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Pub. 100-05 Medicare Secondary Payer Centers for Medicare & Medicaid Services (CMS) Transmittal 23 Date: JANUARY 21, 2005, CHANGE REQUEST 3504

SUBJECT: Modification to Online Medicare Secondary Payer Questionnaire

I. SUMMARY OF CHANGES: Question 6 was a duplicate of Question 5 in the Online Medicare Secondary Payer Manual. Question 6 is being changed to reflect the appropriate follow-up question/answer.

Medicare Secondary Payer (MSP) Manual

Chapter 3 - MSP Provider Billing Requirements

Table of Contents

(Rev. 23, 01-21-05)

20.2.1 - Admission Questions to Ask Medicare Beneficiaries

20.2.1 - Admission Questions to Ask Medicare Beneficiaries

(Rev. 23, Issued: 01-21-05, Effective: 02-22-05, Implementation: 02-22-05)

HO-301.2

The following chart lists questions that can be used to ask Medicare beneficiaries upon each inpatient and outpatient admission. Providers use this chart as a guide to help identify other payers that may be primary to Medicare. If you choose to use this questionnaire, please note that it was developed to be used in sequence. Instructions are listed after the questions to facilitate transition between questions. The instructions will direct them to the next appropriate question to determine Medicare Secondary Payer situations.

Part I

1. Are you receiving Black Lung (BL) Benefits?

___ Yes; Date benefits began: CCYY/MM/DD

BL IS PRIMARY ONLY FOR CLAIMS RELATED TO BL.

___ No.

2. Are the services to be paid by a government program such as a research grant?

___ Yes; Government Program will pay primary benefits for these services

___ No.

3. Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for 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: CCYY/MM/DD

Name and address of WC plan:

______________________________________________________

Policy or identification number: ____________

Name and address of your employer:

______________________________________________________

WC IS PRIMARY PAYER ONLY FOR CLAIMS RELATED TO 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: CCYY/MM/DD

___ No. GO TO PART III

2. What type of accident caused the illness/injury?

___ Automobile.

___ Non-automobile.

Name and address of no-fault or liability insurer:

________________________________________

________________________________________

________________________________________

Insurance claim number: ________________________

NO-FAULT INSURER IS PRIMARY PAYER ONLY FOR THOSE CLAIMS RELATED TO THE ACCIDENT. GO TO PART III.

___ Other

3. Was another party responsible for this accident?

___ Yes;

Name and address of any liability insurer:

_______________________________________

_______________________________________

_______________________________________

Insurance claim number: ________________________

LIABILITY INSURER IS PRIMARY PAYER ONLY FOR THOSE CLAIMS RELATED TO THE ACCIDENT. GO TO PART III.

___ No. GO TO PART III

Part III

1. Are you entitled to Medicare based on:

___ Age. Go to Part IV.

___ Disability. Go to Part V.

___ ESRD. Go to Part VI.

Part IV - Age

1. Are you currently employed?

___ Yes.

Name and address of your employer:

________________________________

________________________________

________________________________

___ No. Date of retirement: CCYY/MM/DD

___ No. Never Employed

2. Is your spouse currently employed?

___ Yes.

Name and address of spouse's employer:

_________________________________

_________________________________

_________________________________

___ No. Date of retirement: CCYY/MM/DD

___ 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.

___ No. STOP. MEDICARE IS PRIMARY PAYER UNLESS THE PATIENT ANSWERED YES TO THE QUESTIONS IN PART I OR II.

4. Does the employer that sponsors your GHP employ 20 or more employees?

___ Yes. STOP. GROUP HEALTH PLAN IS PRIMARY. OBTAIN THE FOLLOWING INFORMATION.

Name and address of GHP:

_________________________________

_________________________________

_________________________________

Policy identification number: ________________________

Group identification number: _________________________

Name of policyholder: ______________________________

Relationship to patient: _______________________________

___ No. STOP. MEDICARE IS PRIMARY PAYER 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. Date of retirement: CCYY/MM/DD

2. Is a family member currently employed?

___ Yes.

Name and address of your employer:

_________________________________

_________________________________

_________________________________

___ No.

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 family member's current employment?

___ Yes.

___ No. STOP. MEDICARE IS PRIMARY PAYER UNLESS THE PATIENT ANSWERED YES TO THE QUESTIONS IN PART I OR II.

4. Does the employer that sponsors your GHP employ 100 or more employees?

___ Yes. STOP. GROUP HEALTH PLAN IS PRIMARY. OBTAIN THE FOLLOWING INFORMATION.

Name and address of GHP:

_________________________________

_________________________________

_________________________________

Policy identification number: ________________________

Group identification number: _________________________

Name of policyholder: ______________________________

Relationship to patient: ______________________________

Membership Number: _______________________________

___ No. STOP. MEDICARE IS PRIMARY PAYER UNLESS THE PATIENT ANSWERED YES TO QUESTIONS IN PART I OR II.

Part VI - ESRD

1. Do you have group health plan (GHP) coverage?

Name and address of GHP:

_________________________________

_________________________________

_________________________________

Policy identification number: ________________________

Group identification number: _________________________

Name of policyholder: ______________________________

Relationship to patient: _______________________________

Name and address of employer, if any, from which you receive GHP coverage:

_________________________________

_________________________________

_________________________________

___ No. STOP. MEDICARE IS PRIMARY.

2. Have you received a kidney transplant?

___ Yes. Date of transplant: CCYY/MM/DD

___ No.

3. Have you received maintenance dialysis treatments?

___ Yes. Date dialysis began: CCYY/MM/DD

If you participated in a self-dialysis training program, provide date training started: CCYY/MM/DD

___ No

4. Are you within the 30-month coordination period?

___ 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. STOP. GHP IS PRIMARY DURING THE 30 MONTH COORDINATION PERIOD.

6. Was your initial entitlement to Medicare (including simultaneous 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 CWF for the beneficiary, the provider still asks the questions found in 20.1 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.