Provider Types Affected
Medicare providers who, upon inpatient or outpatient admissions of Medicare beneficiaries, use a questionnaire to determine other insurance coverage that may be primary to Medicare

Provider Action Needed
Impact to You
CR 4098 clarifies recent changes made to the “Medicare Secondary Payer Questionnaire.”

What You Need to Know
This CR identifies all of the changes that were made to CR 3504 and makes additional changes to the model questionnaire. These changes will assist providers in identifying other payers that may be primary to Medicare.

What You Need to Do
Please refer to the Background and Additional Information sections of this article and make certain that, if there are other payers, these situations are identified.

Background
The Centers for Medicare & Medicaid Services (CMS) received information that a prior instruction (CR3504) did not specifically mention all of the changes that were made to the “Medicare Secondary Payer (MSP) Questionnaire.” CR 4098 identifies all of the changes made as part of CR3504 and makes additional changes to the model questionnaire.

The Medicare Secondary Payer Manual, Chapter 3, Section 20.2.1, available as an attachment to CR4098, provides a model: “Admission Questions to Ask Medicare Beneficiaries.”

The model contains questions that may be printed out and used as a guide to help identify other payers. (The Web site for accessing CR 4098 is provided in the Additional Information section of this article.)

The following bullets identify the changes within the model MSP Questionnaire:

• Parts IV and V of the model questionnaire adds the response: “No, Never Employed.”
• In Parts IV, V, and VI of the model questionnaire, providers should use “Policy Identification Number” to mean a number that is sometimes referred to as the health insurance benefit package number.
• Parts IV, V, VI of the model questionnaire adds “Membership Number” and it refers to the unique identifier assigned to the policyholder/patient.
• Part V , question 2 of the model questionnaire uses “spouse” instead of “family member.”
• Part V , question 4 changes the model questionnaire to read:

Are you covered under the group health plan of a family member other than your spouse? _____Yes _____No

Name and address of your family member’s employer: ___________________

• Part V of the old question 4 is changed to ask whether the beneficiary is covered under a group health plan (GHP), and a question number 5 is added to gather the pertinent information about the GHP.
• In Part VI, question 6 now reads: “Was your initial entitlement to Medicare (including simultaneous or dual entitlement) based on ESRD?”

Providers who use the model questionnaire to elicit MSP information from their Medicare patients should take special note of these changes.

Implementation
The implementation date for the instruction is January 21, 2006.

Additional Information
The official instructions issued to your Medicare carrier or intermediary regarding this change and the model questionnaire can be found at http://www.cms.hhs.gov/Transmittals/ on the CMS Web site. On the above page, scroll down the CR NUM column on the right to find the links for CR4098. Click on the links to open and view the files for this CR.

If you have questions, please contact your carrier/intermediary at their toll-free number which may be found at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

For more information, visit the Medlearn Matters Web page at: http://www.cms.hhs.gov/MedlearnMattersArticles/.

Pub. 100-5, Transmittal# 41, CR# 4098
Medlearn Matters Number: MM4098
Related CR Release Date: October 21, 2005
Effective Date: January 21, 2006
Implementation Date: January 21, 2006

Posted: 11/21/2005

CPT codes, descriptions, and other data only are copyright 2005 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.