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How to fill out the MEDICARE SECONDARY PAYER SCREENING FORM online
Filling out the Medicare Secondary Payer Screening Form is essential for determining if Medicare is your primary insurance. This guide will provide you with clear and supportive steps to complete the form online successfully.
Follow the steps to fill out the form correctly.
- Click ‘Get Form’ button to access the form online and load it in your preferred editor.
- Begin by reviewing the questions listed on the form. Each question is designed to gather important information regarding your insurance coverage.
- Answer the first question regarding whether your illness is due to an automobile accident or other specified accidents. Select 'Yes' or 'No' as applicable.
- Proceed to the next question about coverage under the Black Lung Program or Veterans Administration program. Again, select 'Yes' or 'No'.
- Continue with the question about being under 65 and an end-stage renal patient within your first 36 months of Medicare entitlement. Select your response.
- Answer if your Medicare coverage is due to disability if you are under age 65 by checking 'Yes' or 'No'.
- Indicate if you have health plan coverage through your own or spouse’s employer.
- Next, note whether you are currently a hospital inpatient, hospice patient, or a resident in a skilled nursing facility by selecting the appropriate options.
- Based on your responses, you may need to provide additional information. If you answered 'No' to questions 1-5, Medicare will be your primary insurance.
- If you responded 'Yes' to questions 6-8, include the necessary details about the hospital, hospice, or skilled nursing facility.
- Fill out the fields asking for your insurance company’s name, address, and policy holder’s details if applicable.
- Lastly, provide your signature in the Medicare patient certification section to authorize the release of your information, and indicate if someone else is signing for you.
- Once all fields are completed, save your changes, download, print, or share the form as necessary.
Complete your Medicare Secondary Payer Screening Form online today.
If the employer has 20 or more employees, then the group health plan pays first, and Medicare pays second . If the employer has fewer than 20 employees and isn't part of a multi-employer or multiple employer group health plan, then Medicare pays first, and the group health plan pays second .