When Can I Submit a Claim to Medicare For a Conditional Payment?

Medicare is the secondary payer of claims when no-fault or liability insurance is available as the primary payer, even though state law or the insurance plan or policy states that its benefits are secondary to Medicare or otherwise excludes/limits its payments if the injured party is also entitled to Medicare benefits. No Medicare payments are made when payment has been made or can reasonable be expected to be made promptly by the no-fault or liability insurer, and until no-fault or liability insurance has been exhausted. Providers and suppliers should first try to get claims paid by the no-fault or liability insurer. A provider or supplier may not collect payment from a beneficiary until after the proceeds of the no-fault or liability insurance are available to the beneficiary.

If no-fault or liability insurance does not pay or denies claims, Medicare may make a conditional payment. However, Medicare will only pay for Medicare covered services. Providers and suppliers may collect expenses for non-covered services from the beneficiary who received the service.

If it is determined that the liability or no-fault insurer will not pay "promptly" (within 120 days), providers and suppliers may submit claims to Medicare using the appropriate codes and Medicare may make a conditional payment. However, when the proceeds from the no-fault or liability settlement become available, Medicare has priority right of recovery. This means that Medicare collects the money it used for the conditional payment from the settlement before other providers and suppliers may collect from the settlement proceeds.

Submitting the Conditional Payment Through DDE
(page 1)
Condition Code 02 - condition is employment related
Occurrence Code 04 - Accident/Employment related with the date of the accident
Occurrence Code 24 - Date insurance denied the claim

Payer Code and Insurance Information (page 3)
Apply Payer Code
Name of the insurance company and provider number

Remarks Field (page 4)
Explain why the conditional payment is justified

Page 5
Insured name
Employer name and address

Page 6
MSP additional insurer information