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 a workers' compensation entity. 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 responsible for recovering conditional payments when there is a settlement, judgment, award, or other payment made to the Medicare beneficiary. 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.
If Medicare is pursuing recovery directly from the insurer/workers’ compensation entity, the beneficiary and beneficiary’s attorney or other representative will receive a copy of recovery correspondence sent to the insurer/workers’ compensation entity. The beneficiary does not need to take any action on this correspondence. However, if Medicare is pursuing recovery from the beneficiary, the BCRC will send recovery correspondence to the beneficiary.
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. For cases where Medicare is pursuing recovery from the beneficiary, a CPL is automatically sent to the beneficiary within 65 days of issuance of the Rights and Responsibilities letter (a copy of the Rights and Responsibilities letter can be obtained by clicking the Medicare's Recovery Process link). All entities that have a verified Proof of Representation or Consent to Release authorization on file with the BCRC for the case 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.
You can obtain the current conditional payment amount and copies of CPLs from the BCRC or from the Medicare Secondary Payer Recovery Portal (MSPRP). To obtain conditional payment information from the BCRC, call 1-855-798-2627. To obtain conditional payment information from the MSPRP, see the “Medicare Secondary Payer Recovery Portal (MSPRP)” section below. If a settlement, judgment, award, or other payment occurs, it should be reported to the BCRC as soon as possible so the BCRC can identify any new, related claims that have been paid since the last time the CPL was issued.
For more information about the CPL, refer to the document titled Conditional Payment Letters (Beneficiary). This document can be accessed by clicking the Medicare's Recovery Process link.
Contact information for the BCRC may be obtained by clicking the Contacts link.
Conditional Payment Notification (CPN)
A CPN is issued to the beneficiary in lieu of a CPL when a settlement, judgment, award, or other payment has already occurred. 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 calendar days, the correspondence will be reviewed, and a demand letter will be issued. If a response is not received in 30 calendar days, a demand letter 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 (Beneficiary), which can be accessed using the Medicare's Recovery Process link.
Disputing Claims on a CPL or CPN
If the beneficiary or his or her attorney or other 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 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.
Demand Calculation Option
If the beneficiary is settling a liability case, he or she may be eligible to obtain Medicare's demand amount prior to settlement or to pay Medicare a flat percentage of the total settlement. Click the Demand Calculation Options link to determine if the beneficiary's case meets the required guidelines.
Medicare Secondary Payer Recovery Portal (MSPRP)
The MSPRP is an online self-service tool that may be used by attorneys to report a case and manage cases that have been reported to the BCRC. The MSPRP allows users to obtain updated conditional payment amounts, request a copy of a current conditional payment letter or make an electronic payment. Please click the MSPRP link for further details.