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The Centers for Medicare & Medicaid Services (CMS) is the federal agency that oversees the Medicare
program. Many Medicare beneficiaries have other insurance in addition to theirMedicare benefits. Sometimes,
Medicare is supposed to pay after the other insurance. However, if certain other insurance delays payment,
Medicare may make a “conditional payment” so as not toinconvenience the beneficiary, and recover after the
other insurance pays.
Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA), a new federal law
that became effectiveJanuary 1, 2009, requires that liability insurers (including self-insurers), no-fault insurers,
and workers’ compensation plans report specific information about Medicare beneficiaries who have otherinsurance coverage. This reporting is to assist CMS and other insurance plans to properly coordinate payment
of benefits among plans so that your claims are paid promptly and correctly.
We areasking you to the answer the questions below so that we may comply with this law.

Please review this picture of the
Medicare card to determine if you
have, or have ever had, a similar
Medicarecard.

Section I
Are you presently, or have you ever been, enrolled in Medicare Part A or Part B?
□Yes
If yes, please complete the following. If no, proceed to Section II.
Full Name: (Pleaseprint the name exactly as it appears on your SSN or Medicare card if available.)
Medicare Claim Number:
Social Security Number:
(If Medicare Claim Number is Unavailable)

Date of Birth(Mo/Day/Year)
-

-

Sex

□Female

Section II
I understand that the information requested is to assist the requesting insurance arrangement to accurately
coordinate benefits with Medicare and tomeet its mandatory reporting obligations under Medicare law.
__________________________________________
Claimant Name (Please Print)

__________________________________
Claim Number...