Medicare Secondary Payer Screening Form Page 2

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Medicare Secondary Payer Screening Form
Must be completed for Medicare Recipients or attach hospital's completed MSP form
D
Patient (under age 65) entitled to Medicare solely on the basis of End Stage Renal Disease (ESRD).
Is the GHP coverage through a current or former employer of the patient or family member?
[ ] YES
Bill the GHP listed above as primary, regardless of the number of employees
If the patient is covered by a GHP that is legitimately primary, Medicare is the secondary payer
(regardless of the number of employees) See Section C for the appropriate coordination period.
Proceed to Question #3
E
Patient (of any age) entitled to Medicare due to Age or Disability and ESRD. (Dual Entitlement)
Is the patient covered under a GHP that is legitimately primary, (i.e. the GHP is primary based on age,
employer employs 20 or more employees or disability, employer employs 100 or more employees)?
[ ] YES
Medicare is the secondary payer
[ ] NO
Medicare is primary
Proceed to Question #3
3
Is the illness for which the patient is receiving treatment covered under the Black Lung Program or
are the services provided or authorized by the Department of Veterans Affairs (DVA)?
[ ] YES
Date Black Lung effective __________
[ ] NO
Proceed to Question #4
Bill Black Lung only if dx is B.L. related
Bill DVA if services were authorized and DVA agreed to pay
Is the condition for which the patient is receiving treatment due to an automobile accident, accidental
injury, or third party liability? Note: Please continue if admitting diagnosis is a trauma code.
[ ] YES
[ ] NO
Explain accident,
Please complete the following automobile/medical or
Medicare is primary payer
any liability screening form below.
Automobile/Medical or Any Liability Screening Form
4
Date of Injury _______________
[ ] Other Nature:
Please check type of accident:
[ ] Automobile (complete A)
No liability or medical/premise coverage.
[ ] Third Party Liability (complete B)
Medicare is primary because:
[ ] Premise Medical Coverage (complete A)
[ ] Work Related (complete C)
A. Automobile Medical/Premise Medical (if third party liability also exists, complete A and B)
Automobile medical insurance/Premise medical insurance is the primary payer. Bill auto-medical or
no-fault insurance first.
Insured's Name _______________________________
Insurance Company ______________________________________
Policy # _____________
Insurance Company Address __________________________________________________________
Description of Accident _______________________________________________________________
B. Third Party Liability (other than auto/medical, premise medical or work-related). Bill third party
payer or Medicare conditionally after 120 days.
Description of Accident _______________________________________________________________
Location (if accident occurred at location other than patient's residence, please provide information
even if liability is in question)
______________________________________________
Name of responsible party _________________________________ Policy # _____________
Insurance Address ___________________________________
Insurance Claim # _____________
Attorney Name & Address_______________________________________________ Phone#
C. Work Related - Worker's Compensation is the primary payer. Bill them.
Injury or Illness _____________________________________________________________________
Carrier's Name & Address ____________________________________________________________
Employer ______________________________________________
Case/File # _______________
Signature (optional)
Patient or Patient's Representative
Date:
MSP FORM.xls7/27/2009Sheet2
Page 2

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