When Conditional Primary Medicare Benefits May Not Be Paid

20.7.2 - When Conditional Primary Medicare Benefits May Not Be Paid When a GHP is a Primary Payer to Medicare (Rev. 11755, Issued:12-21-22, Effective: 01-23-23, Implementation: 01-23-23) Conditional primary Medicare payments may not be made if the claim is denied for one of the following reasons [See 42 CFR § 411.175(c)]: • It is alleged that the GHP is secondary to Medicare; • The GHP limits its payment when the individual is entitled to Medicare; • The services are covered by the GHP for younger employees and spouses but not for employees and spouses age 65 or over; • The GHP asserts it is secondary to a liability, no-fault or WC insurer, or other coverage also primary to Medicare. • Failure to file a proper claim (including failure to file timely) if that failure is for any reason other than physical or mental incapacity of the beneficiary.