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
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:
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:
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: 03/28/2019