Medicare MSPQ Form Download Printable Copy Patient Name * First Name Last Name Today's Date * MM DD YYYY HICN * Part I 1. Are you receiving Black Lung (BL) Benefits? * (BL is primary payer for claims related to BL) Yes No Date Benefits Began MM DD YYYY 2. Are the services to be paid by a government research program? * (Government research programs will pay primary benefits for these services) Yes No 3. Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for care at this facility? * (DVA is primary for these services) Yes No 4. Was the illness/injury due to a work related accident/condition? * Yes No Date of injury/illness MM DD YYYY Name and address of worker's compensation (WC) plan Policy or identification number Name and address of your employer Part II 1. Was illness/injury due to a non-work related accident? * Yes No Date of accident MM DD YYYY 2. Is no-fault insurance available? * (No-fault insurance is insurance that pays for healthcare services resulting from injury to you or damage to your property, regardless of who is at fault for causing the accident.) Yes No Name and address of no-fault insurer(s) and no-fault policy owner: Insurance claim number(s) 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 No (No-fault insurer is primary payer only for those services related to the accident. Liabilty insurer is primary payer only for those services related to the liabilty settlement, judgement, or award. No Name and address of any liability insurer(s) and party Insurance claim number(s) Part III 1. Are you entitled to Medicare based on: * 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. Age - Go to Part IV Disability - Go to Part V End Stage Renal Disease (ESRD) - Go to Part VI Not Entitled Part IV 1. Are you currently employed? Yes No, Retired No, Not Employed Name and address of your employer If retired, date of retirement MM DD YYYY 2. Do you have a spouse who is currently employed? Yes No, retired No, not employed Name and address of your spouse's employer If spouse is retired, date of retirement MM DD YYYY IF THE PATIENT ANSWERED "NO" TO BOTH QUESTIONS 1 AND 2, MEDICARE IS PRIMARY UNLESSTHE PATIENT ANSWERED "YES" TO QUESTIONS 1 OR 2. 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 THE QUESTIONS 1 OR 2. 4. If you have GHP coverage based on your current employment, does your employer that sponsers or contributes to the GHP employ 20 or more employees? Yes, (GHP IS PRIMARY) No 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 5. If you have GHP coverage based on your spouse's current employment, does your spouse's employer, that sponsers or contributes to the GHP, employ 20 or more employees? Yes, (GHP IS PRIMARY) No 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 Part V - Disablility 1. Are you currently employed? Yes No, Retired No, Not Employed Name and address of your employer If retired, date of retirement MM DD YYYY 2. Do you have a spouse who is currently employed? Yes No, Retired No, Not Employed Name and address of your spouse's employer If spouse is retired, date of retirement MM DD YYYY 3. Do you have group health plan (GHP) coverage based on your own or a family member's current employment? Yes, Both Yes, Spouse Yes, Self No 4. Are you covered under the group health plan of a family member other than your spouse? Yes No Name and address of your family member's employer 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) No 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 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) No 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 7. If you have GHP coverage based on your 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) No Name and address of GHP Policy identifcation 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 IF THE PATIENT ANSWERED "NO" TO QUESTIONS 1-7. MEDICARE IS PRIMARY. UNLESS THE PATIENT ANSWERED "YES" TO QUESTIONS 1 OR 2 Part VI - ESRD 1. Do you have group health plan (GHP) coverage? Yes, Both Yes, Spouse Yes, Self Yes, Family Member No, MEDICARE IS PRIMARY 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 Name and address of employer, for which member receivies GHP coverage 2. Have you received a kidney transplant? Yes No Date of transplant MM DD YYYY 3. Have you received maintenance dialysis treatment? Yes No Date dialysis began MM DD YYYY If you participated in a self-dialysis training program, provide date training started MM DD YYYY 4. Are you within the 30-month coordination period? [The 30-month coordination period starts the 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 primarily based on age or disability entitlement) Yes (STOP, GHP CONTINUES TO PAY PRIMARY DURING THE 30-MONTH COORDINATION PERIOD) No (MEDICARE CONTINUES TO PAY PRIMARY) If no MSP data are found in the Common Working File (CWF) for the beneficiary, the provider still asks the types of questions above and provides any MSP information on the bill using the proper uniform billing codes. This information will then be used to update CWF through the billing process. Thank you!
