Get the free Medicare Secondary Payer Form - mcrh msu

Visit Date: Asked By: Rural Health Clinic PATIENT S NAME: MEDICARE #: Medicare Secondary Payer Screening Questionnaire 1. Are you covered by Veterans Administration, Black Lung Program or Workers

How to fill out medicare secondary payer form

How to Fill Out Medicare Secondary Payer Form:

1. Start by gathering all the necessary information: You will need personal information such as your name, address, and date of birth. You will also need your Medicare Health Insurance Claim Number (HICN) or Medicare Beneficiary Identifier (MBI), as well as information about your primary insurance coverage.
2. Determine the type of Medicare Secondary Payer (MSP) situation: The Medicare Secondary Payer form, also known as CMS-8552, is used in specific instances when Medicare is not your primary insurance. Make sure to understand whether your situation falls under one of these categories: Workers' Compensation, Liability Insurance (including self-insurance), or No-Fault Insurance.
3. Complete Section A: In this section, provide your personal information as required. Fill in your name, address, phone number, and Medicare HICN or MBI.
4. Provide primary insurance information in Section B: If you have a primary insurance provider other than Medicare, you need to provide the details of this coverage. Include the name of the primary insurer, the policy number, and the type of coverage.
5. Indicate the type of MSP coverage you are seeking in Section C: Determine whether you are applying for conditional payment, no-fault insurance, or workers' compensation.
6. Complete the Certification Statement in Section D: Read the certification statement carefully and sign and date it, confirming that the information you provided is accurate to the best of your knowledge.
7. Attach any supporting documentation: If required, make sure to attach any relevant documents that support your MSP claim. This may include bills, accident reports, or other necessary paperwork.

Who needs Medicare Secondary Payer form:

1. Medicare beneficiaries with other primary insurance: If you have coverage through another insurance plan, such as through your employer or a spouse's plan, you may need to fill out the Medicare Secondary Payer form.
2. Individuals involved in accidents or injuries: If you have been injured and are seeking coverage for your medical expenses through sources like workers' compensation or liability insurance, you may require the Medicare Secondary Payer form.
3. Those who have no-fault insurance coverage: If you have no-fault insurance to cover medical expenses resulting from an accident, you may need to fill out the Medicare Secondary Payer form.

Remember, it is essential to consult with Medicare or a healthcare provider to determine if you need to complete the Medicare Secondary Payer form and to ensure you are providing accurate and complete information.

For pdfFiller’s FAQs

What is medicare secondary payer form?

Medicare Secondary Payer (MSP) form is a form used to report information about insurance coverage that may be primary to Medicare.

Who is required to file medicare secondary payer form?

Healthcare providers, insurers, and employers are required to file Medicare Secondary Payer forms.

How to fill out medicare secondary payer form?

The form can be filled out online or submitted via mail with all required information about the primary insurance coverage.

What is the purpose of medicare secondary payer form?

The purpose of the Medicare Secondary Payer form is to ensure that Medicare is not billed as the primary payer when there is other insurance coverage available.

What information must be reported on medicare secondary payer form?

The form must include information about the primary insurance carrier, coverage details, and any coordination of benefits information.

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