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Prepare and Submit an MSP Conditional Claim

Table of Contents

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Background

Before submitting a conditional claim, you must have:

  • Conducted an MSP screening process and determined there is a primary payer based on an MSP provision per Identify the Proper Order of Payers for a Beneficiary’s Services
  • Submitted the claim(s) to that payer(s) and conducted any necessary follow up with them
  • Received a response from the primary payer indicating they are not paying your claim for a valid reason or not received a response from the primary payer (accidents only) after waiting at least120 days from billing them

If the above is complete, follow the steps below. If the primary payer paid more than zero, submit an MSP claim.

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Step 1: Determine if You Can Submit a Conditional Claim

You can submit a conditional claim to us if:

  • You billed the primary payer, received a response, but did not receive payment for a valid reason (primary payer’s payment = zero). This is applicable for MSP VCs: 12, 13, 14, 15, 41, 41, 43 and 47 but is not applicable when the first payer is PHS/other federal agencies (VC 16) or the VA when the beneficiary chose to use their VA benefits. If you bill either of these payers first and they do not pay your claim, submit a Medicare primary (not conditional) claim.
    • To determine if the reason the primary payer did not pay is valid, refer to the Conditional Billing Code Table below. Review the “Reason Primary Payer Did Not Pay” codes you can report in Remarks (BE, CD, DP, FG, LD, NB, PC, PE, or PP).
  • You billed the primary payer for an accident, but you do not receive a response or payment within 120 days. This is applicable for accidents only (MSP VCs 14, 15, 41 and 47). Note on Liability Plans (MSP VC 47): After waiting 120 days from the date you billed the primary payer, you can choose to submit a conditional claim to us or to maintain all claims/liens against the liability insurance/beneficiary’s liability insurance settlement. If you choose to submit a conditional claim to us, you must 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 for services not covered by Medicare and for Medicare deductible and coinsurance amounts.
    • Refer to the Conditional Billing Code Table below. Review the “Reason Primary Payer Did Not Pay” code you can report in Remarks (DA).

Conditional claims are coded like MSP claims since the primary payer is reported as the first payer and Medicare as the second payer. However, for conditional claims, report:

  • A primary payer’s payment amount of zero with the appropriate MSP VC
  • One “Reason Primary Payer Did Not Pay” code in Remarks
  • An OC 24 and the date you learned the primary payer was not going to pay for the claim (in all situations except when you are reporting code DA in Remarks)
  • Any other required coding, when applicable, in the Conditional Billing Code Table below

If we pay a claim conditionally, we pay the same amount we would have if Medicare were primary.

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Step 2: Prepare a Conditional Claim

To prepare the conditional claim, follow these guidelines:

  • Report a covered TOB. Do not report a noncovered TOB.
  • Complete the claim as if Medicare were primary but report the primary payer(s) before Medicare and Medicare second (or third, if applicable).
  • Report all claim coding as usual including services/charges for all Medicare-covered services.
  • For inpatient conditional claims, report the covered and noncovered days/charges as usual.
  • Follow Medicare’s technical (e.g., one-year timely filing) and medical (e.g., clinical and/or assessment) requirements since these apply to all Medicare claims.
    • Hospice providers: Submit the NOE with Medicare as primary. Report the MSP/conditional information on the claim(s).
    • Home health providers: Submit the NOA with Medicare as primary. Report the MSP/conditional information on the claim(s).
  • Follow Medicare’s usual billing requirements (e.g., “frequency of billing” guidelines for your provider type) since these apply to all Medicare claims. If you are required to submit claims to us from admission to discharge, every 30 days or every 60 days (or at another frequency), this is true even when Medicare is not primary.
    • Do not split bill your claims during your “frequency of billing” period if we become primary or secondary during that period and the primary payer pays for only a portion of that billing period.
      • If another payer paid for a portion of the claim’s billing period, submit the claim to us as you usually would, but as an MSP claim. Refer to Prepare and Submit a Medicare Secondary Payer Claim.
      • To submit a conditional claim, the primary payer must not have paid any portion of the claim. After submitting the claim for which you received some payment from the primary payer as an MSP claim, you may submit the next claim, if applicable, for which you received no payment from the primary payer (for a valid reason or within 120 days for accidents) as a conditional claim.
  • Report applicable conditional billing codes from the Conditional Billing Code Table below.
  • Report primary payer adjustment(s) using CAGCs, CARCs and amount(s) from their RA. Note: If you do not have a primary payer’s RA because you are submitting a conditional claim due to not receiving a response or payment from the primary payer for an accident within 120 days (code DA in Remarks), you will need to use a CAGC/CARC combination that lets us know you do not have a response/payment from the primary payer. A CARC 192 may be necessary.

CAGC(s):

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

CARC(s):

  • Required when the primary payer adjusts your billed charges
  • Explains why the primary payer paid differently than it was billed
  • Options: Refer to the primary payer’s RA which shows CARC(s) for each CAGC. If their RA does not provide CARCs and/or CARC definitions, refer to the external code list.

If using FISS DDE to enter the conditional claim:

  • In addition to the guidelines above, follow the Claim Entry instructions in the Fiscal Intermediary Standard System/Direct Data Entry Provider Online Guide.
  • Enter all required claim coding (non-MSP and MSP/conditional) on the appliable claim pages.
  • Go to claim page 03 (MAP1713) and press the F11/PF11 key for additional pages (MAP1719).
  • Enter CAGC(s) CARC(s) and amount(s) from the primary payer(s) RAs for up to two payers.
    • Enter this information for primary payer 1 (up to 20 entries), if applicable.
    • Enter this information for primary payer 2 (up to 20 entries), if applicable.
  • MAP1719 fields:
    • Paid date: Enter the paid date from the primary payer’s RA
    • Paid amount: Enter the paid amount from the primary payer’s RA. This amount must always be zero for conditional claims. This amount must equal the “MSP VC amount” and “charges minus the total of all CARC amounts”.
    • GRP: Enter the CAGC(s)
    • CARC: Enter the CARC(s)
    • AMT: Enter the dollar amount associated with each CAGC and CARC pair.

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Conditional Billing Code Table

Code UB-04 (CMS-1450) Claim Form Locator (FL) 837I Claim Field FISS DDE Claim Entry Page # & MAP # Instructions – Report code(s), as applicable
Condition code (CC) 18-28 2300.HI (BG) 01 and MAP1711

CC 02 = Condition is employment related (requires OC 04 and VC 15 or 41)

CC 06 = FISS DDE ESRD patient in first 30 months of eligibility or entitlement covered by FISS DDEEGHP (requires VC 13)

Note: Do not report CC 77
OC and date 31-34 2300.HI (BH) 01 and MAP1711

OC 01 and DOA or injury = primary payer is medical-payment (med-pay) coverage (requires VC 14)

OC 02 and DOA or injury = primary payer is no-fault/no-fault set aside (requires VC 14)

OC 03 and DOA or injury = primary payer is liability insurance/liability set aside (requires VC 47)

OC 04 and DOA or injury = primary payer is workers compensation (WC)/WC set aside (requires CC 02 and VC 15)

OC 33 and first day of coordination period for ESRD beneficiaries covered by EGHP (requires CC 06 and VC 13)

OC 24 and date of primary payer’s denial/rejection/EOB statement that explains reason primary payer is not paying. Note: Do not report OC 24 and date when claim is for an accident and reason you are submitting claim is because primary payer did not respond or pay within 120 days.
VC and amount 39-41 2300.HI (BE) 01 and MAP1711

VC that represents MSP provision and dollar amount primary payer paid toward Medicare-covered charges on claim. For a conditional claim, this amount is zero. Note: If primary payer’s payment was reduced to zero because of your failure to file a proper claim, unless failure was due to beneficiary’s mental or physical incapacity, report amount you would have received had you filed a proper claim.

MSP VC options:

VC 12 Working aged beneficiary (65 or older and enrolled in Part A) or spouse with EGHP, employer size 20 or more employees (code ID = A)

VC 13 ESRD patient with EGHP in MSP/ESRD 30-month coordination period (code ID = B) (requires CC 06 & OC 33)

VC 14 No-Fault/no-fault set aside includes auto and other types such as PIP and med-pay (code ID = D or T) (requires OC 01 or 02)

VC 15 WC/WC set aside (code ID = E or W) (requires CC 02 and OC 04)

VC 16 Public Health Services or other Federal agency (code ID = F)

VC 41 Federal Black Lung program (code ID = H) (requires OC 02 & OC 04)

VC 43 Disabled beneficiary (under 65 and enrolled in Part A) or family member employed with LGHP, employer size 100 or more employees (code ID = G)

VC 47 = Liability insurance/liability set aside (code ID = L or S) (requires OC 03)

Do not report VC 44 and the amount you expected to receive from the primary payer.
Primary payer code (Code ID) N/A N/A 03 and MAP1713 For first three payers (marked A, B and C), report code ID) = “C” for first payer, regardless of MSP VC. Report “Z” for Medicare line.
Primary insurer name (Payer Name) 50A, B, C 2320.SBR04 03 and MAP1713 Full, actual name of primary insurer(s). Report Medicare on line 50B (MSP) or on line 50C (Medicare tertiary). If using FISS DDE, Medicare populates for lines where you reported code ID = Z.
Insured’s name 58 A, B, C 2330A.NM104 05 and MAP1715 Insured’s name for each payer.
Patient’s relationship to insured 59 A, B, C 2320.SBR02 05 and MAP1715

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 60A, B, C 2330A.NM109 05 and MAP1715 Insured’s ID for each payer (beneficiary’s MBI for Medicare line)
Insurance Group Name 61A, B, C 2320.SBR04 05 and MAP1715 Name of primary insurance group for each primary payer
Insurance Group Number 62A, B, C 2320.SBR03 05 and MAP1715 Primary insurance group number for each primary payer
Employer Name 65A, B, C N/A N/A Name of employer that provides health care coverage
Reason Primary Payer Did Not Pay (Remarks) 80 2300.NTE 04 and MAP1714

A two-digit code (choose from list below) and, if applicable, a date in MM/DD/YY format or other required information (one space over from code) to explain valid reason primary payer did not pay. Options:

BE = Benefits exhausted. Report date benefits exhausted (one space over from BE) in MM/DD/YY format. This may not be same as date you learned benefits exhausted (OC 24 date). Auto no-fault states do not use BE (see PE). Accepted with VCs 12, 13, 14, 15, 41 or 43. Note: If primary payer is med-pay (VC 14), benefits exhausted, claim’s DOS is after benefits exhaust date, and claim is also not responsibility of another payer such as liability, submit Medicare primary claim instead.

CD = Charges applied to co-payment, coinsurance, and/or deductible. Accepted with VCs 12, 13, 14, or 43.

DA = 120 days passed since primary payer was billed. Report date primary payer was billed (one space over from DA) in month day year format. Do not also report OC 24 with date insurance denied. Accepted with 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 were notified). Accepted with VC 47.

FG = Beneficiary did not follow guidelines of primary plan. Use only in in 3 situations below. Indicate (one space over from FG) which is reason. Accepted with VCs 12, 13, 15, or 43.

  1. Out of network (we pay once)
  2. Untimely filing with primary payer (we pay if timely with us)
  3. No prior authorization (we cannot pay) 

LD = Response from liability insurer states they feel they are not responsible for claim. Accepted with VC 47.

NB = Not a covered benefit. Accepted with VCs 12, 13, 14, 15, 41, or 43.

PC = Pre-existing condition. Accepted with VCs 12, 13, or 43.

PE = No-fault (also known as PIP) benefits exhausted toward medical expenses. Report date benefits exhausted (one space over from PE) in MM/DD/YY format. This may not be same as date you learned benefits exhausted (OC 24 date). Accepted with VC 14. You must have a copy of the PIP. Note: If the primary payer is no-fault, benefits exhausted, claim’s DOS is after the date benefits exhausted, and claim is also not the responsibility of another payer such as liability, submit Medicare primary claim instead.

PP = Beneficiary was paid by liability insurer. Used for conditional claims involving liability insurance payments to beneficiary where you are not expecting any payment from them. Do not use this for med-pay payments to beneficiary (VC 14) as you are required to pursue those dollars. Accepted with VC 47.
Primary Insurer's Address (Remarks except in FISS DDE) 80 2300.NTE 06 and MAP1716

Primary Insurer’s Full Address
For UB-04/CMS-1450 and 837I claims, report primary insurer’s full address in Remarks on the line below two-digit code and any applicable date).

 

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

For a conditional claim to process, there must be a matching MSP record for the beneficiary in the CWF. Before you submit your claim, check for such a record in the CWF using the provider self-service tools listed under Step 1 in Identify the Proper Order of Payers for a Beneficiary's Services. A matching MSP record is one with the same MSP information you will report on your conditional claim. Note: You would have checked for an MSP record in the CWF during your MSP screening process. However, we recommend you check again before submitting your claim since the MSP record could have changed between the time you rendered services to the beneficiary and the time you are submitting a claim to us.

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Step 4: Submit the Conditional Claim

If there is a matching MSP record in the CWF, submit your conditional claim. Ensure the information on your claim matches the information in the MSP record. Note: You would have verified with the beneficiary/representative that the MSP information in the MSP record is current and accurate during your MSP screening process. See Identify the Proper Order of Payers for a Beneficiary’s Services.

If there is not a matching MSP record in the CWF, submit your conditional claim ensuring the information is current and accurate. When processing your claim, we will contact the BCRC to set up a matching MSP record using the claim information.

Submit the conditional claim via:

  • 837I claim
  • FISS DDE
  • Hardcopy format if you have an approved ASCA waiver. Note: You must properly code the claim on a hardcopy UB-04/CMS-1450 claim form, attach any supporting documentation, including the primary payer’s RA 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 5: Keep Checking for the Conditional Claim to Process

You can check the status of your conditional claims via FISS DDE:

Claim Status Status Location (S/L)
Processed PB9997
RTP'd TB9997
Rejected RB9997
Suspended for review Any beginning with an “S”

 

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Step 6: Return or Resubmit a Corrected Claim

If your claim RTP, follow the reason code narrative and return/resubmit a corrected claim. If your claim rejected, follow the reason code narrative and resubmit a corrected claim. If your claim suspended, wait for the claim to process, RTP or reject and follow the reason code narrative.

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Processing Conditional Claims and Setting Up MSP Records

When processing your conditional claim, we compare the claims MSP information to any MSP record(s) in the CWF.

If the claim information matches an existing MSP record’s information, we process the claim. Note: If there is a reason we cannot process your claim, we return it to you and the reason code narrative will advise you of your next steps, if any.

If the claim information does not match an existing MSP record’s information or there is no MSP record, we:

  • Set up a matching MSP record using the claim information and a validity indicator “I” (investigational).
    • Note: If your claim does not have all the MSP information we need to set up a matching MSP record, we return it to you to request the missing information.
  • Send/transmit the matching MSP record to the CWF so the BCRC can investigate and validate it. When they validate it, they change the validity indicator from “I’ to “Y”, which can take up to 45 days.
  • Process your claim (and subsequent claims) while waiting for the BCRC to validate the MSP record.  

There are situations in which we are not able to successfully set up an MSP record in the CWF (validity indicator “I”) and send/transmit it to the BCRC. In these situations, we send the BCRC an Electronic Correspondence Referral System (ECRS) request, with your claim information, asking them to set up, investigate and validate a matching MSP record in the CWF. While our ECRS request is pending with the BCRC, we return your claim. Review the reason code narrative to determine if there is anything you need to do and monitor the CWF, so you know when the MSP record is set up. When you see the MSP record for the beneficiary in the CWF, return or resubmit your claim to us. You should see the MSP record in the CWF within 45 days of when we returned your claim. 

Please be aware the BCRC may not be able to validate an MSP record. This is usually because they did not receive a response to their investigation within 45 days or they received a response to their investigation within 45 days but determined Medicare is the appropriate primary payer. In these situations, the BCRC deletes the MSP record (validity indicator “I”) we set up or they do not set up an MSP record in response to our ECRS request.

  • If we processed your claim, our conditional payment is appropriate if we are the secondary payer but may be inappropriate if we are the primary payer. If you learn the BCRC deleted the MSP record (validity indicator “I”) we set up, refer the beneficiary or other party to the BCRC to confirm/negate his/her MSP status and, if applicable, to ask them to set up an MSP record. If the outcome is that Medicare is the primary payer, you may need to adjust your conditional claim to change it to a Medicare primary claim.
  • If we returned your claim, continue to monitor the CWF. If an MSP record does not appear in the CWF within 45 days from the date we returned your claim, refer the beneficiary or other party to the BCRC to confirm/negate his/her MSP status and, if applicable, to ask them to set up an MSP record.  
    • It is possible for the other payer to be the primary payer, but we cannot process your claim until the BCRC sets up the MSP record for the beneficiary in the CWF.  Once they do, you may return or resubmit your claim.  
    • It is also possible for Medicare to be the primary payer and you will need to submit a Medicare primary claim instead.

For more information about how we process your MSP, Medicare tertiary and conditional claims as well as how MSP records are set up, refer to the CMS IOM,. Publication 100-05, Medicare Secondary Payer Manual, Chapter 5 and Chapter 6.

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Revised 11/15/2024