MACs (A) systems via the automated 
transaction. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR# 
R11996MSP 04/27/2023 Significant Updates to Internet Only  05/29/2023  13160 
Manual (IOM) Publication (Pub.) 100-05 
Medicare Secondary Payer (MSP) Manual, 
Chapter 6 
R11381MSP 04/29/2022 Updating the Common Working File  10/03/2022  12678 
(CWF) Logic Tied to Medicare Secondary 
Payer (MSP) Investigational Records to 
Match Newly Revised Development 
Timeframes 
R10753MSP 05/11/2021 Update the Common Working File (CWF)  10/04/2021  12176 
to Accept a Group Health Plan (GHP) and 
non-GHP (NGHP) Medicare Secondary 
Payer (MSP) Effective Date 3 Months from 
the Current Date for Medicare Enrolled and 
Medicare Entitled Beneficiaries 
R10243MSP 07/31/2020 Updating the Common Working File  01/04/2021  11771 
(CWF) to allow for a Medicare Secondary 
Payer (MSP) Termination Date Greater 
than the Current Date Plus Six Months for 
non-Group Health Plan (NGHP) MSP 
Auxiliary Records 
R125MSP  03/22/2019 Update to Publication (Pub.) 100-05 to  04/22/2019  11193 
Provide Language-Only Changes for the 
New Medicare Card Project 
R124MSP  08/31/2018 Updates to Chapters 5 and 6 of Publication  10/01/2018  10855 
100-05 to Further Clarify Medicare 
Secondary Payer (MSP) Processes that 
Include Electronic Correspondence 
Referral System (ECRS) Requests 
Submissions and Timely Submission of 
MSP I Records, General Inquiries and 
Hospital Reviews  R121MSP  06/01/2018 Update the International Classification of  10/01/2018  10803 
Diseases, Tenth Revision (ICD-10) 2019 
Tables in the Common Working File 
(CWF) for Purposes of Processing Non-
Group Health Plan (NGHP) Medicare 
Secondary Payer (MSP) Records and 
Claims 
R119MSP  04/07/2017 Implement the International Classification  10/02/2017  9947 
of Diseases, Tenth Revision (ICD-10) 2018 
General Equivalence Mappings (GEMs) 
Tables in the Common Working File 
(CWF) for Purposes of Processing Non-
Group Health Plan (NGHP) Medicare 
Secondary Payer (MSP) Records and 
Claims 
R114MSP  09/18/2015 Claims Processing Medicare Secondary  07/06/2015  8984 
Payer (MSP) Policy and Procedures 
Regarding Ongoing Responsibility for 
Medicals (ORM) 
R113MSP  08/06/2015 Instructions for the Shared Systems and  01/04/2016  9009 
Medicare Administrative Contractors 
(MACs) to follow when a Medicare 
Residual Payment must be Paid on 
Workers Compensation Medicare Set-
aside Arrangement (WCMSA) or for 
Ongoing Responsibility of Medicals 
(ORM) Non-Group Health Plan (NGHP) 
Medicare Secondary Payer (MSP) Claims 
R110MSP  03/06/2015 Claims Processing Medicare Secondary  07/06/2015  8984 
Payer (MSP) Policy and Procedures 
Regarding Ongoing Responsibility for 
Medicals (ORM)  Rescinded and replaced 
by Transmittal 114 
R107MSP  10/24/2014 Update to Pub. 100-05, Chapters 05 and 06  11/28/2014  8947 
to Provide Language-Only Changes for 
Updating ICD-10 and ASC X12  R95MSP  08/23/2013 Update of the Common Working File  01/06/2014  8351 
(CWF) to not Allow Certain Diagnosis 
Codes on No-Fault Medicare Secondary 
Payer (MSP) Records 
R94MSP  06/28/2013 Update the Medicare Secondary Payer  07/30/2013  8253 
Manuals to Indicate Unsolicited Refund 
Documentation is No Longer a 
Justification for Submission of an I 
Record 
R89MSP  08/30/2012 Expanding the Coordination of Benefits  01/07/2013  7906 
(COB) Contractor Numbers to Include 
11139 and 11142 for the Common 
Working File (CWF) 
R88MSP  08/17/2012 Expanding the Coordination of Benefits  01/07/2013  7906 
(COB) Contractor Numbers to Include 
11139 and 11142 for the Common 
Working File (CWF) 
R81MSP  07/29/2011 Requesting the Common Working File  01/03/2012  7483 
(CWF) to Cease Submitting First Claim 
Development (FCD) and Trauma Code 
Development (TCD) Alerts to the 
Coordination of Benefits Contractor 
(COBC) 
R77MSP  01/21/2011 Categorizing Diagnosis Codes 500-508 and 07/05/2011  7149 
800-999 on Incoming Medicare Secondary 
Payer (MSP) Claims and on the MSP 
Auxiliary File for non-Group Health Plan 
(GHP) Claims 
R76MSP 11/19/2010 Common Working File (CWF) Medicare  04/04/2011  7216 
Secondary Payer ( MSP) Coordination of 
Benefits Contractor (COBC) Number 
Update and Implementation of MSP Group 
Health Plan (GHP) COBC Hierarchy Rules 
as related  to Mandatory Insurer Reporting 
R74MSP 04/28/2010 New Medicare Secondary Payer Insurer  10/04/2010  6768 
Type Codes  R65MSP  03/20/2009 New Common Working File (CWF)  04/06/2009/ 5371 
Medicare Secondary Payer (MSP) Type for 07/06/2009 
Workers Compensation Medicare Set-
Aside Arrangements (WCMSAs) to Stop 
Conditional Payments 
R64MSP  01/09/2009 New Common Working File (CWF)  04/06/2009/ 5371 
Medicare Secondary Payer (MSP) Type for 07/06/2009 
Workers Compensation Medicare Set-
Aside Arrangements (WCMSAs) to Stop 
Conditional Payments - Rescinded and 
replaced by Transmittal 65 
R61MSP  10/03/2008 Expanding the Mandatory Insurer  01/05/2009  6182 
Reporting (MIR) Coordination of Benefits 
(COB) Contractor Numbers for the 
Common Working File (CWF) 
R60MSP  09/19/2008 Expanding the Mandatory Insurer  01/05/2009  6182 
Reporting (MIR) Coordination of Benefits 
(COB) Contractor Numbers for the 
Common Working File (CWF) - Rescinded 
and replaced by Transmittal 61 
R43MSP  10/31/2005 Expanding the Voluntary Data Sharing  04/03/2006  3826 
Agreement (VDSA) Coordination of 
Benefit (COB) Contractor Numbers for the 
Common Working File (CWF) 
R31MSP  07/08/2005 Full Replacement of CR 3770,Expanding  10/03/2005  3909 
the Number of Source Identifiers for 
Common Working File (CWF) MSP 
Records 
R12MSP  03/05/2004 Converting HIPAA Individual Relationship 03/19/2004  3117 
Codes to Common Working File (CWF) 
Patient Relationship Codes 
R09MSP  02/06/2004 Converting Health Insurance Portability  07/06/2004  3116 
and Accountability ct (HIPAA) Individual 
Relationship Codes to Common Working 
File (CWF) Patient Relationship Codes 
R08MSP  02/06/2004 Common Working File MSP Modifications 07/06/2004  2775  R06MSP  01/162004  Automatic Notice of Change to MSP  01/01/2004  2608 
Auxiliary File 
R01MSP  10/01/2003 Initial Issuance of Manual  N/A  N/A 
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