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Medicare MSP questionnaire worksheet

A downloadable CSV template for organizing the Medicare Secondary Payer (MSP) questionnaire process — a set of admission or registration questions used to identify whether another payer is primary to Medicare. This worksheet helps front-desk and billing staff record patient responses, capture other-coverage details, and document the resulting payer order for a given date of service. Whether Medicare pays primary or secondary depends on the specific MSP situation (for example, working-aged, disability with a group health plan, end-stage renal disease, workers' compensation, liability, no-fault, or veterans coverage), and the governing rules are set by CMS and administered by the Medicare Administrative Contractors. The columns below are structural fields for tracking, not a substitute for the current CMS questionnaire wording or MSP provisions — always confirm exact question text, coverage-order rules, and coordination-of-benefits requirements against the authoritative CMS sources, because they vary by situation and are updated over time. Example rows use non-identifying placeholder values only and contain no protected health information (PHI).

CSV · Reviewed 2026-07-18

Download and use

The download contains headings and blank rows only. The examples below use fictional operational references so you can see the intended structure without copying patient data.

Column guide

Record ID

An internal, non-identifying reference number the practice assigns to this MSP screening entry. Do not use a Medicare Beneficiary Identifier (MBI), Social Security number, or any patient identifier here.

Screening date

The date the MSP questionnaire was completed with the patient or representative. CMS expects MSP information to be collected or reconfirmed on a defined cadence; confirm the current timing and reconfirmation requirements with the authoritative CMS sources rather than assuming a fixed interval.

Date of service

The encounter date the payer order applies to. MSP status is tied to the specific date of service, so record it explicitly rather than assuming prior answers still apply.

MSP situation category

The MSP situation the responses point to (for example, working-aged, disability with a group health plan, ESRD coordination period, workers' compensation, liability, no-fault/auto, or veterans/other government coverage). The applicable rules differ by situation and are defined by CMS; see the MSP situations lookup and the authoritative sources.

Other coverage indicated

Whether the responses indicate any coverage other than Medicare (Yes/No/Unknown). A Yes does not by itself determine order; the specific MSP rules and coordination of benefits decide which payer is primary.

Indicated primary payer

The payer the questionnaire responses indicate should be billed first for this date of service (for example, an employer group health plan, a workers' compensation carrier, or Medicare). Use a generic label such as "Example group health plan"; do not enter policy numbers or member identifiers in an unsecured copy.

Other payer type

A general classification of the non-Medicare coverage (for example, employer group health plan, workers' compensation, liability/no-fault, or veterans coverage). This mirrors the MSP situation categories defined by CMS.

Supporting documentation on file

What corroborating information was noted, described generically (for example, "employer plan card noted" or "injury claim reference"). Store the actual documents in a secured system, not in this worksheet.

Follow-up action

The next step indicated by the responses (for example, verify coverage with the other payer, confirm coordination of benefits, or bill Medicare primary). Steps and timelines vary by payer and situation; confirm against payer and CMS guidance.

Completed by (initials)

Non-identifying initials or a staff code for the person who completed the screening. Avoid full names in an unsecured copy.

Fictional example

Record IDScreening dateDate of serviceMSP situation categoryOther coverage indicatedIndicated primary payerOther payer typeSupporting documentation on fileFollow-up actionCompleted by (initials)
MSP-00012026-07-062026-07-06Working-agedYesExample group health planEmployer group health planEmployer plan card notedVerify coverage with other payer, then confirm coordination of benefitsAB
MSP-00022026-07-062026-07-06No other coverage indicatedNoMedicareNot applicablePatient attests Medicare onlyBill Medicare as primary per responsesCD

Working instructions

  1. 1Use this worksheet to record MSP questionnaire responses per date of service and document the indicated payer order; it organizes screening data but does not replace the current CMS questionnaire wording or the governing MSP provisions, which vary by situation and change over time.
  2. 2Do not enter PHI or identifiers — no patient names, Medicare Beneficiary Identifiers (MBIs), Social Security numbers, policy numbers, or member IDs. Keep only non-identifying reference codes and generic labels, and never store this worksheet as an unsecured copy on a shared drive, email, or personal device.
  3. 3Confirm the exact MSP situation categories, coverage-order rules, and reconfirmation timing against the authoritative CMS sources and the responsible Medicare Administrative Contractor before acting, since Medicare's primary-versus-secondary determination and coordination-of-benefits requirements depend on the specific situation.
  4. 4Treat the example rows as illustrative placeholders only; replace them with real screening data in a secured system and route follow-up (eligibility verification, coordination of benefits, and billing order) through the practice's standard workflow.

Sources

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