Conditional Medicare Secondary Payer (MSP) payments are made from the Medicare Fee-for-Service program when the primary insurer – either Workers Compensation, Liability or No-Fault - rejects the claim or will not pay promptly (within 120 days) or there was a mental or physical incapacity that prevented the Medicare patient from filing the claim.

Conditional MSP payments can also be submitted when the group health plan denies the claim in part or entirely, or there was a mental or physical incapacity that prevented the Medicare patient from filing the claim.

Effective September 1, 2008, MSP claims billed to Highmark Medicare Services for conditional payment will be returned if any of the following is missing or incorrect on the claim:

• Primary payer code of C (denotes conditional payment)
• Occurrence code 01, 02, 03, 04, or 33 (whichever is applicable) with the corresponding date
• Occurrence code 24 with the date the primary insurer was billed
• Value code 12, 13, 14, 15, 16, 41, 42, or 43 (whichever is applicable) with the associated amount equal to $0000.00
• Value code 47 (amount of liability payment applied to this claim) if applicable, with the amount equal to $0000.00

When submitting MSP claims for conditional payment, you must use appropriate remarks explaining the need for the conditional payment. The remarks are placed on page 4, if claim is submitted via DDE; in Record Type 31 Field No. 4 (Sequence 01-03), if submitting via EMC; or the Field Location 80 on the paper UB-04.

IMPORTANT: The remarks section must contain your justification. It must be the first information found in the remarks and must follow the syntax of the word JUSTIFY, followed by a colon, one space and then the appropriate J code. If the appropriate J code and accompanying remarks are not present, the claim will be returned.

Please use the following format and verbiage for your justification:

JUSTIFY: J1 = PROPER CLAIM FILED WITH PRIMARY PAYER BUT THE GHP DENIED THE CLAIM FOR A REASON OTHER THAN AN ASSERTION THAT THE PLAN IS SECONDARY TO MEDICARE.

JUSTIFY: J2 = PROPER CLAIM NOT FILED WITH PRIMARY PAYER DUE TO PHYSICAL OR MENTAL INCAPACITY OF THE PERSON WITH MEDICARE. GHP AND/OR BENEFICIARY WILL REIMBURSE MEDICARE IF PAYMENT IS SUBSEQUENTLY MADE BY THE GHP.

JUSTIFY: J3 = PROPER CLAIM FILED WITH PRIMARY PAYER BUT THE NO-FAULT OR LIABILITY INSURER DENIED THE CLAIM.

JUSTIFY: J4 = PROPER CLAIM FILED WITH PRIMARY PAYER BUT THE WORKER’S COMP PROGRAM DENIED THE CLAIM.

JUSTIFY: J5 = PROPER CLAIM FILED WITH PRIMARY PAYER BUT FEDERAL BLACK LUNG PROGRAM DENIED THE CLAIM.

JUSTIFY: J6 =PRIMARY PAYER NOT EXPECTED TO PAY WITHIN 120 DAYS.

JUSTIFY: J7 = PROPER CLAIM NOT FILED WITH PRIMARY PAYER DUE TO PHYSICAL OR MENTAL INCAPACITY OF THE PERSON WITH MEDICARE.

JUSTIFY: J8 = PRIMARY INSURANCE PAYMENT WAS APPLIED TO BENEFICIARY'S DEDUCTIBLE/COINSURANCE, EOB SENT

It is important to remember that once payment is received from the primary insurer, the facility must submit an adjustment as an MSP claim with the correct payer information. The facility is obligated to reimburse the Medicare program the conditional payment within 60 days of receipt of the primary payment. If the primary insurer denies your claim, please do not resubmit the Medicare claim or submit an adjustment request. Instead, mail a copy of the denial letter or Explanation of Benefits notice to appropriate claims address based on your location:

Include the following information with the copy of the denial letter:

• Beneficiary’s HIC number
• DCN of the original Conditional Payment claim
• Brief statement explaining that this claim was originally submitted as a conditional claim