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Medicare Secondary payer Questionnaire FOR USE BY ALL MEDICARE OUTPATIENTS Patient Name MPI #1. Are you entitled to Medicare based on: Age (65 & over) Disability End Stage Renal Disease Do you have

How to fill out medicare secondary paye r

How to fill out medicare secondary paye r

1. To fill out Medicare Secondary Payer form, follow these steps:
2. Start by providing your personal information such as your name, contact details, and date of birth.
3. Enter your Medicare Health Insurance Claim Number (HICN) or Medicare Beneficiary Identifier (MBI).
4. Indicate whether you have a current employment or are self-employed. If yes, provide the employer's contact information.
5. If you have other health insurance coverage, specify the type of coverage and provide relevant details.
6. If you are enrolled in a Medicare Advantage plan, provide the plan name and number.
7. Complete the section related to any Workers' Compensation or Black Lung benefits you may be receiving.
8. Sign and date the form to indicate your consent and understanding of the information provided.
9. Submit the completed Medicare Secondary Payer form to the appropriate authorities or insurance company.

Who needs medicare secondary paye r?

1. Medicare Secondary Payer (MSP) is needed by individuals who have other health insurance coverage or receive certain types of benefits. Specifically, those who may need MSP include:
2. - Individuals who have employer group health plans (EGHP) through their own or a spouse's current employment.
3. - Individuals who have government or military health coverage such as TRICARE, Veterans Affairs (VA) benefits, or Indian Health Services (IHS) coverage.
4. - Individuals who have Workers' Compensation or Black Lung benefits.
5. - Individuals who are enrolled in Medicare and have other health coverage that pays before Medicare.

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