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Question	Answer
Form Name	Msp Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	msp form pdf, printable medicare as second payer screening questionnaire, dowload msp form, 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 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

MSP FORM.xls7/27/2009Sheet2

Page 1

Medicare Secondary Payer Screening Form

Must be completed for Medicare Recipients or attach hospital's completed MSP form

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

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

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
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

Msp Form – Fill Out and Use

Medicare Secondary Payer Screening Form Details

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