Medicare Conditional Claim

Posted by Matthew Garretson and Elizabeth Vish Schad

Question:
In cases where we set up the claim early on, Medicare has denied payment for services to beneficiaries stating that third party liability policy of defendant is primary insurance. In cases with disputed liability, how does one avoid this problem?

-Recent Seminar Attendee

Answer:
The claim is most likely not being coded as a conditional claim. The provider needs to resubmit the claim as conditional claim. Additionally, if this is a MVA and Med pay is involved then a letter of exhaustion along with the PIP payout needs to be provided to the provider so that the exhaustion date can be included on the claim. Regardless of liability, if there is third party liability then all claims need to be submitted to Medicare conditionally.