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
Note: 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 published by 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 |
| Workers' 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.
The claim must also include remarks indicating reason for conditional payment:
- Explain why primary payment was not made.
- Remarks can be just the abbreviation, just the description words, or have both. Similar verbiage to what is listed below is acceptable.
| Abbreviation | Description/remarks |
|---|---|
| BE | Benefits are exhausted |
| CD | Charges applied to copay, deductible, or coinsurance |
| DA | 120 days have passed since the primary was billed |
| DP | Delay in payment from liability insurer |
| FG |
Beneficiary did not follow guidelines. Note: Must list which guideline was not followed: 1. Untimely filing 2. Out of network 3. No prior authorization |
| LD | Response received from liability insurer stating they are not responsible for claim |
| NB | Not a covered benefit |
| NR | Not related |
| PE or PIP | PIP exhausted toward other medical expenses |
| PP | Patient paid by liability insurer |
| PR | Patient responsibility |
Reimbursing Medicare
Reimburse Medicare by submitting a claim adjustment or reopening within 60 days of receiving payment from the primary payer. Do not cancel the claim.
Situations where conditional payment is denied
Medicare will deny claims submitted for conditional payment when the provider submits the claim to the liability, no-fault, or WC claims and payment is denied if:
- There is an employer GHP that is primary to Medicare; and
- You did not send the claim to the employer GHP first
Medicare will also deny claims when the provider submitted the claim to the liability insurer (including the self-insurer), no-fault, insurer or WC entity, but the insurer entity did not pay the claim if:
- There is an employer GHP that is primary to Medicare; and
- The employer GHP denied the claim because the GHP asserted that the liability insurer (including the self-insurer), no-fault insurer, or WC entity should pay first.
References