Get the free Medicare Secondary Payer Questionnaire - UNM Medical Group

MEDICARE SECONDARY PAYER QUESTIONNAIRE PART I Yes Date Benefits began: / / 2. Are the services to be paid by government programs such an as a research grant? No Yes 3. Has the Department of Veterans

How to fill out medicare secondary payer questionnaire

How to fill out medicare secondary payer questionnaire:

1. Gather all relevant information: Before starting to fill out the questionnaire, gather all the necessary information such as your Medicare card, current health insurance cards, and any documents related to any past or ongoing medical treatments or claims.
2. Understand the purpose of the questionnaire: The Medicare secondary payer questionnaire is used to determine if Medicare should be the primary payer or secondary payer for your healthcare claims. It helps identify if you have any other insurance coverage that should be billed first before Medicare.
3. Provide personal information: Fill out the questionnaire with accurate personal information, including your full name, address, date of birth, and contact details. Make sure to double-check all the information provided to avoid any mistakes.
4. Disclose other health insurance coverage: Indicate whether you have any other health insurance coverage other than Medicare. If you do, provide the details of that insurance policy. This includes the name of the insurance provider, policy number, group number, contact information, and the effective dates of that coverage.
5. Provide information about your employer: If you have health insurance coverage through your current or former employer, provide details about the employer, such as the company name, address, and contact information. This helps determine if your employer's insurance should be the primary payer.
6. Include information about other insurance coverage: If you have any other insurance coverage besides your employer's insurance, such as a private health insurance policy, Medicaid, or Veterans Affairs (VA) benefits, provide the necessary information about that coverage as well.
7. Answer additional questions: The questionnaire may include additional questions about other circumstances that may affect how Medicare pays your claims. Be sure to answer all the questions accurately and truthfully.
8. Review and submit the questionnaire: Review all the information provided on the questionnaire to ensure its accuracy. Make any necessary amendments before submitting the form. Once you are satisfied with the information provided, sign and date the questionnaire, and submit it as instructed by your healthcare provider or Medicare.

Who needs medicare secondary payer questionnaire:

1. Individuals with other health insurance coverage: Anyone who has health insurance coverage other than Medicare, such as a private health insurance policy, employer-sponsored group insurance, Medicaid, or VA benefits, may need to complete the medicare secondary payer questionnaire.
2. Those undergoing medical treatments or claims: People who are undergoing medical treatments, have ongoing health conditions, or have filed claims with Medicare may be required to fill out the medicare secondary payer questionnaire. This helps determine the primary and secondary payers for the healthcare expenses.
3. Individuals with employer-sponsored insurance: If you have health insurance coverage through your current or former employer, your employer's insurance may act as the primary payer before Medicare. Hence, you may need to complete the medicare secondary payer questionnaire to establish the order of payment.

Note: The specific circumstances and requirements for needing the medicare secondary payer questionnaire may vary. It is always recommended to consult with your healthcare provider or Medicare to determine if you need to fill out the questionnaire.

For pdfFiller’s FAQs

What is medicare secondary payer questionnaire?

Medicare Secondary Payer Questionnaire is a form used to gather information about an individual's health insurance coverage to determine if Medicare should be the primary or secondary payer for medical services.

Who is required to file medicare secondary payer questionnaire?

The individual who is eligible for Medicare and has other health insurance coverage is required to file the Medicare Secondary Payer Questionnaire.

How to fill out medicare secondary payer questionnaire?

The Medicare Secondary Payer Questionnaire can be filled out online or on paper by providing information about the individual's health insurance coverage, including the name of the insurance company, policy number, and coverage details.

What is the purpose of medicare secondary payer questionnaire?

The purpose of the Medicare Secondary Payer Questionnaire is to determine if Medicare should be the primary or secondary payer for an individual's medical services based on their other health insurance coverage.

What information must be reported on medicare secondary payer questionnaire?

The Medicare Secondary Payer Questionnaire must include information about the individual's health insurance coverage, such as the name of the insurance company, policy number, and coverage details.

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