Printable msp questionnaire 2025

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  1. Click ‘Get Form’ to open the printable MSP questionnaire in the editor.
  2. Begin by entering your personal information at the top, including your name and Medicare number as it appears on your card.
  3. Proceed to answer the questions regarding home health care and any recent injuries. For each question, select 'Yes' or 'No' and provide additional details where prompted.
  4. If applicable, fill out the section regarding group insurance coverage through a family member's employer. Indicate whether this insurance will be primary.
  5. Complete any follow-up questions if you answered 'Yes' to previous inquiries, ensuring all relevant details about accidents or liability insurance are included.
  6. Finally, review your entries for accuracy before signing and dating the form at the bottom.

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Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have primary payment responsibility - that is, when another entity has the responsibility for paying before Medicare.
CMS developed an MSP questionnaire for providers to use as a guide to help identify other payers that may be primary to Medicare. This questionnaire is a model of the type of questions you should ask to help identify MSP situations.
As a Part A institutional provider rendering recurring outpatient services, the MSP questionnaire should be completed prior to the initial visit and verified every 90 days.

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Providers may use this as a guide to help identify other payers that may be primary to Medicare. This questionnaire is a model of the type of questions that may be asked to help identify Medicare Secondary Payer (MSP) situations.
In accordance with guidelines established by the Centers for Medicare & Medicaid Services (CMS), all providers are required to complete the MSP questionnaire upon admission.
Medicare does not require you to collect MSP information from beneficiaries who are members of MAO plans though the MAO plan may require you to do so. For more details about the MSP screening process, refer to the CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Sections 20.1 and 20.2.
Known as the Medicare Secondary Payer Questionnaire (MSPQ), this information is required to help determine if Medicare is a primary or secondary payer for the patient. Background. According to CMS, this new form is only a model of the questions to be asked and does not require use of the exact format.
Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have primary payment responsibility - that is, when another entity has the responsibility for paying before Medicare.

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