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Last Modified: 10/12/2018 Location: FL, PR, USVI Business: Part A

Conditional payment requests for MSP claims

Providers may file a Medicare secondary payer (MSP) claim and request a conditional payment for a Medicare-covered service when the following criteria have been met:
Another payer is responsible for payment
Prompt payment (i.e., within 120 days) is not expected from the primary payer
A time period of 120 days has lapsed before filing the MSP claim
Once the primary payer has remitted payment, Medicare has the right to recover any conditional payments made. For more information, please refer to the MSP fact sheet external pdf file published by the Centers for Medicare & Medicaid Services (CMS).
When requesting a conditional payment via hardcopy UB-04, the claim must have payer code "C" listed with the primary insurance's name in the "A" field and Medicare in the "B" field with payer code "Z". In addition, the claim must state why the primary insurance did not make a payment on the claim in the remarks section and the associated claim adjustment reason code (CARC). Value code (VC) 44 should not be billed on a claim requesting a conditional payment. VC 44 is used to report the amount the provider or facility has agreed to accept by the primary payer as payment in full. Billing VC 44 on a conditional payment claim is contradictory.
The chart below provides the appropriate value code (VC) to also be included on the claim.

MSP claim type

Value code (VC)

Value amount

Occurrence codes

Condition code

Working aged
12
$0
24 -- date insurance denied or last date primary payer contacted
N/A
End-stage renal disease (ESRD)
13
$0
24 -- date insurance denied or last date primary payer contacted
N/A
No-fault
14
$0
01 -- auto accident date
02 -- no-fault insurance involvement date
24 -- date insurance denied or last date primary payer contacted
N/A
Worker’s compensation (WC)
15
$0
04 -- accident/tort liability date
24 -- date insurance denied or last date primary payer contacted
02 -- condition is employment related
WC set-aside
N/A
N/A
N/A
N/A
Disabled
43
$0
24 -- date insurance denied or last date primary payer contacted
N/A
Liability
47
$0
24 -- date insurance denied or last date primary payer contacted
N/A
Note: WC set-aside claims are ineligible for conditional payments.
Source: Centers for Medicare & Medicaid Services (CMS) internet-only manual (IOM) publication100-05 Medicare Secondary Payer (MSP) Manual, chapter 5 Contractor Prepayment Processing Requirement, change requests (CR)6426 external pdf file, 7355 external pdf file
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