MSP Auditor Tip on Conditional Payment Billing

Money applied to the primary Group Health Plan (GHP) deductible/coinsurance does not meet the requirements for conditional payments. The Palmetto GBA Medicare Secondary Payer (MSP) Auditors recommend the following for when providers submit claims as conditional payment.

A conditional primary payment may be requested if conditional payment criteria are met. When a group health plan (GHP) does not make payment for the reasons listed below, a conditional Medicare payment can be requested (CMS IOM 100-05, Chapter 3, Section 40.3.1). Conditional payments may be requested where:

  • Provider has filed a proper claim under the plan and the plan denies the claim in whole or in part; or
  • Provider fails to file a proper claim because of the physical or mental incapacity of the beneficiary

Benefit determinations applied to the deductible/coinsurance are excluded from this criteria. Neither primary benefits nor conditional primary Medicare payments may be made where a GHP denies payment for particular services on the grounds they are not covered by the plan, and the contractor believes the plan does cover them.

Conditional benefits are not paid if a plan offers only secondary coverage for services covered by Medicare, and the GHP does not allege that the employer has fewer than 20 employees. Conditional primary benefits are not paid even if the GHP has only collected premiums for secondary rather than primary coverage. Where a GHP has denied the claim for Medicare primary benefits unless the single employer GHP or multi-employer plan with an approved multiple employer plan exemption alleges that the employer has fewer than 20 employees. 

Listed below is a claim example that illustrates the proper way for these claims to be submitted without the claim being suspended:

  • Value code 12: 0.00
  • Value code 44: 145.53
  • Page 7 Remarks: Primary Insurance Benefits Applied Towards Deductible

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