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.
Reference