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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.
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:
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Last Updated: 12/12/2019