A. Is the patient receiving Black Lung benefits? Yes No Department of Labor is PRIMARY for this service. B. Is the care authorized by the Department of Veterans Affairs? Yes No Department of Veterans Affairs is PRIMARY for this service. C. Is the patient's condition related to an accident or an injury? Yes No Is it work related? Yes No Workers' Compensation is the primary payer for claims related to work related injuries or illnesses only. Providers are required to accept Workers' Compensation payments as payment in full. If Medicare made a payment, send a refund. The claim must be submitted to Workers' Compensation. Is the accident or injury an auto or other liability situation? Yes No The other insurer is the primary payer ONLY for claims related to the accident. This is true for all types of accidents and applies to liability and no-fault insurers. Note the date of the accident, and the name/address of the no-fault or liability insurer. Submit the claim to the liability or no-fault insurer during the "promptly" period (120 days). Did the liability or no-fault insurer pay the claim? Yes No If Medicare made a payment, send a refund. Does the patient have other insurance coverage through a group health plan (GHP)? Yes No Submit the claim to Medicare. If the other insurer will not pay "promptly", Medicare may make a conditional payment. Refund this payment to Medicare if the no-fault insurer pays later. If the other insurer will not pay because benefits are exhausted or the individual's coverage has expired, submit the claim to Medicare for primary payment. D. Does the patient have End Stage Renal Disease (ESRD)? Yes No Did the patient first become entitled to Medicare on the basis of End Stage Renal Disease (ESRD)? Yes No This patient's entitlement to Medicare is based on age or disability: Prior to the patient's entitlement based on End Stage Renal Disease (ESRD), was Medicare already established as the PRIMARY payer? Yes No If Medicare was already the PRIMARY payer when the patient became entitled based on End Stage Renal Disease (ESRD), Medicare will remain PRIMARY. An End Stage Renal Disease (ESRD) coordination period will not go into effect. If the patient's entitlement to Medicare is based on disability or age: If Medicare was already the SECONDARY payer prior to the End Stage Renal Disease (ESRD), Medicare will remain the secondary payer for 30 months from the date the patient became entitled to Medicare based on End Stage Renal Disease (ESRD). Is the date of the service within 30 months of the date of Medicare entitlement based on End Stage Renal Disease (ESRD)? Yes No Medicare is PRIMARY for the patient unless: 36 months have passed since the first day of the month of a successfull kidney transplant, AND The patient falls under another MSP provision. Check here to go to next question. Is the patient covered by an Employer Group Health Plan (EGHP)? Yes No For the first 30 months that a patient is entitled to Medicare based on End Stage Renal Disease (ESRD), Medicare is SECONDARY to any employer sponsored group health plan for all services. This is known as the coordination period. Medicare is PRIMARY. E. Is the patient 65 years or older? Yes No Does the patient have group health plan coverage based on his/her own or his/her spouse's employment? Yes No Medicare is the PRIMARY insurer. Patient is under 65 years of age. Does the employer that sponsors the Group Health Plan employ 100 or more employees? Yes No Medicare is the SECONDARY insurer. Medicare is the PRIMARY insurer. Does the patient have group health plan coverage based on his/her own or his/her spouse's employment? Yes No Medicare is the PRIMARY insurer. Patient is 65 or older. Does the employer that sponsors the Group Health Plan employ 20 or more employees? Yes No Medicare is the SECONDARY insurer. Medicare is the PRIMARY insurer.
A. Is the patient receiving Black Lung benefits? Yes No
Department of Labor is PRIMARY for this service.
B. Is the care authorized by the Department of Veterans Affairs? Yes No
Department of Veterans Affairs is PRIMARY for this service.
C. Is the patient's condition related to an accident or an injury? Yes No
Is it work related? Yes No
Workers' Compensation is the primary payer for claims related to work related injuries or illnesses only. Providers are required to accept Workers' Compensation payments as payment in full. If Medicare made a payment, send a refund. The claim must be submitted to Workers' Compensation.
Workers' Compensation is the primary payer for claims related to work related injuries or illnesses only. Providers are required to accept Workers' Compensation payments as payment in full. If Medicare made a payment, send a refund.
The claim must be submitted to Workers' Compensation.
Is the accident or injury an auto or other liability situation? Yes No
The other insurer is the primary payer ONLY for claims related to the accident. This is true for all types of accidents and applies to liability and no-fault insurers. Note the date of the accident, and the name/address of the no-fault or liability insurer. Submit the claim to the liability or no-fault insurer during the "promptly" period (120 days). Did the liability or no-fault insurer pay the claim? Yes No
The other insurer is the primary payer ONLY for claims related to the accident. This is true for all types of accidents and applies to liability and no-fault insurers.
Note the date of the accident, and the name/address of the no-fault or liability insurer.
Submit the claim to the liability or no-fault insurer during the "promptly" period (120 days).
Did the liability or no-fault insurer pay the claim? Yes No
If Medicare made a payment, send a refund.
Does the patient have other insurance coverage through a group health plan (GHP)? Yes No
Submit the claim to Medicare. If the other insurer will not pay "promptly", Medicare may make a conditional payment. Refund this payment to Medicare if the no-fault insurer pays later. If the other insurer will not pay because benefits are exhausted or the individual's coverage has expired, submit the claim to Medicare for primary payment.
Submit the claim to Medicare.
D. Does the patient have End Stage Renal Disease (ESRD)? Yes No
Did the patient first become entitled to Medicare on the basis of End Stage Renal Disease (ESRD)? Yes No
This patient's entitlement to Medicare is based on age or disability: Prior to the patient's entitlement based on End Stage Renal Disease (ESRD), was Medicare already established as the PRIMARY payer? Yes No
This patient's entitlement to Medicare is based on age or disability:
Prior to the patient's entitlement based on End Stage Renal Disease (ESRD), was Medicare already established as the PRIMARY payer? Yes No
If Medicare was already the PRIMARY payer when the patient became entitled based on End Stage Renal Disease (ESRD), Medicare will remain PRIMARY. An End Stage Renal Disease (ESRD) coordination period will not go into effect.
If the patient's entitlement to Medicare is based on disability or age: If Medicare was already the SECONDARY payer prior to the End Stage Renal Disease (ESRD), Medicare will remain the secondary payer for 30 months from the date the patient became entitled to Medicare based on End Stage Renal Disease (ESRD).
If the patient's entitlement to Medicare is based on disability or age:
Is the date of the service within 30 months of the date of Medicare entitlement based on End Stage Renal Disease (ESRD)? Yes No
Medicare is PRIMARY for the patient unless: 36 months have passed since the first day of the month of a successfull kidney transplant, AND The patient falls under another MSP provision. Check here to go to next question.
Medicare is PRIMARY for the patient unless:
Is the patient covered by an Employer Group Health Plan (EGHP)? Yes No
For the first 30 months that a patient is entitled to Medicare based on End Stage Renal Disease (ESRD), Medicare is SECONDARY to any employer sponsored group health plan for all services. This is known as the coordination period.
Medicare is PRIMARY.
E. Is the patient 65 years or older? Yes No
Does the patient have group health plan coverage based on his/her own or his/her spouse's employment? Yes No
Medicare is the PRIMARY insurer.
Patient is under 65 years of age. Does the employer that sponsors the Group Health Plan employ 100 or more employees? Yes No
Patient is under 65 years of age.
Does the employer that sponsors the Group Health Plan employ 100 or more employees? Yes No
Medicare is the SECONDARY insurer.
Patient is 65 or older. Does the employer that sponsors the Group Health Plan employ 20 or more employees? Yes No
Patient is 65 or older.
Does the employer that sponsors the Group Health Plan employ 20 or more employees? Yes No
