Medicare Secondary Payer Inquiry Form

A Medicare Secondary Payer Inquiry form is available in the Medicare Secondary Payer forms section of the Palmetto GBA website. To ensure timely processing of your request, this form should be used for any Medicare Secondary Payer (MSP) request pertaining to primary or secondary payment of claims.

Helpful Hints

• Please forward all inquiries for MSP Recovery to the MSP Contractor
• Do not include a refund check with the new form
• If you are sending a refund check, please use the Medicare Secondary Payer Refund Overpayment — Check Enclosed form
• Only use this form if Medicare should have paid as secondary to a primary insurance
• Do not use this form for new claim submissions
• Do not use this form for situations that involve the Veteran’s Administration. Use the Reopening form instead.