April 14, 2008
Medicare Secondary Payer (MSP) Questionnaire
Questions to Periodically Ask Medicare Beneficiaries
The following questionnaire can be used to help Medicare Part B providers identify other payers that may be primary to Medicare. The Medicare Secondary Payer (MSP) Questionnaire below is an updated version per Change Request 5087, effective 09/11/06.
Please note that the Provider Outreach and Education department of First Coast Service Options suggests that Part B providers utilize the MSP Questionnaire in order to properly determine a patient’s MSP status. Please note that use of the Questionnaire is not required by the Centers for Medicare and Medicaid Services (CMS) for Part B providers. However, providers are required by law to obtain proper payer information from the beneficiary prior to submitting a claim to Medicare. Refer to the CMS Internet Only Manual (IOM) 100-05, Chapter 3, Section 20 for questions regarding the provider’s responsibility for obtaining proper payer information, as well as the regulations regarding how often to collect primary payer information from the beneficiary. These regulations are on the CMS Web site at www.cms.hhs.gov/manuals/downloads/msp105c03.pdf 
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.Using the Questionnaire: Beginning with Part 1, ask the patient each question in sequence and comply with any instructions that follow an answer. If the instructions direct you to go to another part, have the patient answer (in sequence) each question under the new part.
Part I
1. Are you receiving Black Lung (BL) Benefits?
• Yes; Date benefits began: MM/DD/CCYY. BL IS PRIMARY PAYER ONLY FOR CLAIMS RELATED TO BL.
• No.
2. Are the services to be paid by a government research program?
• Yes; Government research program will pay primary benefits for these services
• No.
3. Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for your care at this facility?
• Yes. DVA IS PRIMARY FOR THESE SERVICES.
• No.
4. Was the illness/injury due to a work-related accident/condition?
• Yes; Date of injury/illness: MM/DD/CCYY
• Name and address of workers’ compensation (WC) plan:
• Policy or identification number:
• Name and address of your employer:
WC IS PRIMARY PAYER ONLY FOR CLAIMS FOR WORK-RELATED INJURIES OR ILLNESS, GO TO PART III.
• No. GO TO PART II.
Part II
1. Was illness/injury due to a non-work related accident?
• Yes; Date of accident: MM/DD/CCYY
• No. GO TO PART III.
2. Is no-fault insurance available? (No-fault insurance is insurance that pays for health care services resulting from injury to you or damage to your property regardless of who is at fault for causing the accident.)
• Yes.
• Name and address of no-fault insurer(s) and no-fault insurance policy owner:
• Insurance claim number(s):
• No.
3. Is liability insurance available? (Liability insurance is insurance that protects against claims based on negligence, inappropriate action or inaction, which results in injury to someone or damage to property.)
• Yes.
• Name and address of liability insurer(s) and responsible party:
• Insurance claim number(s):
No.
NO-FAULT INSURER IS PRIMARY PAYER ONLY FOR THOSE SERVICES RELATED TO THE ACCIDENT. LIABILITY INSURER IS PRIMARY PAYER ONLY FOR THOSE CLAIMS RELATED TO THE LIABILITY SETTLEMENT, JUDGMENT, OR AWARD. GO TO PART III.
Part III
1. Are you entitled to Medicare based on:
• Age. GO TO PART IV.
• Disability. GO TO PART V.
• End-Stage Renal Disease (ESRD). GO TO PART VI
Please note that both “Age” and “ESRD” OR “Disability” and “ESRD” may be selected simultaneously. An individual cannot be entitled to Medicare based on “Age” and “Disability” simultaneously. Please complete ALL “PARTS” associated with the patient’s selections.
Part IV – Age
1. Are you currently employed?
• Yes. Name and address of your employer:
• No. If applicable, date of retirement: MM/DD/CCYY
• No. Never Employed.
2. Do you have a spouse who is currently employed?
• Yes. Name and address of your spouse’s employer:
• No. If applicable, date of retirement: MM/DD/CCYY
• No. Never Employed.
IF THE PATIENT ANSWERED “NO” TO BOTH QUESTIONS 1 AND 2, MEDICARE IS PRIMARY UNLESS THE PATIENT ANSWERED “YES” TO QUESTIONS IN PART I OR II. DO NOT PROCEED FURTHER.
3. Do you have group health plan (GHP) coverage based on your own, or a spouse's current employment?
• Yes, both.
• Yes, self.
• Yes, spouse.
• No. STOP. MEDICARE IS PRIMARY PAYER UNLESS THE PATIENT ANSWERED “YES” TO QUESTIONS IN PART I OR II.
4. If you have GHP coverage based on your own current employment, does your employer that sponsors or contributes to the GHP employ 20 or more employees?
• Yes. GHP IS PRIMARY. OBTAIN THE FOLLOWING INFORMATION.
• Name and address of GHP:
• Policy identification number (this number is sometimes referred to as the health insurance benefit package number):
• Group identification number:
• Membership number (prior to the Health Insurance Portability and Accountability Act [HIPAA], this number was frequently the individual’s Social Security Number [SSN]; it is the unique identifier assigned to the policyholder/patient):
• Name of policyholder/named insured:
• Relationship to patient:
• No.
5. If you have GHP coverage based on your spouse’s current employment, does your spouse’s employer, that sponsors or contributes to the GHP, employ 20 or more employees?
• Yes. GHP IS PRIMARY. OBTAIN THE FOLLOWING INFORMATION.
• Name and address of GHP:
• Policy identification number (this number is sometimes referred to as the health insurance benefit package number):
• Group identification number:
• Membership number (prior to HIPAA, this number was frequently the individual’s SSN; it is the unique identifier assigned to the policyholder/patient):
• Name of policyholder/named insured:
• Relationship to patient:
• No.
IF THE PATIENT ANSWERED “NO” TO BOTH QUESTIONS 4 AND 5, MEDICARE IS PRIMARY UNLESS THE PATIENT ANSWERED “YES” TO QUESTIONS IN PART I OR II.
Part V - Disability
1. Are you currently employed?
• Yes. Name and address of your employer:
• No. If applicable, date of retirement: MM/DD/CCYY
• No. Never Employed.
2. Do you have a spouse who is currently employed?
• Yes. Name and address of your spouse’s employer:
• No. If applicable, date of retirement: MM/DD/CCYY
• No. Never Employed.
3. Do you have group health plan (GHP) coverage based on your own or a spouse’s current employment?
• Yes, both.
• Yes, self.
• Yes, spouse.
• No.
4. Are you covered under the GHP of a family member other than your spouse?
• Yes. Name and address of your family member’s employer:
• No.
IF THE PATIENT ANSWERED “NO” TO QUESTIONS 1, 2, 3, AND 4, STOP. MEDICARE IS PRIMARY UNLESS THE PATIENT ANSWERED “YES” TO QUESTIONS IN PART I OR II.
5. If you have GHP coverage based on your own current employment, does your employer that sponsors or contributes to the GHP employ 100 or more employees?
• Yes. GHP IS PRIMARY. OBTAIN THE FOLLOWING INFORMATION.
• Name and address of GHP:
• Policy identification number (this number is sometimes referred to as the health insurance benefit package number):
• Group identification number:
• Membership number (prior to HIPAA, this number was frequently the individual’s SSN; it is the unique identifier assigned to the policyholder/patient):
• Name of policyholder/named insured:
• Relationship to patient:
• No.
6. If you have GHP coverage based on your spouse’s current employment, does your spouse’s employer, that sponsors or contributes to the GHP, employ 100 or more employees?
• Yes. GHP IS PRIMARY. OBTAIN THE FOLLOWING INFORMATION.
• Name and address of GHP:
• Policy identification number (this number is sometimes referred to as the health insurance benefit package number):
• Group identification number:
• Membership number (prior to HIPAA, this number was frequently the individual’s SSN; it is the unique identifier assigned to the policyholder/patient):
• Name of policyholder/named insured:
• Relationship to patient:
• No.
7. If you have GHP coverage based on a family member’s current employment, does your family member’s employer, that sponsors or contributes to the GHP, employ 100 or more employees?
• Yes. GHP IS PRIMARY. OBTAIN THE FOLLOWING INFORMATION.
• Name and address of GHP:
• Policy identification number (this number is sometimes referred to as the health insurance benefit package number):
• Group identification number:
• Membership number (prior to HIPAA, this number was frequently the individual’s SSN; it is the unique identifier assigned to the policyholder/patient):
• Name of policyholder/named insured:
• Relationship to patient:
• No.
IF THE PATIENT ANSWERED “NO” TO QUESTIONS 5, 6, AND 7, MEDICARE IS PRIMARY UNLESS THE PATIENT ANSWERED “YES” TO QUESTIONS IN PART I OR II.
Part VI – ESRD
1. Do you have group health plan (GHP) coverage?
• Yes.
IF APPLICABLE, YOUR GHP INFORMATION:
• Name and address of GHP:
• Policy identification number (sometimes referred to as the health insurance benefit package number):
• Group identification number:
• Membership number (prior to the HIPAA, this number was frequently the individual’s SSN; it is the unique identifier assigned to the policyholder/patient):
• Name of policyholder/named insured:
• Relationship to patient:
• Name and address of employer, if any, from which you receive GHP coverage:
IF APPLICABLE, YOUR SPOUSE’S GHP INFORMATION:
• Name and address of GHP:
• Policy identification number (sometimes referred to as the health insurance benefit package number):
• Group identification number:
• Membership number (prior to the HIPAA, this number was frequently the individual’s SSN; it is the unique identifier assigned to the policyholder/patient):
• Name of policyholder/named insured:
• Relationship to patient:
• Name and address of employer, if any, from which your spouse receives GHP coverage:
IF APPLICABLE, YOUR FAMILY MEMBER’S GHP INFORMATION:
• Name and address of GHP:
• Policy identification number (sometimes referred to as the health insurance benefit package number):
• Group identification number:
• Membership number (prior to the HIPAA, this number was frequently the individual’s SSN; it is the unique identifier assigned to the policyholder/patient):
• Name of policyholder/named insured:
• Relationship to patient:
• Name and address of employer, if any, from which your family member receives GHP coverage:
• No. STOP. MEDICARE IS PRIMARY.
2. Have you received a kidney transplant?
• Yes. Date of transplant: MM/DD/CCYY
• No.
3. Have you received maintenance dialysis treatments?
• Yes. Date dialysis began: MM/DD/CCYY
If you participated in a self-dialysis training program, provide date training started: MM/DD/CCYY
• No.
4. Are you within the 30-month coordination period that starts MM/DD/CCYY? (The 30-month coordination period starts the first day of the month an individual is eligible for Medicare [even if not yet enrolled in Medicare] because of kidney failure [usually the fourth month of dialysis]. If the individual is participating in a self-dialysis training program or has a kidney transplant during the 3-month waiting period, the 30-month coordination period starts with the first day of the month of dialysis or kidney transplant.)
• Yes.
• No. STOP. MEDICARE IS PRIMARY.
5. Are you entitled to Medicare on the basis of either ESRD and age or ESRD and disability?
• Yes.
• No.
6. Was your initial entitlement to Medicare (including simultaneous or dual entitlement) based on ESRD?
• Yes. STOP. GHP CONTINUES TO PAY PRIMARY DURING THE 30-MONTH COORDINATION PERIOD.
• No. INITIAL ENTITLEMENT BASED ON AGE OR DISABILITY.
7. Does the working aged or disability MSP provision apply (i.e., is the GHP already primary based on age or disability entitlement)?
• Yes. GHP CONTINUES TO PAY PRIMARY DURING THE 30-MONTH COORDINATION PERIOD.
• No. MEDICARE CONTINUES TO PAY PRIMARY.
