---
kind: "section"
citation: "42 C.F.R. § 411.165"
title: "42"
number: "411.165"
heading: "Basis for conditional Medicare payments."
url: "https://uscodex.org/cfr/42/411.165"
---

# §411.165. Basis for conditional Medicare payments.

- (a) **General rule.** Except as specified in [paragraph (b)](#b) of this section, the Medicare intermediary or carrier may make a conditional payment if—
  - (1) The beneficiary, the provider, or the supplier that has accepted assignment files a proper claim under the group health plan and the plan denies the claim in whole or in part; or
  - (2) **The beneficiary, because of physical or mental incapacity, fails to file a proper claim.**
- (b) **Exception.** Medicare does not make conditional primary payments under either of the following circumstances:
  - (1) **The claim is denied for one of the following reasons—**
    - (i) **It is alleged that the group health plan is secondary to Medicare.**
    - (ii) **The group health plan limits its payments when the individual is entitled to Medicare.**
    - (iii) Failure to file a proper claim if that failure is for any reason other than the physical or mental incapacity of the beneficiary.
  - (2) The group health plan fails to furnish information requested by CMS and necessary to determine whether the employer plan is primary to Medicare.

## Notes

### Amendments

[57 FR 36015, Aug. 12, 1992. Redesignated and amended at 60 FR 45362, 45370, Aug. 31, 1995; 60 FR 53877, Oct. 18, 1995]

### Authority

Authority: 42 U.S.C. 1302, 1395w-101 through 1395w-152, 1395hh, and 1395nn.

### Source

Source: 54 FR 41734, Oct. 11, 1989, unless otherwise noted.

### Amendments

[57 FR 36015, Aug. 12, 1992. Redesignated and amended at 60 FR 45362, 45370, Aug. 31, 1995; 60 FR 53877, Oct. 18, 1995]