Msp Form – Fill Out and Use This PDF

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 DisabilityOTHER 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

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