Msp Form – Fill Out and Use This PDF

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HealthcareSolutions

Medicare Secondary Payer Part A Form

Please complete and forward this form to Noridian Healthcare Solutions

Helpful Hints:

•This form may be utilized for any Medicare Secondary Payer (MSP) request pertaining to Primary or Secondary payment of claims.

•This form is used when you need assistance canceling or adjusting a previous claim submission.

•Please forward all inquiries for MSP Recovery to the BCRC.

•Do not include a refund check with this form.

•Do not use this form for new claim submissions.

•Do not use this form if you are requesting a Redetermination on a MSP claim that is not MSP related.

•Do not send a UB Claim Form with this form.

Provider/Physician/Supplier or Other Entity Name: __________________________________________________________________________________________________________

Address: ___________________________________________________________________ City: ____________________________________ State:__________ Zip Code:______________________

NPI/Tax ID/PTAN: ____________________________________________________________________________________________________________________________________________________________

Contact Person:_______________________________________________________________________________________________________Phone #:___________________________________________

Provide the following information for each claim:

Patient Name: ________________________________________________________________________________________________________ Medicare Number: ___________________________

Medicare Claim # (ICN): ___________________________________________________________________________________________ Claim Amount: $ ______________________________

Date of Service: ______________________________________________________________________________________________________________________________________________________________

Reason for Request: _______________________________________________________________________________________________________________________________________________________

MEDICARE SECONDARY PAYER: Complete the following primary insurance information and attach a copy of the primary payer Explanation of Benefts (EOB) or payment sheet, and/or a copy of the check received from the primary payer and the Medicare EOB.

Insurance Name: _______________________________________________________________________________________________Subscriber Name: ____________________________________

Insurance Address: ___________________________________________________________________________________________Subscriber Relationship: __________________________

City, State, Zip: _________________________________________________________________________________________________Phone #:__________________________________________________

Policy Number: ______________________________________Group Number:____________________________________ *Injury Date: ____________________________________________

Effective Date: ______________________________________Term Date: __________________________________________ Injury Diagnosis: ______________________________________

NOTE: If specifc patient/Medicare Number/Claim #/primary insurance EOB information is not provided, we may be unable to process your request appropriately or in a timely manner.

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