Loops and Segments Table

The following are instructions for the segments and elements that are required when submitting MSP information electronically. Please note that some segments and elements are situational but may become required when used.

Loop 2000B – Subscriber Information

Usage : Required
Element : SBR01
Value :
S =Secondary
Use to indicate ‘payer of last resort’
Comment : Code identifying the insurance carrier’s level of responsibility for payment of a claim. (To identify whether Medicare is primary, secondary or tertiary) For Medicare Secondary Payer (MSP) claims being sent to Medicare Part B the code would be “S”.

Usage: Situational
Element : SBR02
Value : 18
Comment : Specifies the relationship to the person insured.

Usage: Situational
Element : SBR03
Value : Nil
Comment : Policy or group number

Usage: Situational
Element : SBR04
Value : Nil
Comment :The name of group plan

Usage: Situational
Element : SBR05
Value :
12 = Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
13 = Medicare Secondary End-Stage Disease Beneficiary in the 12 month coordination period with an employer’s group health plan
14 = Medicare Secondary, No-fault Insurance including Auto is Primary
15= Medicare Secondary Worker’s Compensation
16 = Medicare Secondary Public Health Services (PHS) or Other Federal Agency
41 = Medicare Secondary Black Lung
42 = Medicare Secondary Veteran’s Administration
43 = Medicare Secondary Disabled Beneficiary Under Age 65 with Large group Health Plan (LGHP)
47 = Medicare Secondary, Other Liability Insurance is Primary

Comment :
Code to identify the type of insurance policy within a specific insurance program.
(Required when SBR01 = S)

Usage: Situational
Element : SBR09
Value :
09 = Selfpay
10 = Central Certification
11 = Other Non-Federal Programs
12 = Preferred Provider Organization (PPO)
13 = Point of Service (POS)
14 = Exclusive Provider Organization (EPO)
15 = Indemnity Insurance
16 = Health Maintenance Organization (HMO) Medicare Risk
AM = Automobile Medical
BL = Blue Cross/Blue Shield
CH = Champus
CI = Commercial Insurance Co.
DS= Disability
HM= Health Maintenance Organization
LI = Liability
LM = Liability Medical
MB = Medicare Part B
MC = Medicaid
OF = Other Federal Program
TV = Title V
VA = Veteran Administration Plan
WC = Workers’ Compensation Health Claim
ZZ = Mutually Defined

Comment : Code to identify the type of claim.