CMS Pub. 100-05, ch. 1, § 20.7

When specified conditions are met, the MSP statute prohibits Medicare from making

payment where payment has been made or can reasonably be expected to be made by

GHPs, a WC law or plan, liability insurance (including self-insurance), or no-fault

insurance. If payment has not been made or cannot be reasonably be expected to be made

promptly by WC, liability insurance (including self-insurance), or no-fault insurance,

Medicare may make conditional payments. (See 42 CFR § 411.52.)

In order to adhere to the provisions in the MSP statute, all A/B MACs and DME MACs shall

follow 42 CFR § 411.21, reflected in Pub. 100-05, Chapter 1, §40, for the definition of

prompt or promptly. Prompt or promptly, with regard to no-fault insurance and workers’

compensation, means payment within 120 days after receipt of the claim for specific items

and services by the no-fault insurer or WC entity. In the absence of evidence to the

contrary, A/B MACs and DME MACs shall treat the date of service for specific items and

services as the claim date for the purpose of determining the promptly period. Further, with

respect to inpatient services, in the absence of evidence to the contrary, A/B MACs and

DME MACs shall treat the date of discharge as the date of service with respect to no-fault

insurance and WC situations for the purpose of determining the promptly period.

Additionally, A/B MACs and DME MACs shall follow 42 CFR §411.50, also reflected in

Pub. 100-05, Chapter 2, for the definition of prompt or promptly with regard to liability

insurance (including self-insurance). Prompt or promptly, with regard to liability insurance

(including self-insurance), means payment within 120 days after the earlier of the

following: (1) The date a general liability claim is filed with an insurer or a lien is filed

against a potential liability settlement; and (2) the date the service was furnished or, in the

case of inpatient services, the date of discharge. Generally, the MSP auxiliary record for

the liability situation is posted to CWF after the beneficiary files a claim against the alleged

tortfeasor and the associated liability insurance (including self- insurance) Accordingly, in

the absence of evidence to the contrary, the date the general liability claim is filed against

liability insurance (including self-insurance) is no later than the date that the record was

posted on CWF. Therefore, A/B MACs and DME MACs shall consider the date of accretion

listed on liability MSP auxiliary record on CWF to be the date the general liability claim

was filed, for the purposes of determining the promptly period, with regard to liability

insurance (including self-insurance) situations.

Subject to Medicare payment rules and other stipulations, primary payers (GHP, liability

insurance, including self-insurance, no-fault insurance, and WC) are obligated to

reimburse Medicare if they were properly primary to Medicare, but have not paid as

primary, pursuant to 42 CFR 411.22. A primary plan's responsibility for such payment may

be demonstrated by a judgment, a payment conditioned upon the recipient's compromise,

waiver, or release (whether or not there is a determination or admission of liability) of

payment for items and services included in a claim against the primary plan or the primary

plan's insured, or by other means.

NOTE: If the injury resulted from an automobile accident and/or there is an indication of

primary coverage under a GHP, the provider, physician, or other supplier bills the liability

insurer or no-fault insurer and/ GHP as appropriate before requesting conditional Medicare

payments. Except as delineated in in Pub.100-05, Chapter 2, Medicare does not make

conditional primary payment when there is GHP coverage that is a primary payer to Medicare

until the claim has been sent to the primary payer first for payment.