US · guidance
CMS Pub. 100-05, ch. 1, § 20.7.2
When Conditional Primary Medicare Benefits May Not Be Paid
When a GHP is a Primary Payer to Medicare
(Rev. 11755, Issued:12-21-22, Effective: 01-23-23, Implementation: 01-23-23)
Conditional primary Medicare payments may not be made if the claim is denied for one of
the following reasons [See 42 CFR § 411.175(c)]:
• It is alleged that the GHP is secondary to Medicare;
• The GHP limits its payment when the individual is entitled to Medicare;
• The services are covered by the GHP for younger employees and spouses but not
for employees and spouses age 65 or over;
• The GHP asserts it is secondary to a liability, no-fault or WC insurer, or other
coverage also primary to Medicare.
• Failure to file a proper claim (including failure to file timely) if that failure is for
any reason other than physical or mental incapacity of the beneficiary.
History
(Rev. 11755, Issued:12-21-22, Effective: 01-23-23, Implementation: 01-23-23)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
8c23e624a5133c88de88f1ad148f09f7d251975a345edbb95fdb3c5c55372827
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