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Requesting Medicare secondary payer conditional payments

Medicare may not make payment if workers’ compensation, no-fault or liability insurance is the proper primary payer. 

Medicare may make a conditional payment when there is evidence that payment has not been made or cannot reasonably be expected to be made promptly by workers’ compensation, liability insurance (including self-insurance), or no-fault insurance. These payments are referred to as conditional payments because the money must be repaid to Medicare when a settlement, judgment, award, or other payment is secured.

Prompt or promptly means:

  • Liability insurance (including self-insurance)
    • Payment within 120 days after the earlier of the following: 
      • Date a general liability claim is filed with an insurer or a lien is filed against a potential liability settlement, or
      • Date the service was furnished 
    • After the 120-day period 
      • If you choose to bill Medicare withdraw claims against the liability insurer and any liens placed on the beneficiary’s settlement. 
      • If you choose to continue the claim against the liability insurer, you may not submit the claim to Medicare.
  • No-fault and workers' compensation 
    • Payment within 120 days after receipt of the claim
    • After the 120-day period, you may bill Medicare conditionally.

Note: If an injury resulted from an automobile accident and/or there is an indication of primary coverage under a group health plan (GHP), bill the liability insurer or no-fault insurer and/or GHP before requesting conditional Medicare payments. Medicare does not make conditional primary payment when there is GHP coverage that is primary to Medicare.

Billing

When submitting paper claims:

For providers who have been approved to submit paper claims, attach a copy of the primary payer’s Explanation of Benefits (EOB) statement or other supporting documentation that clearly shows the reason for non-payment or payment delay.

When submitting electronic claims:

No-fault/liability

  • 2320 SBR05 = Insurance type code
    • 14 - No-Fault
    • 47 - Liability
  • 2320 SBR09 = Claim filing indicator
    • AM - Automobile medical
    • LM - Liability medical
  • 2320 AMT02 = $0 if whole claim is a non-GHP claim and conditional payment is being requested for the whole claim, or
  • 2430 SVD02 = complete for line level conditional payment requests if the claim contains other service line activity not related to the accident or injury
  • Date of accident 
    • 2300 DTP 01 through 03 (Qualifier 439, D8) and 2300 CLM 11-1 through 11-3 with value AA or OA

Worker's compensation

  • 2320 SBR05 = Insurance type code
    • 15 - Worker's Compensation
  • 2320 SBR09 = Claim filing indicator
    • WC - Workers’ Compensation
  • 2320 AMT02 = $0 if whole claim is a non-GHP claim and conditional payment is being requested for the whole claim, or
  • 2430 SVD02 = complete for line level conditional payment requests if the claim contains other service line activity not related to the accident or injury
  • 2300 HI = Condition code
    • 02-Condition is Employment Related
  • Date of accident
    • 2300 DTP 01 through 03 (Qualifier 439, D8) and 2300 CLM 11-1 through 11-3 with value EM

 

References