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Prepare and Submit an MSP Conditional Claim

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Prepare and Submit an MSP Conditional Claim

  • Fact: Before you can bill Medicare, you are first required to bill the payer(s) you have identified as primary for the beneficiary’s services. Refer to the 'Identify the Proper Order of Payers for a Beneficiary’s Services' instructions linked on the left.

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Step 1: Determine if You Can Submit a Conditional Claim

If you bill the primary payer but you do not receive payment for a valid reason (for all primary payers except MSP VC 16 (PHS) or VC 42 (Veterans Administration), you can submit a conditional claim to Medicare. For MSP VCs 16 or 42, if these payers do not make payment for a valid reason, you can submit Medicare primary (not conditional) claims.

If you bill the primary payer for an accident but you do not receive payment within 120 days (for primary payers of accidents including MSP VCs 14, 15, 41, or 47), you can submit a conditional claim to Medicare.

Note on Liability Plans: After waiting 120 days from the date on which you billed the primary payer, you can choose to submit a conditional claim to Medicare or to maintain all claims/liens against the liability insurance/beneficiary’s liability insurance settlement. If you choose to submit a conditional claim to Medicare in a case where liability is the primary payer, you must first withdraw all claims/liens against the liability insurance/beneficiary’s liability insurance settlement. You may maintain liens with the liability insurance/beneficiary’s liability insurance settlement only for services not covered by Medicare and for Medicare deductible and coinsurance amounts. See CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 2, Section 40.2, letter B.

Conditional claims are coded similarly to MSP claims since the primary payer is reported as the first payer and Medicare is reported as the secondary payer (unless Medicare is tertiary or greater). However, for conditional claims, you report:

  • A primary payer’s payment amount of zero
  • An OC 24 and the date on which you learned that the primary payer was not going to pay for the claim (in all but one situation)
  • Remarks to indicate the two-digit code representing why the primary payer did not make payment

From a reimbursement standpoint, a claim paid conditionally is paid the same as if there was no insurance other than Medicare.

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Step 2: Prepare a Conditional Claim

Once it has been determine that a conditional claim will be submitted, prepare the conditional claim using the following guidelines:

  1. Use a covered TOB; do not use a noncovered TOB, e.g., 110 or 130, etc.
  2. Complete the claim (UB-04CMS-1450 claim form, FISS DDE claim entry or 837I claim) in the usual manner.
  3. Report all claim coding usually required for the services including charges for all Medicare-covered services
  4. If submitting an inpatient conditional claim, report the covered and noncovered days/charges as usual
  5. Follow Medicare’s technical, medical and billing requirements since these requirements apply to conditional claims (just as they do to Medicare primary claims).
    • Hospice providers: Submit the NOE showing Medicare as primary regardless of the order of payers. You will report the applicable MSP information on your claim(s).
    • Home health providers: Submit the RAP showing Medicare as primary regardless of the order of payers. You will report the applicable MSP information on your final episode claim(s).
  1. Follow your Medicare “frequency of billing” guidelines. For example, if your provider type is required to submit claims to Medicare every 30 days or every 60 days, then this remains true even though Medicare is not the primary payer.
  2. In addition, report the following MSP billing codes from the Conditional Billing Code Table (below) on the claim, if applicable.
  3. Report on the claim any applicable adjustment(s) made by the primary payer by including the CAGC(s), CARC(s) and associated amount(s) from the primary payer’s RA. Refer to CRs 6426 and 8486.

CAGC(s):

  • Required when primary payer adjusts billed charges
  • Identifies the general category of the payment adjustment
  • Options:
    • CO (Contractual Obligations)
    • OA (Other Adjustments)
    • PI (Payer Initiated Reductions)
    • PR (Patient Responsibility)

CARC(s):

  • Required when the primary payer adjusts billed charges
  • Explains why the primary payer paid differently than it was billed
  • Options:
    • Primary payer’s RA shows the CARC(s) for each CAGC. For CARC definitions, refer to X12

If using FISS DDE to enter a conditional claim:

  • Enter the information from the primary payer’s RA in the new Claim Entry page 03 (MAP1719).
  • To reach MAP1719, press F11/PF11 from MAP1713 (the original Claim Entry page 03).
  • You can enter information for up to two primary payers (up to 20 entries for each payer).
  • Once you enter the information for primary payer #1, you can enter information for primary payer #2 on the second page of MAP1719 (press F6/PF6 from the first page of MAP1719).
  • MAP1719 fields:
    • Paid date: Enter paid date from primary payer’s RA
    • Paid amount: Enter paid amount from primary payer’s RA. This amount must equal MSP VC amount reported on claim (which must be zero for conditional claims) and must equal charges less amount(s) with the CAGC(s) and CARC(s).
    • GRP: Enter CAGC(s)
    • CARC: Enter CARC(s)
    • AMT: Enter dollar amount associated with each CAGC and CARC pair

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Conditional Billing Code Table

Code UB-04 (CMS-1450) Associated Field on 837I Claim Page in FISS DDE Claim Entry Instruction
Condition Code FL 18-28 2300.HI (BG) Page 01 (MAP1711) In addition to any other required CC, report, as applicable:
  • CC 02 = Condition is employment-related (also requires OC 04 and MSP VC 15 or 41)
  • CC 06 = ESRD beneficiary in first 30 months of eligibility/entitlement covered by an EGHP (also requires MSP VC 13)
  • Note: Do not report a CC 77.
Occurrence code and date FL 31-34 2300.HI (BH) Page 01 (MAP1711) In addition to any other required OC and date, report, as applicable:
  • 01 and DOA or injury = primary payer is medical-payment coverage (also requires MSP VC = 14)
  • 02 and DOA or injury = primary payer is no-fault (also requires MSP VC = 14)
  • 03 and DOA or injury = primary payer is liability (also requires MSP VC = 47)
  • OC 04 and DOA or injury = primary payer is WC (also requires CC 02 and MSP VC 15 or 41)
  • OC 24 and date of primary payer’s denial/rejection/EOB statement that explains the reason why the primary payer is not making payment on the claim. Note: Do not report OC 24 and date on the conditional claim when the claim is for an accident AND the reason the conditional claim is being submitted is because the primary payer has not made payment within 120 days (promptly).
  • OC 33 and first day of MSP ESRD coordination period for ESRD beneficiaries covered by an EGHP (also requires CC 06 and MSP VC = 13)
Value code and amount FL 39-41 2300.HI (BE) Page 01 (MAP1711) In addition to any other required VC and amount, report the MSP VC that represents MSP Provision (see options below) and the dollar amount paid by primary payer toward Medicare covered charges on claim. For a conditional claim, the primary payer’s payment amount is zero (there is no specific requirement as to the number of zeroes that must be reported next to the MSP VC).

Note: If the primary payer’s payment was zero because of failure to file a proper claim (unless failure was due to beneficiary’s mental or physical incapacity), report the amount you would have received had you filed a proper claim with the primary payer. This means you submit the claim as an MSP claim and not as a conditional claim. MSP VC options:
  • 12 = Working Aged beneficiary/spouse with an EGHP (beneficiary age 65 or over) – Beneficiary must be enrolled in Part A for this Provision to apply
  • 13 = ESRD beneficiary with EGHP in MSP/ESRD 30-month coordination period (also requires CC 06 and OC 33)
  • 14 = No-fault including automobile/other types – Examples: Personal injury protection (PIP) and medical-payment coverage (also requires OC 01 or 02)
  • 15 = WC (also requires CC 02 and OC 04)
  • 16 = PHS or other federal agency
  • 41 = Federal Black Lung program (also requires CC 02 and OC 04)
  • 43 = Disabled beneficiary under age 65 with LGHP – Beneficiary must be enrolled in Part A for this Provision to apply
  • 47 = Any liability insurance (also requires OC 03)
Notes:
  • Do not submit conditional claims for MSP VC 16 or VC 42. If these payers do not make primary payment for a valid reason, submit the claims as primary claims.
  • Do not report VC 44 and the amount you expected to receive from the primary payer on conditional claims.
Payer code (Code ID) N/A N/A Page 03 (MAP1713) For first three payers (payers marked A, B and C), report payer ID (code ID). Use payer code Z for Medicare. For conditional claims, always report a “C” for the payer code (Code ID) of the primary payer, regardless of the MSP Provision and MSP VC on the claim.
Primary insurer name (Payer Name) FL 50A, B, C 2320.SBR04 Page 03 (MAP1713) Report name of primary insurer(s). Report full, actual, complete names; not vague names such as “no-fault”, “GHP”, etc. Note: If using FISS DDE, “Medicare” will populate for lines on which you reported the payer code (code ID) “Z”.
Insured’s name FL 58 A, B, C 2330A.NM104 Page 05 (MAP1715) Report insured’s name for each payer.
Patient’s relationship to insured FL 59 A, B, C 2320.SBR02 Page 05 (MAP1715) Report beneficiary’s relationship to insured for each payer. Options:
01 = spouse
18 = self
19 = child
20 = employee
21 = unknown
39 = organ donor
40 = cadaver
53 = life partner
G8 = other relationship
Insured’s unique ID FL 60A, B, C 2330A.NM109 Page 05 (MAP1715) Report insured’s ID for each payer (beneficiary’s HICN for Medicare line)
Insurance Group Name FL 61A, B, C 2320.SBR04 Page 05 (MAP1715) Report name of primary insurance group for each primary payer
Insurance Group Number FL 62A, B, C 2320.SBR03 Page 05 (MAP1715) Report primary insurance group number for each primary payer
Employer Name FL 65A, B, C N/A N/A For UB-04 (CMS-1450) only, report name of employer that provides health care coverage for individual
Reason Why Primary Payer did Not Make Payment (use Remarks) FL 80 2300.NTE Page 04 (MAP1714) Reason Why Primary Payer did Not Make Payment

Report a two-digit explanation code and, if applicable, a date in MM/DD/YY format to explain the reason why the primary payer did not make payment. There are ten options each developed by NGS Medicare as a means to summarize the various reasons why the primary payer did not make payment promptly or for a valid reason.

Options:
  • BE = Benefits exhausted. Requires date benefits exhausted in MM/DD/YY format. This is the date on which benefits exhausted which may not be the same as the date on which you learned that benefits exhausted (reported with OC 24). Automobile no-fault states should not use BE for automobile accident claims - see code PE below. Acceptable with MSP VCs 12, 13, 14, 15, 41 or 43. Note: If the primary payer is medical-payment coverage (VC 14), benefits have exhausted, the claim’s date of service is after the date on which benefits are exhausted, and the claim is also not the responsibility of another payer such as liability, submit the claim as a primary claim.
  • CD = Charges applied to co-payment, coinsurance, and/or deductible. Acceptable with MSP VCs 12, 13, 14, or 43.
  • DA = 120 days have passed since the primary payer was billed. Requires date primary payer was billed in MM/DD/YY format. Do not also report OC 24 with date insurance denied. Acceptable with MSP VCs 14, 15, 41, or 47 but for VC 47, you must have withdrawn claim with liability.
  • DP = Delay in payment from liability insurer (you have been notified of the delay). Acceptable with MSP VC 47.
  • FG = Beneficiary did not follow guidelines of their primary health plan. Used in only three situations (see below) and provider must indicate which is the reason for submission of the conditional claim. Acceptable with MSP VCs 12, 13, 15, or 43.
    1. Out of network (Medicare can pay only one time)
    2. Untimely filing with primary payer (Medicare can pay but claim must be filed timely with Medicare) or
    3. No prior authorization (Medicare cannot pay).
  • LD = Response is received from liability insurer stating they feel they are not responsible for the claim. Acceptable with MSP VC 47.
  • NB = Not a covered benefit. Acceptable with MSP VCs 12, 13, 14, 15, 41, or 43.
  • PC = Pre-existing condition. Acceptable with MSP VCs 12, 13, or 43.
  • PE = No-fault (also known as PIP) benefits exhausted toward medical expenses. Requires date benefits exhausted in MM/DD/YY format. This is the date on which benefits are exhausted which may not be the same as the date on which you learned that benefits exhausted (reported with OC 24). Acceptable with MSP VC 14. You must have copy of PIP on file. Note: If the primary payer is no-fault, benefits have exhausted, the claim’s date of service is after the date on which benefits are exhausted, and the claim is also not the responsibility of another payer such as liability, submit the claim as a primary claim.
  • PP = Beneficiary paid by liability insurer. Used only for conditional claims involving liability insurance payments to the beneficiary where you are not expecting any payment from the beneficiary. May not be used for medical payment insurance payments to the beneficiary (MSP VC 14). You are required to pursue those dollars. Acceptable with MSP VC 47.
Primary Insurer's Address (use Remarks unless entering in FISS DDE, then use page 06) FL 80 2300.NTE Page 06 (MAP1716) Primary Insurer Address
For UB-04 (CMS-1450) and 837I claims, report primary insurer’s full address in Remarks (on the line below the two-digit explanation code (and associated date, if any). The primary insurer was reported in FL 50A (see above).
For FISS DDE Claim Entry, report primary insurer(s) full address in Page 06.

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Step 3: Check for a Matching MSP Record for the Beneficiary in the CWF.

Before you submit a conditional claim to Medicare, check for a matching MSP record in the CWF. You can use the provider self-service tools listed under Step 2 in the Identify the Proper Order of Payers for a Beneficiary’s Services. A matching MSP record is one that has the same MSP information you are reporting on your MSP claim.

If there is no such record, the submission of your claim notifies us of the new MSP information and allows us to send the information to the BCRC and request they set one up. Refer to Set Up a Beneficiary's MSP Record instructions linked on the left.

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Step 4: If a Matching MSP Record is on CWF, Submit the Conditional Claim

You can submit conditional claims via:

  • 837I claim
  • FISS DDE
  • Hardcopy format if you have an approved ASCA waiver. For hardcopy claim submissions, you must properly code the MSP claim on a hardcopy UB-04/CMS-1450 claim form, attach any supporting documentation including the primary payer’s remittance advice and EOB statement and submit it to the applicable National Government Services Medicare Claims Department. You can find the applicable address on our website under Contact Us.

As long as there was a matching MSP record on CWF prior to your claim submission, and there is no other reason not to process the claim, we will process your MSP claim.

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Step 5: If a Matching MSP Record is not on CWF, Submit the Conditional Claim and Wait for Medicare to Contact the BCRC with the New MSP Information You Reported on the Claim

If a Matching MSP Record is not on CWF, Submit the Conditional Claim and Wait for Medicare to Contact the BCRC with the New MSP Information You Reported on the Claim.

If there is no matching MSP record in CWF, the submission of your conditional claim notifies us of the new MSP information and allows us send that information to the BCRC and request that they set one up. Refer to Set Up a Beneficiary’s MSP Record shown on the left.

You can submit conditional claims via:

  • 837I claim
  • FISS DDE
  • Hardcopy format if you have an approved ASCA waiver. For hardcopy claim submissions, you must properly code the MSP claim on a hardcopy UB-04/CMS-1450 claim form, attach any supporting documentation including the primary payer’s remittance advice and EOB statement and submit it to the applicable National Government Services Medicare Claims Department. You can find the applicable address on our website under Contact Us.

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Step 6: Return Your Conditional Claim After the New MSP Record is on the CWF.

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Medicare’s Processing of Conditional Claims

  • Claim accepted: If conditional claims are submitted in accordance with the above instructions and do not encounter any other editing, they proceed to the payment floor.
  • Claim RTP: If conditional claims fail to meet Medicare’s usual claim submission requirements (technical, medical, and frequency of billing) and/or fail to meet the requirements for conditional billing, they will not be accepted and you must correct the claims which you may do in the FISS DDE per CMS CR 8486 effective 1/1/16.

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Revised 10/26/2023