Reminder: Jurisdiction 6 and Jurisdiction K Providers Using Medicare Part B MSP Overpayment Request Form for Non-MSP

Use the Medicare Part B MSP Overpayment Request Form for the following situations, not for non-MSP overpayments:

• 07–MSP Group Health Plan Insurance: (working aged, disability, ESRD)
  • When Medicare is truly the secondary payer for people working (spouse or self) and have employer health insurance coverage through a primary payer.
• 08–MSP Auto No-Fault Insurance
  • When Medicare is truly the secondary payer for injuries sustained in an accident, whether it is no fault or liability.
• 09–MSP Liability Insurance
  • When Medicare is truly the secondary payer for injuries sustained in an accident, whether it is no fault or liability.
• 10–MSP Worker’s Compensation: (Incudes Black Lung)
  • When Medicare is truly the secondary payer for injuries sustained while working and Workers’ Compensation.

If you are using this form to notify us of Veterans Administration (includes USFHP, Martin’s Point; Brighton Marine; Tricare), claims billed in error, reporting duplicate services, this is inappropriate. Please use the clerical error reopening process.

Posted 2/12/2024