Medicare Secondary Payer Screening Form

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Medicare Secondary Payer Screening Form




If answer is “no” to all questions then Medicare is primary. If answers are “yes” Medicare
Yes
no
is likely secondary and additional information is needed.
1.
Is the patient under 65?
If yes process to question 2, if no process to question 3
2.
Patient under 65 years of age and entitled to Medicare due to a Disability
A) Disability (Under age 65, non-ESRD) Proceed to # 4
B) Covered by Black Lung: proceed to #7
C) ESRD: Proceed to #8
3.
Are you (the patient) currently employed?
If Not what your retirement date:____ ____ ____
If yes complete section “A” on back
4.
Is your spouse (the patient’s) employed?
If not Spouse’s retirement date:____ /____ /____
5.
Is the Patient covered under a Group Health Plan (GHP)
(Either their own or that of another family member)?
If yes complete read and answer the following:
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.
The GHP is not primary for these 3 situations.
-------------------------------------------------
Medicare is tertiary if the patient and spouse are both employed and covered by a
GHP. Proceed to back of page and complete section “A”
6.
Is the condition for which the patient is receiving treatment due to any automobile
accident, accidental injury or third party liability? (i.e. Work related injury) Note:
Please continue if admitting diagnosis is a trauma code. If yes
Please complete section “B” for the automobile/ liability screening on back. Or
Section “C” for work related injury.
7.
Is the illness for which the patient is receiving treatment covered under the
Black Lung Program, Government Grant Program or are the services
provided or authorized by the Department of Veterans Affairs (DVA)?
If Yes
Date Black Lung Effective _____ /_____ /_____
Bill Black Lung only if diagnosis is Black Lung related
If Yes
Date Government Grant Program Effective _____ /_____ /_____
Bill Government Grant Program
If Yes
Bill the Department of Veterans Affairs (DVA) if services were
authorized and the DVA agree to pay
8.
Solely end stage renal disease (ESRD) or ESRD and Age –
Date of first Dialysis treatment _ _/_ _/_ _
9.
Did patient begin dialysis less than 33 months ago? If yes proceed to section D/E
If no Medicare is primary
ESRD and disability proceed to section E/F


HIC Number________________ Patient Name___________________________________
secondaryMedicarescreening
022211




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