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Attachment B1.003D Page 1 of 2 MEDICARE SECONDARY PAYER QUESTIONNAIRE Person Giving Information: Patient Name: HIC Number: Patient Age Basis for Patient Entitlement to Medicare Age Disability Relationship

How to fill out medicare secondary payer questionnaire

How to fill out Medicare Secondary Payer Questionnaire:

1. Start by obtaining the Medicare Secondary Payer Questionnaire form from the appropriate source, such as your insurance company or the Medicare website.
2. Read the instructions on the form carefully to understand the purpose and requirements of the questionnaire.
3. Begin filling out the form by providing your personal information, including your name, address, and contact details.
4. Proceed to provide your Medicare information, such as your Medicare Beneficiary Identifier (MBI) or other relevant details.
5. If applicable, provide information about any other insurance coverage you may have, such as through another employer or a private insurer.
6. Answer the specific questions on the questionnaire accordingly, ensuring accuracy and completeness in your responses.
7. Attach any necessary supporting documentation, such as copies of insurance cards or explanation of benefits (EOBs), as directed by the form.
8. Review the completed questionnaire thoroughly to check for any errors or missing information.
9. Sign and date the form in the appropriate section to certify the accuracy of the information provided.
10. Make copies of the completed questionnaire and all supporting documents for your records.
11. Submit the filled-out Medicare Secondary Payer Questionnaire to the designated recipient, as specified in the form's instructions.

Who needs Medicare Secondary Payer Questionnaire:

1. Individuals who have Medicare coverage and also have another source of insurance, such as through an employer or a private insurer, may be required to fill out the Medicare Secondary Payer Questionnaire.
2. If you are eligible for Medicare but have another primary insurance provider, Medicare may request you to complete this questionnaire to determine if other insurance should pay before Medicare.
3. Those who have been involved in a workers' compensation case or personal injury lawsuit may also be required to submit a Medicare Secondary Payer Questionnaire to determine insurance coverage liabilities.

For pdfFiller’s FAQs

What is medicare secondary payer questionnaire?

Medicare Secondary Payer questionnaire is a form used to determine whether Medicare or another health insurance plan is the primary payer for an individual's medical expenses.

Who is required to file medicare secondary payer questionnaire?

Healthcare providers, insurers, and individuals involved in a personal injury settlement are required to file the Medicare Secondary Payer questionnaire when applicable.

How to fill out medicare secondary payer questionnaire?

To fill out the Medicare Secondary Payer questionnaire, individuals must provide information about their insurance coverage, any settlements, and any other relevant information.

What is the purpose of medicare secondary payer questionnaire?

The purpose of the Medicare Secondary Payer questionnaire is to ensure that Medicare is not billed for expenses that should be covered by another insurance plan.

What information must be reported on medicare secondary payer questionnaire?

The Medicare Secondary Payer questionnaire must include information about the individual's insurance coverage, settlements, and any other relevant information that may impact Medicare coverage.

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