Jul 9, 2025 · View and/or access common MSP related forms.

Submit an Explanation of Benefits (EOB) form with all appropriate MSP information to the designated carrier. If submitting an electronic claim, provide the necessary fields, loops, and segments needed …

This form may be utilized for any Medicare Secondary Payer (MSP) request pertaining to Primary or Secondary payment of claims Please forward all inquiries for MSP Recovery to the MSP Contractor …

Please review this list and submit the documents that you will need to provide in order for the Medicaid Program to determine if you are eligible for MSP. If you are requesting retroactive reimbursement of …

If no MSP data are found in the Common Working File (CWF) for the beneficiary, the provider still asks the types of questions above and provides any MSP information on the bill using the proper uniform …

This questionnaire is a model of the type of questions that may be asked to help identify Medicare Secondary Payer (MSP) situations. If you choose to use this questionnaire, please note that it was …

Instructions: Please complete this form and include it with the submission. Each submission should include a completed form and the primary explanation of benefits (if applicable). If multiple patients or …

The Multiple Pistol Sales Record (RI-060a) form is used only by federally licensed firearm (FFL) dealers when purchasing multiple pistols from a single seller on the same date of purchase, in lieu of filling …

APPLICATION FOR MEDICARE PREMIUM ASSISTANCE Please read the following before completing the application. You will need to answer all questions before we will know if we can help you. If you …

The information contained in this form is used by Medicare to determine if there is other insurance that should pay claims primary to Medicare. 1. Are you receiving benefits from any of the following …