Conditional Medicare Payment

40.6.1 - Conditional Medicare Payment (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) There is frequently a long delay between an injury and the decision by a State Workers’ Compensation agency, no-fault insurance, or liability insurer (including self-insurance) in cases where compensability is contested. A denial of Medicare benefits pending the outcome of the final decision means that beneficiaries might use their own funds for expenses that are eventually borne by either Liability insurance (including self-insurance), No Fault insurance or Workers’ Compensation situations or Medicare. To avoid imposing a hardship pending a decision, conditional Medicare payments may be made if there is no other GHP that is primary to Medicare. Note: if there is a primary GHP and the physician, provider or other supplier did not send the claim to the GHP first Medicare will not pay conditionally on the Liability insurance (including self-insurance), No Fault insurance or Workers’ Compensation claim. When such conditional Medicare payments are made, they are conditioned upon reimbursement, by the insurer and beneficiary, to the trust fund if it is demonstrated that the Liability insurance (including self-insurance), No Fault insurance or Workers’ Compensation Carrier has or had a responsibility to make payment. 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. When making a conditional payment, the MSP Contractor notifies the beneficiary and the insurer of the requirement for repayment. (However, failure to do so does not relieve them of the obligation to refund the payments.) The MSP Contractor asks the insurer to notify them when the insurer is prepared to pay the claim, so that direct refund can be arranged. For Part A claims involving Liability insurance (including self-insurance), No Fault insurance, or Workers’ Compensation situations, if there is no primary payer GHP to Medicare that will pay for services and the promptly period has expired, the A/B MAC (Part A) shall make a conditional payment. Providers of service may request Medicare conditional non-GHP payments by submitting a claim with the appropriate insurance Value Code (i.e., Value Code 14, 15 or 47) with zero reflected as the value amount. Type of Insurance CAS Part A Value Code (2300 HI) Value Amount (2300 HI) Occurrence Code (2300 HI) Condition Code (2300 HI) No- Fault/Liability 2320 - valid informatio n why NGHP or GHP did not make payment 14 or 47 $0 01-Auto Accident & Date 02-No- fault Insurance Involved & Date 24 – Date Insurance Denied Workers’ Compensation 2320 - valid informatio n why NGHP or GHP did not make payment 15 $0 04- Accident/Tort Liability & Date 24 – Date Insurance Denied 02- Condition is Employment Related A/B MACs (Part A) are required to look for the zero-value code paid amount and occurrence code in the 2300 HI when claims are received electronically in the ASC X12 837 institutional claim format. The appropriate Occurrence code (2300 HI), coupled with the zeroed paid amount and MSP value code (2300 HI), and the CAS segment (see previous CMS MSP change requests on processing MSP claims utilizing the CAS) may be used in billing situations in cases where the provider has attempted to bill a primary payer in non-GHP (i.e., Liability, No-Fault and Workers’ Compensation) situations, but the primary payer is not expected to pay in the promptly period. A conditional payment by Medicare may be made. For hardcopy claims, the identity of the other payer is shown on line A of Payer Name, the identifying information about the insured is shown on line A of Insured’s Name, Patient’s Relationship to Insured, Insured’s Unique Identifier, Insured’s Group Name, Insured’s Group Number, Treatment Authorization Code, DCN, Employer Name (of the Insured) and the address of the insured is shown in Responsible Party Name and Address or in Remarks. Medicare claims processing A/B MACs process conditional payment bills following normal procedures. In determining conditional payments for physician and other supplier electronic claims it is known that the ASC X12 837 professional claim format does not include Value Codes nor Condition Codes. To determine whether conditional payment should be granted for ASC X12 837 professional claims the following fields must be completed and defined as follows: The physician/supplier must complete the 2320AMT02 = $0 if whole claim is a non-GHP claim and conditional payment is being requested for the whole claim, or 2430 SVD02 is completed for line level conditional payment requests if the claim contains other service line activity not related to the accident or injury. The CAS shall be taken into consideration when processing NGHP claims and determining if a conditional payment should be made. For the 2320 SBR05 it is acceptable to receive and include CP Medicare Conditionally Primary, AP for auto insurance policy or OT for other. The 2320 SBR09 may contain the claim filing indicator code of AM (automobile medical); LI (Liability), LM (Liability Medical) or WC (Workers’ Compensation Health Claim). Any one of these claim filing indicators are acceptable for the non-GHP MSP claim types. The 2300 DTP identifies the date of the accident with appropriate Value. The accident “related causes code” is found in 2300 CLM 11-1 through CLM 11-3. NOTE: There is no occurrence code for ASC X12 837 professional format claims so the following conditional payment policy is being implemented. For Part B claims involving Liability insurance (including self-insurance), No Fault insurance, or Workers’ Compensation situations, if there is no primary payer GHP to Medicare that will pay for services and the promptly period has expired, the A/B MAC (Part B) shall make a conditional payment for Medicare payable and covered services. A conditional payment may be made by Medicare where the physician or other supplier has attempted to bill a primary payer in non-GHP (i.e., Liability, No-Fault and Workers’ Compensation) situations, but the NGHP insurer is not expected to pay in the promptly period. The A/B MACs (Part B) and shared systems shall take into consideration the CAS segment on the ASC X12 837 to also determine if conditional payment shall be made. The graph below explains what the ASC X12 837 professional claim should look like when a physician/supplier is requesting MSP conditional payments: Type of CAS Insurance Claim Paid Amount Insurance Date of A id Insurance Type C d Filing (2320 AMT or Type Code (2320 Indicator 2430 SVD02) (2000B SBR05) (2320 SBR05) SBR09) No-Fault/ 2320 or AP or CP AM, LI, or $0.00 14 2300 DTP 01 Liability 2430 valid informa tion on why LM through 03 and 2300 CLM 11- 1 through 11-3 with value AA, AB, AP or OA GHP did Type of Insurance CAS Insurance Type Code (2320 SBR05) Claim Filing Indicat or (2320 Paid Amount (2320 AMT or 2430 SVD02) Insurance Type Code (2000B SBR05) Date of Accident not make payment Workers’ Compensation 2320 or 2430 valid informa tion on why NGHP or GHP did not make payme nt OT WC $0.00 15 2300 DTP 01 through 03 and 2300 CLM 11-1 through or 11-3 with value EM For the ASC X12 837 professional claims the insurance codes change and the acceptable information for Medicare conditional payment request is modified to look like the following: Type of Insurance CAS Insuran ce Type Code 2320 SBR05 from previous Claim Filing Indicat or (2320 SBR09) Paid Amount (2320 AMT or 2430 SVD02) Condition Code (2300 HI) Date of Accident No- Fault/Liabilit y 2320 or 2430 – valid informat ion on why NGHP or GHP did not make payment 14 / 47 AM or LM $0.00 2300 DTP 01 through 03 (Qualifier 439, D8) and 2300 CLM 11-1 through 11-3 with value AA or OA Workers’ Compensation 2320 or 2430 – valid informat ion on why NGHP or GHP did not make payment 15 WC $0.00 02- Condition is Employm ent Related 2300 DTP 01 through 03 (Qualifier 439, D8) and 2300 CLM 11-1 through or 11-3 with value EM