In Section 40.3 and 40.3.2 of the Centers for Medicare & Medicaid Services' (CMS's) Medicare Secondary Payer Manual (CMS Manual System, Pub 100-05, Chapter 5), providers are required to submit documentation when requesting a group health plan (value codes 12, 13 or 43 only) conditional payment when
one of the following situations applies:
1. The primary benefits have been exhausted
2. The services are not covered under primary plan
3. The services were applied to the deductible or coinsurance
In order for a conditional payment claim to meet one of the above situations, documentation must be received.
The above situations would be the only time documentation should be sent to Medicare. Please submit a completed Request for a Conditional Payment form and a copy of the explanation of benefits (EOB)/denial to:
Palmetto GBA
Medicare Part A Claims Department
Mail Code: AG- 600
PO BOX 100238
Columbia, SC 29202-3238
Palmetto GBA's Claims Department created this form to expedite the processing of conditional payments. We encourage providers to begin using this form immediately when submitting conditional payments.
The Request for a Conditional Payment Form is available on the Palmetto GBA Web site. To access this form:
1. Go to
http://www.PalmettoGBA.com/anc (for North Carolina Part A providers,
http://www.PalmettoGBA.com/asc (for South Carolina Part A providers) or
http://www.PalmettoGBA.com/RHHI (for home health and hospice providers).
2. Scroll down to the
Resources section and select
Forms
3. Select the
Request for a Conditional Payment Form link
4. Click on the
View Attachments icon at the top of the page.
5. Select the
Request for a Conditional Payment Form.pdf file and print the form
.
A copy of this form is also attached. Select the
View Attachments icon to view this form.
If the required information is not received, the claim will be returned to the provider requesting documentation to support the conditional payment request.
Once the form and Explanation of Benefits (EOB) have been sent to Medicare, your claim will be worked out of Return to Provider (RTP) status.
Please do not suppress the claim. Documentation that has been received will be returned to the provider if the claim has been suppressed.
All other types of requests for conditional payment should be noted in the Remarks section of the claim and no EOB/denial should be submitted. Providers should refer to Section 40.6 of the Medicare Secondary Payer Manual (CMS Manual System, Pub 100-05, Chapter 5) for a list of situations when conditional primary Medicare benefits can be paid.
Questions and Answers
Should I send a UB04 claim with the EOB for conditional payment?
No. The only documentation needed is the Request for Conditional Payment Form and a copy of the EOB.
If my claim is not on the system with reason code 31102, should I send a hardcopy UB 04 with the EOB information?
No. These claims will be returned for the provider to enter them into the system.
If my claim has been inactivated what do I need to do prior to sending EOB information?
Re-enter the claim and when the claim returns with 31102, submit the form and EOB. Leave the claim in RTP status and it will process from there. Remember do not suppress your claim.