CMS Pub. 100-05, ch. 3, § 20.2.1

The following outline of questions provides important points of data to gather from Medicare

beneficiaries that are helpful for providers to determine who has primary payment responsibility

for a claim or set of claims by asking the questions upon each inpatient and outpatient admission.

The information assists in the proper coordination of benefits to ensure adherence to MSP

provisions as outlined in section 1862(b) of the Social Security Act.

Part I. INFORMATION ABOUT BLACK LUNG, WORKERS’

COMPENSATION (WC), NO-FAULT AND LIABILITY

1. Are you receiving benefits under the Black Lung Benefits Act (BL)?

2. If yes, the following BL information is required to submit claims appropriately:

• Date Black Lung Benefits began

Note: BL is the primary payer for claims related to BL.

3. Was the illness/injury due to a work-related accident/condition?

4. If yes, the following WC information is required to submit claims appropriately:

• Name and address of employer

• Name and address of insurance carrier

• Policy or claim number

• Date of the workplace illness or the injury

Note: WC is the primary payer only for services related to work-related injuries

or illness.

5. Are you receiving treatment for an injury or illness covered under no-fault (and/or

medical-payment coverage) including premises or automobile?

6. If yes, the following no-fault/auto insurance information is required to submit claims

appropriately:

• Name and address of insurance carrier

• Policy or claim number

• Date of illness or injury

Note: No-fault insurance is the primary payer only for services related to the

accident.

7. Are you receiving treatment for an injury, or illness, which another party may be

liable?

8. If yes, the following liability information is required to submit claims appropriately:

• Name and address of insurance carrier

• Policy or claim number

• Date of illness or injury

Note: Liability insurance is the primary payer only for services related to the

liability settlement, judgment, or award.

Part II. INFORMATION ABOUT MEDICARE ENTITLEMENT AND

GROUP HEALTH PLANS

1. Are you entitled to Medicare based on Age, Disability or ESRD?

Note: If entitlement is based solely on ESRD, skip Part II and complete Part III.

Stop after completing Part II if you are entitled to Medicare based on Age or

Disability.

2. Do you have group health plan (GHP) coverage based on your own current

employment, or the current employment of either your spouse or another family

member?

If yes, the employer GHP may be primary to Medicare. Continue below. If no,

stop here as Medicare is primary.

3. How many employees, including yourself or spouse, work for the employer

from whom you have GHP coverage? (1-19, 20 – 99 or 100 or more)

Note: If you are aged and there are 20 or more employees, your GHP is primary.

If you are disabled and your employer, spouse, or family member employer, has

100 or more employees, your GHP is primary.

4. The following employer GHP information is required to submit claims appropriately:

• Name and address of the employer (your own or your spouse’s/family member’s)

through which you receive GHP coverage

• Name and address of GHP

• Policy number (sometimes referred to as the health insurance benefit package

number)

• Group number

• Date the GHP coverage began

• Name of policyholder (if coverage is through your spouse/other family member)

• Relationship to patient (if other than self)

Part III. INFORMATION ABOUT THE PATIENT IF ESRD

MEDICARE ENTITLEMENT APPLIES (INLUDING DUAL

ENTITLEMENT: AGE AND ESRD OR DISABILITY AND ESRD)

1. Do you have employer group health plan (GHP) coverage through yourself, a spouse,

or family member if dually entitled based on Disability and ESRD?

If yes, the employer GHP may be primary to Medicare. Continue below.

2. Have you received a kidney transplant?

• Date of transplant

3. Have you received maintenance dialysis treatments?

• Date dialysis began

4. Are you within the 30-month coordination period?

Note: 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) regardless of entitlement due to age or

disability. 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.

5. Were you receiving GHP coverage prior to and on the date of Medicare entitlement

due to ESRD (or simultaneous entitlement due to ESRD and Age or ESRD and

Disability)?

Note: If yes, the GHP is primary during the 30-month coordination period.

6. The following information is required to submit claims appropriately:

• Name and address of the employer (your own or your spouse’s/family member’s)

through which you receive GHP coverage

• Name and address of GHP

• Policy number (sometimes referred to as the health insurance benefit package

number)

• Group number

• Name of policyholder (if coverage is through your spouse/other family member)

• Relationship to patient (if other than self)