Tip for MAC-specific MSP form

Report ALL changes in other insurance coverage to the BCRC promptly

Tip for MAC-specific MSP form

Include your Medicare number (HICN or MBI) on all correspondence

Tip for MAC-specific MSP form

If Medicare has been paying primary by mistake, they may seek recovery from the other insurer — not from you

Medicaremoderate

MSP Correspondence Form

MAC-specific MSP form · Medicare Administrative Contractors

Used to submit Medicare Secondary Payer information to the MAC when another insurer is primary to Medicare.

Form Details

Total fields: 22
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Where to Submit This Form

📬

Mail to the Benefits Coordination & Recovery Center (BCRC)

Medicare — Loss: COB PO Box 138899 Oklahoma City, OK 73113-8899

📠

Fax to the BCRC

Fax: 405-869-3309

Required Attachments

📎 Letter explaining the insurance coverage change or dispute
📎 Documentation of other insurance coverage (or proof that coverage ended)
📎 Claim details or Medicare Summary Notices affected by the MSP issue

Processing Time

30-60 days for the BCRC to review and update records.

What Happens Next

The BCRC will review the correspondence and update coordination of benefits records. Affected claims may be reprocessed.

Tips for This Form

✓ Report ALL changes in other insurance coverage to the BCRC promptly
✓ Include your Medicare number (HICN or MBI) on all correspondence
✓ If Medicare has been paying primary by mistake, they may seek recovery from the other insurer — not from you
✓ Call the BCRC at 1-855-798-2627 if you need help resolving MSP issues

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