Medicare Secondary Payer Questionnaire Form

Black lung yes long form part i no. Insurer pays your medical bills before medicare.

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Completion required for any situation where another payer or.

Medicare secondary payer questionnaire form. May pay as the secondary payer if the pharmacy used is also a. If you have ghp coverage on your own current. Dme mac jurisdiction c medicare secondary payer msp questionnaire page 6 reviewed january 4 2016.

Background according to cms this new form is only a model of the questions to be asked and does not require use of the exact format. 01 opyright gs administrators lc rembun noitaficitnedi puogr membership number prior to hipaa this number was frequently the individual s ssn. Medicare secondary payer msp questionnaire patient name please print date of birth.

Research grant yes long form part i no. This questionnaire is a model of the type of questions that may be asked to help identify medicare secondary payer msp situations. Are you receiving black lung bl benefits.

Known as the medicare secondary payer questionnaire mspq this information is required to help determine if medicare is a primary or secondary payer for the patient. Are you receiving benefits from any of the following programs. We ask that you complete this form with either a y for yes or n for no dates and.

Medicare secondary payer questionnaire short form the information contained in this form is used by medicare to determine if there is other insurance that should pay claims primary to medicare. Use this questionnaire to determine if medicare is the primary or secondary payer. Insurance coverage to medicare beneficiaries pay beneficiary claims as.

Medicare secondary payer questionnaire there may be situations where medicare is not your primary payer or medicare coverage policies vary. 0 medicare part b physician fees ub04 uniform bill 2004 the ub04 is the universal healthcare form accepted by all carriers for hospital inpatient. Overlapping bills non coverage letters medicare secondary payer questionnaire etc.

Medicare law requires that we investigate all possible situations where other insurance besides medicare might be the primary payer we appreciate your help by completing this questionnaire. The bcrc is responsible for maintaining msp records in the common working file cwf. Medicare is primary payer unless the patient answered yes to the questions in part i or ii.

Yes date benefits began. If you choose to use this questionnaire please note that it was developed to be used in sequence. Instructions are listed after the questions to facilitate transition between questions.

Your answers can be changed at any time or start a new questionnaire.

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