Tip for MSP Questionnaire

Respond promptly — failure to return MSP questionnaires can cause claims processing delays

Tip for MSP Questionnaire

If you have employer coverage AND Medicare, the employer plan is typically primary if the employer has 20+ employees

Tip for MSP Questionnaire

Report changes in other coverage promptly to avoid incorrect billing

Medicareeasy

MSP Screening Worksheet

MSP Questionnaire · CMS / Medicare Administrative Contractors

Screening worksheet used at every admission or outpatient encounter to determine whether Medicare is primary or secondary payer.

Form Details

Total fields: 15
Auto-fillable: 12 (80%)
Time without BeneFill: 10 minutes
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Filled by: patient
Frequency: per incident

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Where to Submit This Form

📬

Return to the Medicare Secondary Payer (MSP) contractor or your Medicare Administrative Contractor (MAC)

Address is on the form or in the correspondence requesting the information.

📠

Fax to the MSP contractor

Fax number provided in the request letter.

Required Attachments

📎 Completed MSP questionnaire
📎 Information about other insurance coverage (employer group health, liability, workers' comp, no-fault)
📎 Employer information and group health plan details

Processing Time

30-60 days for CMS to update MSP records. This determines which insurer is primary and which is secondary.

What Happens Next

CMS will update the coordination of benefits records to reflect the correct primary and secondary payer. Claims will be processed accordingly.

Tips for This Form

✓ Respond promptly — failure to return MSP questionnaires can cause claims processing delays
✓ If you have employer coverage AND Medicare, the employer plan is typically primary if the employer has 20+ employees
✓ Report changes in other coverage promptly to avoid incorrect billing
✓ Call the Benefits Coordination & Recovery Center at 1-855-798-2627 for MSP questions

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