Department of Health & Human Services(DHHS) Centers for Medicare & Medicaid Services(CMS) Transmittal 53 Date: JUNE 9, 2006

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1 M Manual ystem Pub Medicare econdary Payer Department of Health & Human ervices(dhh) enters for Medicare & Medicaid ervices(m) Transmittal 53 Date: JUNE 9, 2006 hange Request 5087 ubject: Modifications to Online Medicare econdary Payer Questionnaire. This R Rescinds and Replaces R 4098 I. UMMARY OF HANGE: R4098 made several changes to the 'Medicare econdary Payer Questionnaire.' everal questions have arisen with respect to the changes made to PART V. This R will modify the changes previously made to PART V to address the questions that have arisen, will incorporate all other changes that were made via R4098, and will make additional changes to other parts of the model questionnaire to improve the wording and sequencing of questions in these parts. New / Revised Material Effective Date: eptember 11, 2006 Implementation Date: eptember 11, 2006 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents. II. HANGE IN MANUAL INTRUTION: (N/A if manual is not updated) R=REVIED, N=NEW, D=DELETED-Only One Per Row. R/N/D R hapter / ection / ubsection / Title 3/20.2.1/Admission Questions to Ask Medicare Beneficiaries III. FUNDING: No additional funding will be provided by M; ontractor activities are to be carried out within their FY IV. ATTAHMENT: Business Requirements Manual Instruction *Unless otherwise specified, the effective date is the date of service.

2 Attachment - Business Requirements Pub Transmittal: 53 Date: June 9, 2006 hange Request 5087 UBJET: Modifications to Online Medicare econdary Payer Questionnaire. This R Rescinds and Replaces R I. GENERAL INFORMATION A. Background: R4098 made several changes to the 'Medicare econdary Payer Questionnaire.' everal questions have arisen with respect to the changes made to PART V. This R will modify the changes previously made to PART V to address the questions that have arisen, will incorporate all other changes that were made via R4098, and will make additional changes to other Parts of the model questionnaire to improve the wording and sequencing of questions in these Parts. B. Policy: N/A II. BUINE REQUIREMENT hall" denotes a mandatory requirement "hould" denotes an optional requirement Requirement Number Requirements ontractors shall educate providers that the MP Questionnaire is a model of the type of questions that may be asked to help identify Medicare econdary Payer (MP) situations ontractors shall educate providers that if they choose to use the model questionnaire in its entirety, then this instruction represents major revisions to the model questionnaire As such, contractors shall recommend that the providers replace any previous versions of the model questionnaire with the new version. Responsibility ( X indicates the columns that apply) F I hared ystem Maintainers Other R H H I a r r i e r D M E R X X X X X X X X X X X X F I M V M W F

3 III. PROVIDER EDUATION Requirement Number Requirements A provider education article related to this instruction will be available at shortly after the R is released. You will receive notification of the article release via the established 'medlearn matters' listserv. ontractors shall post this article, or a direct link to this article, on their Web site and include information about it in a listserv message within 1 week of the availability of the provider education article. In addition, the provider education article shall be included in your next regularly scheduled bulletin and incorporated into any educational events on this topic. ontractors are free to supplement Medlearn Matters articles with localized information that would benefit their provider community in billing and administering the Medicare program correctly. Responsibility ( X indicates the columns that apply) F I hared ystem Maintainers Other R H H I a r r i e r D M E R X X X X F I M V M W F IV. UPPORTING INFORMATION AND POIBLE DEIGN ONIDERATION A. Other Instructions: N/A X-Ref Requirement # Instructions B. Design onsiderations: N/A X-Ref Requirement # Recommendation for Medicare ystem Requirements. Interfaces: N/A D. ontractor Financial Reporting /Workload Impact: N/A

4 E. Dependencies: N/A F. Testing onsiderations: N/A V. HEDULE, ONTAT, AND FUNDING Effective Date*: eptember 11, 2006 Implementation Date: eptember 11, 2006 Pre-Implementation ontact(s): uzanne Lewis, (410) No additional funding will be provided by M; contractor activities are to be carried out within their FY 2006 operating budgets. Post-Implementation ontact(s): uzanne Lewis, (410) *Unless otherwise specified, the effective date is the date of service.

5 Medicare econdary Payer (MP) Manual hapter 3 - MP Provider, Physician, and Other upplier Billing Requirements Admission Questions to Ask Medicare Beneficiaries (Rev.53, Issued: , Effective: , Implementation: ) The following questionnaire contains questions that can be used to ask Medicare beneficiaries upon each inpatient and outpatient admission. Providers may use this as a guide to help identify other payers that may be primary to Medicare. This questionnaire is a model of the type of questions that may be asked to help identify Medicare econdary Payer (MP) situations. 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 the patient to the next appropriate question to determine MP situations. PART I 1. Are you receiving Black Lung (BL) Benefits? Yes; Date benefits began: MM/DD/YY BL I PRIMARY PAYER ONLY FOR LAIM RELATED TO BL. 2. Are the services to be paid by a government research program? GOVERNMENT REEARH PROGRAM WILL PAY PRIMARY BENEFIT FOR THEE ERVIE. 3. Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for your care at this facility? DVA I PRIMARY FOR THEE ERVIE.

6 4. Was the illness/injury due to a work-related accident/condition? Yes; Date of injury/illness: MM/DD/YY Name and address of workers compensation plan (W) plan: Policy or identification number: Name and address of your employer: W I PRIMARY PAYER ONLY FOR LAIM FOR WORK-RELATED INJURIE OR ILLNE, GO TO PART III. GO TO PART II. PART II 1. Was illness/injury due to a non-work-related accident? Yes; Date of accident: MM/DD/YY GO TO PART III 2. Is no-fault insurance available? (No-fault insurance is insurance that pays for health care services resulting from injury to you or damage to your property regardless of who is at fault for causing the accident.) Yes.

7 Name and address of no-fault insurer(s) and no-fault insurance policy owner: Insurance claim number(s): No. 3. Is liability insurance available? (Liability insurance is insurance that protects against claims based on negligence, inappropriate action or inaction, which results in injury to someone or damage to property.) Yes. Name and address of liability insurer(s) and responsible party: Insurance claim number(s): No. NO-FAULT INURER I PRIMARY PAYER ONLY FOR THOE ERVIE RELATED TO THE AIDENT. LIABILITY INURANE I PRIMARY PAYER ONLY FOR THOE ERVIE RELATED TO THE LIABLITY ETTLEMENT, JUDGMENT, OR AWARD. GO TO PART III.

8 PART III 1. Are you entitled to Medicare based on: Age. Go to PART IV. Disability. Go to PART V. End-tage Renal Disease (ERD). Go to PART VI. Please note that both Age and ERD OR Disability and ERD may be selected simultaneously. An individual cannot be entitled to Medicare based on Age and Disability simultaneously. Please complete ALL PART associated with the patient s selections. PART IV AGE 1. Are you currently employed? Name and address of your employer: If applicable, date of retirement: MM/DD/YY No. Never Employed. 2. Do you have a spouse who is currently employed? Name and address of your spouse's employer: If applicable, date of retirement: MM/DD/YY No. Never Employed. IF THE PATIENT ANWERED NO TO BOTH QUETION 1 AND 2, MEDIARE I PRIMARY UNLE THE PATIENT ANWERED YE TO QUETION IN PART I OR II. DO NOT PROEED FURTHER.

9 3. Do you have group health plan (GHP) coverage based on your own or a spouse's current employment? Yes, both. Yes, self. Yes, spouse. TOP. MEDIARE I PRIMARY PAYER UNLE THE PATIENT ANWERED YE TO THE QUETION IN PART I OR II. 4. If you have GHP coverage based on your own current employment, does your employer that sponsors or contributes to the GHP employ 20 or more employees? GHP I PRIMARY. OBTAIN THE FOLLOWING INFORMATION. Name and address of GHP: insurance benefit package number): Group identification number: Membership number (prior to the Health Insurance Portability and Accountability Act (HIPAA), this number was frequently the individual s ocial ecurity Number (N); it is the unique identifier assigned to the policyholder/patient): Name of policyholder/named insured: Relationship to patient: 5. If you have GHP coverage based on your spouse s current employment, does your spouse s employer, that sponsors or contributes to the GHP, employ 20 or more employees? GHP I PRIMARY. OBTAIN THE FOLLOWING INFORMATION. Name and address of GHP: insurance benefit package number):

10 Group identification number: Membership number (prior to HIPAA, this number was frequently the individual s N; it is the unique identifier assigned to the policyholder/patient): Name of policyholder/named insured: Relationship to patient: IF THE PATIENT ANWERED NO TO BOTH QUETION 4 AND 5, MEDIARE I PRIMARY UNLE THE PATIENT ANWERED YE TO QUETION IN PART I OR II. PART V DIABILITY 1. Are you currently employed? Name and address of your employer: If applicable, date of retirement: MM/DD/YY No. Never Employed. 2. Do you have a spouse who is currently employed? Name and address of your spouse s employer: If applicable, date of retirement: MM/DD/YY No. Never Employed. 3. Do you have group health plan (GHP) coverage based on your own or a spouse s current employment? Yes, both. Yes, self.

11 Yes, spouse. 4. Are you covered under the GHP of a family member other than your spouse? Yes. Name and address of your family member s employer: No. IF THE PATIENT ANWERED NO TO QUETION 1, 2, 3, AND 4, TOP. MEDIARE I PRIMARY UNLE THE PATIENT ANWERED YE TO QUETION IN PART I OR If you have GHP coverage based on your own current employment, does your employer that sponsors or contributes to the GHP employ 100 or more employees? GHP I PRIMARY. OBTAIN THE FOLLOWING INFORMATION. Name and address of GHP: insurance benefit package number): Group identification number: Membership number (prior to HIPAA, this number was frequently the individual s N; it is the unique identifier assigned to the policyholder/patient): Name of policyholder/named insured: Relationship to patient: 6. If you have GHP coverage based on your spouse s current employment, does your spouse s employer, that sponsors or contributes to the GHP, employ 100 or more employees? GHP I PRIMARY. OBTAIN THE FOLLOWING INFORMATION.

12 Name and address of GHP: insurance benefit package number): Group identification number: Membership number (prior to HIPAA, this number was frequently the individual s N; it is the unique identifier assigned to the policyholder/patient): Name of policyholder/named insured: Relationship to patient: 7. If you have GHP coverage based on a family member s current employment, does your family member s employer, that sponsors or contributes to the GHP, employ 100 or more employees? GHP I PRIMARY. OBTAIN THE FOLLOWING INFORMATION. Name and address of GHP: insurance benefit package number): Group identification number: Membership number (prior to HIPAA, this number was frequently the individual s N; it is the unique identifier assigned to the policyholder/patient): Name of policyholder/named insured: Relationship to patient: IF THE PATIENT ANWERED NO TO QUETION 5, 6, and 7, MEDIARE I PRIMARY UNLE THE PATIENT ANWERED YE TO QUETION IN PART I OR II.

13 PART VI ERD 1. Do you have group health plan (GHP) coverage? Yes. IF APPIABLE, YOUR GHP INFORMATION: Name and address of GHP: insurance benefit package number: Group identification number: Membership number (prior to HIPAA, this number was frequently the individual s N; it is the unique identifier assigned to the policyholder/patient): Name of policyholder /named insured: Relationship to patient: Name and address of employer, if any, from which you receive GHP coverage: IF APPIABLE, YOUR POUE GHP INFORMATION: Name and address of GHP: insurance benefit package number: Group identification number:

14 Membership number (prior to HIPAA, this number was frequently the individual s N; it is the unique identifier assigned to the policyholder/patient): Name of policyholder /named insured: Relationship to patient: Name and address of employer, if any, from which your spouse receives GHP coverage: IF APPIABLE, YOUR FAMILY MEMBER GHP INFORMATION: Name and address of GHP: insurance benefit package number: Group identification number: Membership number (prior to HIPAA, this number was frequently the individual s N; it is the unique identifier assigned to the policyholder/patient): Name of policyholder /named insured: Relationship to patient: Name and address of employer, if any, from which your family member receives GHP coverage: TOP. MEDIARE I PRIMARY. 2. Have you received a kidney transplant? Date of transplant: MM/DD/YY 3. Have you received maintenance dialysis treatments? Date dialysis began: MM/DD/YY If you participated in a self-dialysis training program, provide date training started: MM/DD/YY

15 4. Are you within the 30-month coordination period that starts MM/DD/YY? (The 30-month coordination period starts the first day of the month an individual is eligible for Medicare (even if not yet enrolled in Medicare) because of kidney failure (usually the fourth month of dialysis). If the individual is participating in a self-dialysis training program or has a kidney transplant during the 3-month waiting period, the 30-month coordination period starts with the first day of the month of dialysis or kidney transplant.) TOP. MEDIARE I PRIMARY. 5. Are you entitled to Medicare on the basis of either ERD and age or ERD and disability? 6. Was your initial entitlement to Medicare (including simultaneous or dual entitlement) based on ERD? TOP. GHP ONTINUE TO PAY PRIMARY DURING THE 30- MONTH OORDINATION PERIOD. INITIAL ENTITLEMENT BAED ON AGE OR DIABILITY. 7. Does the working aged or disability MP provision apply (i.e., is the GHP already primary based on age or disability entitlement)? GHP ONTINUE TO PAY PRIMARY DURING THE 30-MONTH OORDINATION PERIOD. MEDIARE ONTINUE TO PAY PRIMARY. If no MP data are found in the ommon Working File (WF) for the beneficiary, the provider still asks the types of questions above and provides any MP information on the bill using the proper uniform billing codes. This information will then be used to update WF through the billing process.

Medicare Secondary Payer (MSP) Questionnaire

Medicare Secondary Payer (MSP) Questionnaire Patient Name Please print Date of Birth PART I 1. Are you receiving Black Lung (BL) Benefits? Yes Date benefits began: / / BL is Primary payer only for claims