Medicare As Secondary Insurance Form Cms

If the insurance company doesn t pay the claim promptly usually within 120 days your doctor or other provider may bill medicare.

Medicare as secondary insurance form cms. Instructions are listed after the questions to facilitate transition between questions. You can also get this form in spanish. Cms 1500 02 12 claim form instructions when medicare is secondary. The medicare secondary payer msp provisions protect the medicare trust fund.

Fill out the patient request for medical payment form cms 1490s you ll find the address for form submission in the instructions. Expedited review notice notice of medicare provider non coverage. Follow the instructions on the second page to submit the form to your carrier. Ghp pays primary medicare pays secondary.

Many cms program related forms are available in portable document format pdf. Cms then uses this information in the medicare claims payment process and if medicare paid first when it should not have uses it to seek repayment from the other insurer or the medicare beneficiary. Appointment of representative form cms 1696 if an enrollee would like to appoint a person to file a grievance request a coverage determination or request an appeal on his or her behalf the enrollee and the person accepting the appointment must fill out this form or a written equivalent and submit it with the request. The instructions will direct the patient to the next appropriate question to determine msp situations.

Hard copy forms may be available from intermediaries carriers state agencies local social security offices or end stage renal disease networks that service your state. Upon receipt of this information cms checks whether the injured party associated with the claim report is a medicare beneficiary and determines if the other insurance is primary to medicare. An overview of the msp provisions and explains your responsibilities. 1 800 medicare authorization to disclosure personal health information.

The centers for medicare medicaid services cms is a federal agency within the u s. The necessary fields outlined below for medicare secondary payer msp must be completed. If you choose to use this questionnaire please note that it was developed to be used in sequence. This booklet gives.

National provider identifier npi application update form. Individual is age 65 or older is self employed and covered by a ghp through current employment or spouse s current employment and the employer has 20 or more employees or at least one employer is a multi employer group that employs 20 or more individuals. The secondary payer which may be medicare may not pay all the uncovered costs. Complete the items below on the cms 1500 02 12 claim form or electronic equivalent in addition to all other claim form requirements when medicare is the secondary payer.

Department of health and human services. If you don t know the address for your carrier you can look at your medicare summary notice msn. Help identify medicare secondary payer msp situations.