MEDICARE SECONDARY PAYER QUESTIONNAIRE
What is the Medicare Secondary Payer questionnaire?
MEDICARE
A statutory requirement that private insurers providing general health
SECONDARY PAYER
insurance coverage to Medicare beneficiaries pay beneficiary claims as
primary payers.
Use: Completion required for any situation where another payer or
insurer pays your medical bills before Medicare.
We ask that you complete this form with either a “Y” for yes or “N” for No, dates and
address required where indicated.
Part I
Government Program Coverage:
1.
Is the patient receiving Black Lung Benefits? __________
Date benefits began: ______/______/_______
2.
Are services covered by a government program (research)? _______
3.
Has Dept of Veteran Affairs agreed to pay for care?
________
4.
Was illness due to work related accident/condition?
________
If yes, name and address of workers compensation plan:
________________________________________________
________________________________________________
________________________________________________
(Please note: If you answered “yes” to any questions, then that plan is primary to Medicare.
If you answered “no” to all, then go to the next section).
Part II
Accident Related Injuries:
1.
Was illness/injury due to non-work related accident? _______
If “No”, then go to the next section
If “yes, date:_____/_____/_____
2.
Was accident caused by automobile______, non-automobile _____
or another party? _______
If yes, provide name, address, phone, claim # of no-fault or liability insurer:
___________________________________________________
___________________________________________________
___________________________________________________
Part III
Reasons for Medicare Benefits:
1.
Is beneficiary entitled to Medicare benefits based on
Age:________
Disability: _________; if yes, go to Part V
End Stage Renal Disease: _______, if yes, go to Part VI
2.
Is beneficiary part of a Medicare HMO? _________
If yes, then the HMO replaces Medicare.
T u r n O v e r t o C o m p l e t e
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