Home: Forms: Medicare Secondary Payer Group Information Form: Forms

Forms In late 2008 the Centers for Medicare and Medicaid Services (CMS) announced a new requirement for health plans to gather key data about commercial group plans and their enrollees. To comply with this directive, HealthPartners needs the following information from all groups: Tax Identification Number Group size/number of employees (see definition below) Social Security Number (SSN) or Health Insurance Claim Number (HICN) for HealthPartners-covered employees, spouses/ex-spouses, domestic partners and any other adult dependents Employment status (active, COBRA or retired) for all employees, including effective and term dates of status Disability status of all employees and dependents, if known, with effective and term dates of status We appreciate you helping us meet this reporting requirement. To submit employee information, including Social Security Numbers, please follow these instructions: Medicare Secondary Payer Reporting Process. To submit group size and Federal Tax ID number, please fill out the online form. Additional information on this requirement is available below. Please contact your broker or HealthPartners Sales Representative if you have additional questions. Medicare Secondary Payer Reporting Information Medicare Secondary Payer Employer FAQ Medicare Secondary Payer Employee Explanation