Please Note: There is no Medicare information on our corporate website. Please select a specific contract in the 'Search Within' box for Medicare related information.
© 2019 Palmetto GBA, LLC
We frequently update our articles to reflect the latest changes and updates to Medicare, and strongly recommend you visit this article at link below to confirm you have the latest version.
Printed Date: 9/22/2015
The information on this tip sheet is designed to assist providers in understanding when Medicare will make a conditional payment for Medicare covered services. When the conditional payment requirements outlined below are met, refer to the billing instructions provided in the Medicare Secondary Payer (MSP) Interactive Process Tool for submitting claims.
Definition of Conditional Payment
A provider may submit a claim to Medicare for conditional payment for services for which another payer is responsible. If payment has not been made or cannot be expected to be made promptly from the other payer, Medicare may make a conditional payment, under some circumstances, subject to Medicare payment rules. Conditional payments are made subject to repayment when the primary plan makes payment.
Group Health Plan (GHP) Conditional Payment
A conditional payment may be made in situations where a Group Health Plan (GHP) applies only when the physical or mental incapacity of the beneficiary, provider, physician or other supplier, or beneficiary failed to file a proper claim with the GHP.
No-Fault, Workers’ Compensation, and Liability Insurance Conditional Payment
A conditional payment may be made in situations where liability, no-fault or workers’ compensation claims apply when:
Situations When 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:
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:
To indicate that claims were denied by Medicare because the claim was not submitted to the appropriate primary GHP for payment, Medicare will use the following codes on the remittance advice (RA):
Medicare Secondary Payer (MSP) Adjustment
If a provider submits a Medicare Secondary Payer (MSP) adjustment claim, enter one of the following condition codes:
We value your opinion and want to provide the highest-quality and most relevant Medicare knowledge possible. Please let us know if this article was helpful.
It didn't answer my question
This article was helpful
We’re glad we could help you today and appreciate your feedback. When you rate our articles as most helpful, we know that we are on the right track for providing you with important news and information.
We're sorry this article didn't help you today. We'll use your feedback to review this article to try to revise or expand it. Contact us with more feedback or a question on this topic.
Last Updated: 10/09/2019