Conditional Primary Medicare Benefits

20.7 - Conditional Primary Medicare Benefits (Rev. 11755, Issued:12-21-22, Effective: 01-23-23, Implementation: 01-23-23) When specified conditions are met, the MSP statute prohibits Medicare from making payment where payment has been made or can reasonably be expected to be made by GHPs, a WC law or plan, liability insurance (including self-insurance), or no-fault insurance. If payment has not been made or cannot be reasonably be expected to be made promptly by WC, liability insurance (including self-insurance), or no-fault insurance, Medicare may make conditional payments. (See 42 CFR § 411.52.) In order to adhere to the provisions in the MSP statute, all A/B MACs and DME MACs shall follow 42 CFR § 411.21, reflected in Pub. 100-05, Chapter 1, §40, for the definition of prompt or promptly. Prompt or promptly, with regard to no-fault insurance and workers’ compensation, means payment within 120 days after receipt of the claim for specific items and services by the no-fault insurer or WC entity. In the absence of evidence to the contrary, A/B MACs and DME MACs shall treat the date of service for specific items and services as the claim date for the purpose of determining the promptly period. Further, with respect to inpatient services, in the absence of evidence to the contrary, A/B MACs and DME MACs shall treat the date of discharge as the date of service with respect to no-fault insurance and WC situations for the purpose of determining the promptly period. Additionally, A/B MACs and DME MACs shall follow 42 CFR §411.50, also reflected in Pub. 100-05, Chapter 2, for the definition of prompt or promptly with regard to liability insurance (including self-insurance). Prompt or promptly, with regard to liability insurance (including self-insurance), means payment within 120 days after the earlier of the following: (1) The date a general liability claim is filed with an insurer or a lien is filed against a potential liability settlement; and (2) the date the service was furnished or, in the case of inpatient services, the date of discharge. Generally, the MSP auxiliary record for the liability situation is posted to CWF after the beneficiary files a claim against the alleged tortfeasor and the associated liability insurance (including self- insurance) Accordingly, in the absence of evidence to the contrary, the date the general liability claim is filed against liability insurance (including self-insurance) is no later than the date that the record was posted on CWF. Therefore, A/B MACs and DME MACs shall consider the date of accretion listed on liability MSP auxiliary record on CWF to be the date the general liability claim was filed, for the purposes of determining the promptly period, with regard to liability insurance (including self-insurance) situations. Subject to Medicare payment rules and other stipulations, primary payers (GHP, liability insurance, including self-insurance, no-fault insurance, and WC) are obligated to reimburse Medicare if they were properly primary to Medicare, but have not paid as primary, pursuant to 42 CFR 411.22. A primary plan's responsibility for such payment may be demonstrated by a judgment, a payment conditioned upon the recipient's compromise, waiver, or release (whether or not there is a determination or admission of liability) of payment for items and services included in a claim against the primary plan or the primary plan's insured, or by other means. NOTE: If the injury resulted from an automobile accident and/or there is an indication of primary coverage under a GHP, the provider, physician, or other supplier bills the liability insurer or no-fault insurer and/ GHP as appropriate before requesting conditional Medicare payments. Except as delineated in in Pub.100-05, Chapter 2, Medicare does not make conditional primary payment when there is GHP coverage that is a primary payer to Medicare until the claim has been sent to the primary payer first for payment.