2017 Medicare Second Payer Questionnaire

Dear Valued Client,

The Centers for Medicare and Medicaid Services (CMS) requires health plans and their contract administrators who process claims for the Plan to keep accurate records as to the Plan’s secondary payer status to Medicare and to report this information to CMS with respect to all Medicare eligible employees and beneficiaries (spouses and dependents) enrolled in the Employer’s group medical and prescription drug coverage.

In order for Diversified to properly report and determine whether your health plan is primary or secondary to Medicare, we need you to complete and return the attached the Medicare Second Payer (MSP) Plan Questionnaire by February 1, 2017.

Click here to download the MSP Plan Questionnaire.  Please fax the completed MSP Questionnaire to: (860) 295-0340, Attn: Account Executive.

Should you have any questions, please contact your Account Executive at (888) 322-2524.

Thank you in advance for your assistance.

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