Medicare Secondary Payer Screening Form

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Medicare Secondary Payer Screening Form
Must be completed for Medicare Recipients or attach hospital's completed MSP form
HIC Number
Patient's Name
1
Is the patient covered under a Group Health Plan (either their own or that of another family member?
[ ] YES
Complete the following:
[ ] NO
Date of coverage termination: _______________ proceed to Question #2
Employer Information for:
Insurance Information for:
[ ] Patient
[ ] Spouse
[ ] Other ____________
[ ] Patient
[ ] Spouse
[ ] Other _________
Employer Name ____________________________
Insurance Name ________________________
Address ___________________________________ Address _______________________________
City, State, Zip
City, State, Zip
_________________________________________ _____________________________________
Insured's Name _________________________
Policy/Group No. _______________________
Proceed to Question 2
Are you or your spouse retired?
2
[ ] YES Patient retirement date: ____________
Spouse retirement date: ____________
What is your Reason For Medicare Entitlement?
[ ] Age (65 years old or older) Proceed to section A
[ ] Disability (under age 65, non-ESRD) Proceed to section B
[ ] ESRD:
[ ] Solely ESRD - Proceed to Section C/D
[ ] ESRD and Age - Proceed to Section C/E
[ ] ESRD and Disability - Proceed to Section C/E
A
Patient non-ESRD and 65 years of age or older (Working Elderly)
Is the GHP in Section 1 based on patient's or spouse's current employment?
[ ] YES Bill GHP listed above as primary. Medicare is tertiary if the patient and spouse are both
employed and covered by a GHP.
The GHP is not primary for:
1) Employees of employers with fewer than 20 employees (full time, part time, or leased) unless
the plan is part of a multi-employer plan that pays primary benefits for all individuals.
2) Self employed individuals with fewer than 20 employees.
3) Individuals entitled to premium Part A or have Part B only.
[ ] NO
Proceed to Question #3
B
Patient under 65 years of age and entitled to Medicare due to a Disability other than ESRD.
(Disability)
Is the GHP in Section 1 based on patient's or spouse's current employment?
[ ] YES
Bill the GHP listed above as primary. Medicare is tertiary if the patient and spouse
are both employed and covered by a GHP.
The GHP is not primary for:
1) Employees of employers with fewer than 100 employees (full time, part time, or leased) unless
the plan is part of a multi-employer plan that pays primary benefits for all individuals.
2) Self employed individuals with fewer than 100 employees.
3) Individuals entitled to Premium Part A or have Part B only.
[ ] NO
Proceed to Question #3
C
Dialysis
Coordination Periods
Did patient begin dialysis less than
Did the coordination period begin 3/96 or after?
33 months ago?
[ ] YES - Medicare is secondary for 30 months
[ ] YES - Proceed to Coordination Periods
[ ] NO
[ ] NO - Medicare is Primary
Did the coordination period begin 2/96 or before?
Date of 1st treatment ________________
[ ] YES - Medicare is secondary for 18 months
Date of kidney transplant/home dialysis:
[ ] NO
(3 month waiting period does not apply)
__________________
Proceed to Section D or E as appropriate
MSP FORM.xls7/27/2009Sheet2
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