NSR — Insurance & Medicare Secondary Payer (MSP)
Fields marked * are required. All information is kept strictly confidential and protected under HIPAA.

Primary Insurance

Please have your insurance card(s) available. This information is required to process your claims.
Subscriber's relationship to you:

Secondary Insurance (if applicable)

Medicare Secondary Payer (MSP) Questionnaire

Federal law (42 U.S.C. §1395y(b)) requires Next Step Rehab to ask these questions to determine whether Medicare is your primary or secondary payer. Please answer all questions honestly.

PART I — Liability, No-Fault & Workers' Compensation

1. Are you currently receiving benefits under the Federal Black Lung Program?
2. Was this injury or illness due to a work-related accident or condition (Workers' Compensation)?
3. Was this injury/illness covered under no-fault or auto/premises liability insurance?
4. Is this injury/illness subject to a pending lawsuit or litigation?

PART II — Group Health Plan (GHP) Coverage

5. My Medicare entitlement is based on:
6. Do you have Group Health Plan (GHP) coverage through current employment of yourself, your spouse, or a family member?
If 20+ employees: GHP is primary (age-based). If 100+ employees: GHP is primary (disability-based).

PART III — End-Stage Renal Disease (ESRD)

7. Do you have group health plan coverage due to ESRD?
8. Are you within the 30-month ESRD coordination period?
I certify that the above information is accurate and complete to the best of my knowledge.
Patient / Representative Signature — Medicare Secondary Payer Certification

Form 2 of 11  ·  Next Step Rehab Patient Intake Suite  ·  www.nextstep-rehab.com

NSR — Insurance & Medicare Secondary Payer (MSP)
Fields marked * are required. All information is kept strictly confidential and protected under HIPAA.

Primary Insurance

Please have your insurance card(s) available. This information is required to process your claims.
Subscriber's relationship to you:

Secondary Insurance (if applicable)

Medicare Secondary Payer (MSP) Questionnaire

Federal law (42 U.S.C. §1395y(b)) requires Next Step Rehab to ask these questions to determine whether Medicare is your primary or secondary payer. Please answer all questions honestly.

PART I — Liability, No-Fault & Workers' Compensation

1. Are you currently receiving benefits under the Federal Black Lung Program?
2. Was this injury or illness due to a work-related accident or condition (Workers' Compensation)?
3. Was this injury/illness covered under no-fault or auto/premises liability insurance?
4. Is this injury/illness subject to a pending lawsuit or litigation?

PART II — Group Health Plan (GHP) Coverage

5. My Medicare entitlement is based on:
6. Do you have Group Health Plan (GHP) coverage through current employment of yourself, your spouse, or a family member?
If 20+ employees: GHP is primary (age-based). If 100+ employees: GHP is primary (disability-based).

PART III — End-Stage Renal Disease (ESRD)

7. Do you have group health plan coverage due to ESRD?
8. Are you within the 30-month ESRD coordination period?
I certify that the above information is accurate and complete to the best of my knowledge.
Patient / Representative Signature — Medicare Secondary Payer Certification

Form 2 of 11  ·  Next Step Rehab Patient Intake Suite  ·  www.nextstep-rehab.com