Conditional Payment Information
Under Medicare Secondary Payer law (42 U.S.C. § 1395y(b)), Medicare does not pay for items or services to the extent that payment has been, or may reasonably be expected to be, made through a no-fault or liability insurer or through Workers' Compensation (WC). Medicare may make a conditional payment when there is evidence that the primary plan does not pay promptly conditioned upon reimbursement when the primary plan does pay. The Benefits Coordination & Recovery Center (BCRC) is the organization responsible for recovering conditional payments when there is a settlement, judgment, award, or other payment made. When the BCRC has information concerning a potential recovery situation, it will identify the affected claims and begin recovery activities. Beneficiaries and their attorney(s) should recognize the obligation to reimburse Medicare during any settlement negotiations.
Conditional Payment Letter (CPL)
A CPL provides information on items or services that Medicare paid conditionally and the BCRC has identified as being related to the pending claim. A CPL is automatically sent within 65 days of issuance of the Rights and Responsibilities letter, which can be found on the Reporting a Case page. All entities that have a verified Proof of Representation or Consent to Release authorization on file with the BCRC will receive a copy of the CPL. Please refer to the Proof of Representation and Consent to Release page for more information on these topics. The CPL includes a Payment Summary Form that lists all items or services the BCRC has identified as being related to the pending claim. The letter includes the interim total conditional payment amount and explains how to dispute any unrelated claims. The total conditional payment amount is considered interim as Medicare might make additional payments while the beneficiary’s claim is pending.
Updated conditional payment amounts are generally unavailable until at least 90 days after the initial CPL is issued. BCRC systems retrieve additional paid claims for each established case once every 90 days. If a settlement, judgment, award, or other payment occurs, it should be reported to the BCRC as soon as possible so the necessary steps are taken to expedite a final retrieval of claims.
For more information about the CPL, refer to the document titled What to Know About Conditional Payment Letters. This document can be accessed by clicking the Non-Group Health Plan Recovery link in the Related Links section below.
Contact information for the BCRC may be obtained by clicking the Contacts link found in the Related Links section below.
Conditional Payment Notification (CPN)
A CPN is issued in lieu of a CPL when a settlement, judgment, award, or other payment has already occurred when the case is first reported. A CPN provides conditional payment information and advises what actions must be taken because the settlement, judgment, award, or other payment has already occurred. After the CPN has been issued, the recipient is allowed 30 days to respond. If a CPN is received, any of the items listed below should be forwarded to the BCRC if they have not previously been sent:
- Proof of Representation documentation.
- Proof of any items and/or services that are not related to the case, if applicable.
- All settlement documentation if you are providing proof of any items and/or services not related to the case.
- Procurement costs and fees paid by the beneficiary.
- Documentation for any additional or pending settlements, judgments, awards, or other payments related to the same incident.
If a response is received within 30 days, the correspondence will be reviewed and a demand will be issued. If a response is not received in 30 days, a demand will automatically be issued requesting repayment on all conditional payments related to the case without a proportionate reduction for fees or costs.
For more information about a CPN, refer to the document titled Conditional Payment Notice, which can be accessed using the Non-Group Health Plan Recovery link in the Related Links section below.
Disputing Claims on a CPL or CPN
If the beneficiary or his/her representative believes any claims included on the CPL or CPN should be removed from Medicare's conditional payment amount, documentation supporting that position must be sent to the BCRC. The documentation provided should establish that the claims are not related to what was claimed or were released by the beneficiary. This process can be handled via mail, fax, or the Medicare Secondary Payer Recovery Portal (MSPRP). See the “Medicare Secondary Payer Recovery Portal (MSPRP)” section below for additional details. The BCRC will adjust the conditional payment amount to account for any claims it agrees are not related to what has been claimed or released. Upon completion of its dispute review process, the BCRC will notify all authorized parties of the resolution of the dispute.
The Self-Service Option is a means to obtain the conditional payment amount, an updated conditional payment amount, copies of conditional payment letters, and dates that letters were issued via the telephone without having to speak with a Customer Service Representative. To use this option, call 1-855-798-2627 and select the Self-Service option. When you use the Self-Service Option you will need the Case ID and the beneficiary’s Medicare Health Insurance Claim Number (HICN), date of birth, and last name.
Self-Calculated Conditional Payment Amount
A beneficiary or his/her representative has the option to self-calculate the final conditional payment amount before settlement in certain situations. The following conditions must be met for Medicare to provide the final conditional payment amount before settlement is reached:
- The claim and settlement must be for an injury caused by physical trauma. The settlement cannot involve or relate to injuries caused by exposure, ingestion, or medical implant.
- The beneficiary’s medical treatment for the injury must be completed with no further treatment expected. Treatment must have been completed at least 90 days before the beneficiary submits the proposed conditional payment amount to Medicare. These requirements are proven to Medicare by providing either a physician’s written confirmation or beneficiary certification that he/she has not had care related to the case within the last 90 days and expects no further care.
- The total settlement, judgment, award, or other payment cannot exceed $25,000.
- The date of the incident must have occurred at least 6 months before the beneficiary submits the self-calculated final conditional payment amount to Medicare.
The beneficiary will be asked to forfeit the right to appeal the amount or existence of the debt, but will keep the right to pursue waiver of recovery.
For additional information related to the requirements of the Self-calculated Conditional Payment Amount, please review the Self-calculated Conditional Payment Amount Presentation which can be accessed using the Non-Group Health Plan Recovery link in the Related Links section below. Here you will also find the Self-calculated Conditional Payment Amount model language to be used when sending in the request.
Medicare Secondary Payer Recovery Portal (MSPRP)
The MSPRP is an online self-service tool that may be used by Attorneys to manage cases that have been reported to the BCRC. The MSPRP allows users to request an update to the conditional payment amount or a copy of a current conditional payment letter. Please click the MSPRP link found in the Related Links section below for further details.
- Page last Modified: 01/30/2014 11:11 PM
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