Prepare and Submit an MSP Conditional Claim

Table of Contents

• Background
• Step 1: Determine if You Can Submit a Conditional Claim
• Step 2: Prepare a Conditional Claim
  • Conditional Billing Code Table
• Step 3: Check for a Matching MSP Record for the Beneficiary in the Common Working File
• Step 4: Submit the Conditional Claim
• Step 5: Keep Checking for the Conditional Claim to Process
• Step 6: Return or Resubmit a Corrected Claim
  • Processing Conditional Claims and Setting Up MSP Records
• Related Content

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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

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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:

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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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Related Content

• ASCA Requirements for Paper Claim Submissions
• CMS Change Request 6426: Instructions on Utilizing 837 Institutional CAS Segments for Medicare Secondary Payer (MSP) Part A Claims
• CMS Change Request 7355: Clarification of Medicare Conditional Payment Policy and Billing Procedures for Liability, No-Fault and Workers’ Compensation Medicare Secondary Payer (MSP) Claims
• CMS Change Request 8486: Instructions on Using the Claim Adjustment Segment (CAS) for Medicare Secondary Payer (MSP) Part A CMS-1450 Paper Claims, Direct Data Entry (DDE), and 837 Institutional Claims Transactions
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Completing and Processing the Form CMS-1450 Data Set, Section 75
• CMS IOM Publication 100-05, Medicare Secondary Payer Manual,
  • Chapter 1, Background and Overview, Sections 10, 10.5, 10.7, 20, 30 and 40
  • Chapter 2, Sections 40, 40.2, 50, and 60
  • Chapter 3, MSP Provider, Physician, and Other Supplier Billing Requirements, Sections 10.2, 20.1, 30.2.1, 30.3, and 40.3.1
  • Chapter 5, Contractor Prepayment Processing Requirements, Sections 40 and 50
  • Chapter 6, Medicare Secondary Payer CWF Process
• Coordination of Benefits & Recovery Contact Page (for BCRC)
• Identify the Proper Order of Payers for a Beneficiary’s Services
• Prepare and Submit a Medicare Secondary Payer Claim
• Prevent an MSP Rejection on a Medicare Primary Claim
• Set Up a Beneficiary's MSP Record
• Fiscal Intermediary Standard System/Direct Data Entry Provider Online Guide
• External code list

Revised 11/15/2024