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Medicare Secondary Claim Development Questionnaire

The Secondary Claim Development (SCD) Questionnaire is a Medicare Secondary Payer (MSP) questionnaire that is sent to obtain information about other insurers that may pay before Medicare. The SCD is mailed when a claim is submitted to Medicare with an explanation of benefits (EOB) attached, a self-report is made by you or your attorney identifying an MSP situation, or a third party payer submits MSP information to a contractor, or the Coordination of Benefits (COB) Contractor. This questionnaire asks:

  1. If you have other health care coverage based upon your current employment;
  2. If you are receiving black lung benefits, workers' compensation benefits, or treatment for an injury or illness for which another party could be held liable, or are covered under automobile no-fault insurance; and
  3. If you have other health care coverage based upon a family member's current employment.

When you return the SCD in a timely manner, you help ensure correct payment of your Medicare claims.

View sample SCD Questionnaires under downloads.

Contact the COB Contractor's Customer Service Department using our toll-free lines: 1-800-999-1118 or TTY/TDD: 1-800-318-8782 for the hearing and speech impaired with any questions you have. Representatives are available to assist you Monday through Friday, from 8:00 a.m. to 8:00 p.m., Eastern Time, except holidays.

Downloads

Medicare Secondary Claim Development (SCA), Page 1 (PDF 801 KB)
Medicare Secondary Claim Development (SCA), Page 2 (PDF 846 KB)
Medicare Secondary Claim Development (SCD), Page 1 (PDF 891 KB)
Medicare Secondary Claim Development (SCD), Page 2 (PDF 2,496 KB)
Medicare Secondary Claim Development (SCE), Page 1 (PDF 880 KB)
Medicare Secondary Claim Development (SCE), Page 2 (PDF 812 KB)
Related Links Inside CMS

Beneficiary and Advocate Services Overview
Coordination of Benefits and You
The Medicare Initial Enrollment Questionnaire
End-Stage Renal Disease
Group Health Insurance
No-fault and Liability Insurance
Workers' Compensation
Beneficiaries' and Advocates' Frequently Asked Questions
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Page Last Modified: 12/14/2005 12:00:00 AM
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