Edit, Download, and Sign the Medicare Secondary Payer Inquiry Form Instructions
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How do I fill this out?
To fill out the Medicare Secondary Payer Inquiry Form, you need to provide accurate information in all the required fields. The form requires details about the provider, patient, claim, and any other insurance involved. Ensure all fields are completed to avoid any delays in processing.
How to fill out the Medicare Secondary Payer Inquiry Form Instructions?
1
Fill out the Provider Information section with provider's name, address, telephone number, and other identifiers.
2
Fill out the Patient & Claim Information section with patient name, MBI, claim number, dates of service, and other relevant details.
3
Fill out the Other Insurance Information section if applicable, including insurance name, address, and policy information.
4
Attach additional required documentation, such as a copy of the explanation of benefits received from other insurance.
5
Send the form and documentation to the provided fax number or mailing address.
Who needs the Medicare Secondary Payer Inquiry Form Instructions?
1
Healthcare providers who need to report overpayments to Medicare.
2
Healthcare providers with claims involving other insurance such as Workers' Compensation or Group Health Plan.
3
Providers handling End Stage Renal Disease (ESRD) claims.
4
Insurers managing claims with liability or no-fault insurance coverage.
5
Providers dealing with MSP Recovery inquiries.
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What are the instructions for submitting this form?
Send the completed form and all additional documentation to: Fax: (803) 699-3583 or Mail to: Palmetto GBA, Medicare Secondary Payer - Part B, P.O. Box 100190, Columbia, SC 29202. Ensure all required fields and attached documents are included to avoid processing delays.
What are the important dates for this form in 2024 and 2025?
Ensure to submit the form as soon as the need arises to avoid processing delays.
What is the purpose of this form?
The purpose of the Medicare Secondary Payer Inquiry Form is to facilitate communication between healthcare providers and Medicare regarding overpayments and claim inquiries. This form helps providers report situations where Medicare should not be the primary payer, such as cases involving other insurance coverage, Workers' Compensation, or other liability insurance. By providing detailed information, the form assists in resolving issues accurately and efficiently.
Tell me about this form and its components and fields line-by-line.
- 1. Provider Information: Includes Provider Name, Address, Telephone Number, National Provider Identifier (NPI), Provider Number (PTAN), and Tax ID.
- 2. Patient & Claim Information: Includes Patient Name, Medicare Beneficiary Identifier (MBI), Claim Number, Dates of Service, Diagnosis Code(s), Claim Amount, and CPT Code(s).
- 3. Other Insurance Information: If applicable, includes Insurance Name, Address, Policy Number, Insured Name, Relationship, and Group Number.
- 4. Reason(s) for Overpayment: Select from Group Health Plan Insurance, Workers' Compensation, End Stage Renal Disease (ESRD), No Fault Insurance, Black Lung, Disability, and Liability Insurance.
- 5. Contact and Submission Information: Includes Contact Name and Instructions for submitting the form via fax or mail.
What happens if I fail to submit this form?
Failing to submit this form may result in delays or inability to process your Medicare Secondary Payer request.
- Delayed Processing: Your inquiry may not be addressed in a timely manner.
- Unresolved Claims: Claims involving secondary payers may remain unresolved without proper documentation.
How do I know when to use this form?
- 1. Reporting Overpayments: Utilize the form to report overpayments to Medicare.
- 2. Coordination of Benefits: For situations where other insurers are involved, such as Workers' Compensation or Group Health Plans.
- 3. End Stage Renal Disease (ESRD): For claims involving ESRD and related payments.
- 4. Liability or No-Fault Insurance: For claims involving liabilities or no-fault insurance coverage.
- 5. Other Insurance Involvements: For any other insurance involvement that impacts the Medicare payment.
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