MLN BookletMedicare Secondary Payer
Page 13 of 20 MLN006903 October 2023
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Liability, including self-insurance, no-fault, or WC has payment liability and responsibility
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We don’t expect a prompt payment
When a patient has non-ORM liability, no-fault, or WC coverage, we may make conditional claims
payments when:
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The claim information or the Common Working File (CWF) shows liability, no-fault insurance, or a
specic item or service with WC involvement
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There’s no open GHP CWF MSP le record for the service date
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The claim information shows the physician, provider, or supplier sent the claim to the liability,
no-fault insurer, or WC entity rst
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The claim information shows the liability, no-fault insurer, or WC entity didn’t pay the claim during
the 120-day paid promptly period for identied reasons
Always send the claim to the primary payer rst. If the primary payer denies the claim because of
liability, the no-fault or WC insurer must place the reason for denial on the claim, which you can nd
on your remittance advice that you’ll send to Medicare. Without this reason, Medicare will deny the
claim. If this is a non-ORM situation and the claim is less than 120 days past the date of service,
Medicare may make a payment on the claim. You can nd electronic remittance advices and reasons
for claim denial in the claim adjustment segment. We can recover any conditional payments. The
MSP contractor recovers conditional payments from the patient or that person’s attorney if the patient
gets a settlement, judgment, award, or other payment.
We may pay for conditional primary benets if the provider, physician, supplier, or patient doesn’t le a
proper claim with the GHP (or Large Group Health Plan (LGHP)) due to the patient’s physical or mental
incapacity. The provider, physician, or other supplier must prove the patient’s physical or mental incapacity
prevented them from providing other payer information, which led to the failure to le a proper claim.
If the patient has a primary GHP and the provider doesn’t bill the primary GHP rst, we won’t pay
conditionally on the liability (including self-insurance), no-fault, or WC claim. Providers must bill the
GHP before billing Medicare. We won’t pay for conditional primary benets for non-ORM claims in
other situations where the:
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GHP says it’s secondary to Medicare
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GHP limits its payment when the patient is entitled to Medicare
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GHP covers the services for younger employees and spouses, but not for employees and spouses
65 and older
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GHP says it’s secondary to liability, no-fault, or WC insurance
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The provider doesn’t le a proper and timely claim with Medicare
Additionally, we won’t make conditional payments associated with WCMSAs or when ORM exists.