When can Conditional Primary Medicare Benefits be Paid?
The beneficiary, provider, physician, or supplier has filed a proper claim with a Group Health Plan in the case of services for which payment under Workers Comp, or liability, or no-fault insurance can reasonably be expected, and the contractor determines that the Group Health Plan insurer will not pay promptly (within 120 days of receipt of the claim) for any reason except when the Group Health Plan claims that its benefits are secondary to Medicare; or The beneficiary or provider, physician, or supplier that has accep…
• The beneficiary, provider, physician, or supplier has filed a proper claim with a Group Health Plan in the case of services for which payment under Workers Comp, or liability, or no-fault insurance can reasonably be expected, and the contractor determines that the Group Health Plan insurer will not pay promptly (within 120 days of receipt of the claim) for any reason except when the Group Health Plan claims that its benefits are secondary to Medicare; or • The beneficiary or provider, physician, or supplier that has accepted assignment filed a proper claim with a Group Health Plan or Large Group Health Plan denied the claim in whole or in part; or • Because of physical or mental incapacity of the beneficiary, the physician, the supplier or beneficiary failed to file a proper claim with the Group Health Plan. When such conditional Medicare payments are made, they are made on condition that both the insurer and beneficiary will reimburse the program to the extent that payment is subseq
