Conditional Primary Medicare Benefits

40.6 - Conditional Primary Medicare Benefits (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) Conditional primary Medicare benefits may be paid if; • The beneficiary has appealed or is protesting the GHP denial of the claim for any reason other than that the GHP offers only secondary coverage of services covered by Medicare; • The GHP denied the claim (that is, the claim made on behalf of the beneficiary) because the time limit for filing the claim with the GHP has expired (whether appealed or not); • The provider, physician, or other supplier fails to file a proper claim because of mental or physical incapacity of the beneficiary; • The beneficiary, because of physical or mental incapacity, failed to meet a claim- filing requirement of the workers’ compensation carrier. • GHP or NGHP benefits are exhausted and the one of the following CARCs are identified: 27 – Expenses occurred after coverage terminated. 35 – Lifetime benefit maximum has been reached. 119– Benefit maximum for this time period, or occurrence, has been reached. 149 – Lifetime benefit maximum has been reached for this source/benefit category. • A/B MACs, DME MACs and shared systems shall make conditional payments for claims for specific items and service where the following conditions are met: (1) there is information on the claim or information on CWF that indicates that no-fault insurance or workers’ compensation is involved for that specific item or service, (2) there is/was no open GHP record on the MSP auxiliary file as of the date of service, (3) there is information on the claim that indicates that the physician, provider or other supplier sent the claim to the no-fault insurer or workers’ compensation entity first, and (4) there is information on the claim that indicates that the no-fault insurer or workers’ compensation entity did not pay the claim during the promptly period for any reason except when the workers’ compensation carrier claims that its benefits are only secondary to Medicare. • A/B MACs, DME MACs and shared systems shall make conditional payments for claims for specific items and services where the following conditions are met: (1) there is information on the claim or information on CWF that indicates that liability insurance (including self-insurance) is involved for that specific item or service, (2) there is/was no open GHP record on the MSP auxiliary file as of the date of service, (3) there is information on the claim that indicates that the physician, provider or other supplier sent the claim to the liability insurer (including the self-insurer) first, and (4) there is information on the claim that indicates that the liability insurer (including the self-insurer) did not make payment on the claim during the promptly period. Before making a conditional primary payment in cases involving appealed or protested claims, the A/B MAC and DME MAC notifies the GHP, as well as the beneficiary, that the payment is conditioned upon reimbursement, by the insurer and the beneficiary, to the trust fund if it is demonstrated that the GHP has or had responsibility to make primary payment. The A/B MAC and DME MAC reminds the GHP that it is obligated to reimburse Medicare if it should be later determined that it was the proper primary payer for the services. A 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 or services included in a claim against the primary payer or the primary payer’s insured, or by other means.