US · guidance
CMS Pub. 100-05, ch. 5, § 70.5.1
Exhibit 1: Assessment of Medicare Secondary Payer Hospital
Review
(Rev. 38, Issued: 10-14-05: Effective/Implementation Dates: 01-14-06)
Contractor Name and No.: _________________________
ASSESSMENT OF MEDICARE SECONDARY PAYER HOSPITAL REVIEW
1 Name of hospital reviewed
2 Number of cases reviewed
3 Period of review (month/year)
4 Selection criteria used to determine why hospital selected for review. (See §70.1.1)
5 Describe findings in accordance with review protocol standards found at §70.3 and
§70.4.
6 Recommendations
cc: CMS Regional Office, MSP Coordinator
Hospital Reviewed
Attachment: Survey of bills reviewed.
History
(Rev. 38, Issued: 10-14-05: Effective/Implementation Dates: 01-14-06)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
50470e0ca566a4e4349af8c9cc4054cc305b5191e4ff5ff9fb5589260dea93d1
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