Document Title: Coordination of Benefits Questionnaire Document#: CHPSCMFM000373 Rev 004
Effective Date: 05/18/2017 Page 1 of 2 Owner: Claims Processing
Cerner Corporation Confidential Information
©Cerner Corporation. All rights reserved. This document contains confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
Coordination of Benefits Questionnaire
We are requesting information to verify if your spouse and/or your dependent(s) have other health
insurance coverage. If so, we are required to coordinate benefits with the other carrier.
Please complete the requested information to avoid delay in claims processing. Claims will not be
considered for payment without this information.
Name: ____________________________ Member ID Number: __________________
(999999 99999)
1. Do you or any dependents have any other Group Health or Medicare coverage?
No _________ Yes _______
If ‘NO’, please sign, date and return this form.
If ‘YES’ please complete the information below, sign, date and return the form.
Mail to: Cerner HealthPlan Services, PO Box 165750, Kansas City, MO. 64116-5750
Fax to: Cerner HealthPlan Services (816) 571-6994
Email to: ClientServices@cernerhps.com
Call the Contact Center, toll-free at 1-877-765-1033
Your signature___________________________________ Date:________________
2. Please list the family member covered by the other Group policy and the type of coverage.
_________________________________ __ Medical __Drug __ Medicare
_________________________________ __ Medical __Drug __ Medicare
_________________________________ __ Medical __Drug __ Medicare
_________________________________ __ Medical __Drug __ Medicare
3. Name of other policyholder: ______________________________________________
Other policy holder’s date of birth: _______________ Relationship to you: __________
4. Employer name if coverage is provided through an employer: ____________________
5. Name of other insurance: __________________________ Effective Date:__________
6. If there is a divorce or separation, please list who is responsible for the healthcare expenses:
___________________________________________________________________________
If there is not a court decree, who has custody of the children? _________________________
Information
Document Title: Coordination of Benefits Questionnaire Document#: CHPSCMFM000373 Rev 004
Effective Date: 05/18/2017 Page 2 of 2 Owner: Claims Processing
Cerner Corporation Confidential Information
©Cerner Corporation. All rights reserved. This document contains confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
7. Is the policyholder actively working? ____ Yes ___ No
If ‘No’, last day of active employment _________
8. Family members covered by Medicare, please list name and effective date.
Name__________________________________ Effective Date________________
Coverage Type:______________________________________________________
Name__________________________________ Effective Date________________
Coverage Type:______________________________________________________
9. Do you or any dependents qualify for Medicare for ESRD? ___Yes___No (If Yes, see ESRD form on back)
ESRD Type of Treatment
The effective date of ESRD Medicare is dependent upon the type of treatment the individual is receiving. Please provide
the type of treatment below:
Hemodialysis
Home/Self Dialysis
Transplant
Coordination of benefits with a group health plan will begin the first month that the individual is eligible for Medicare.
Please provide Medicare effective date: _ _/ _ _/ _ _ _ _
M M D D Y Y Y Y
When an individual has medical coverage through an employer group health plan (EGHP) that plan is the primary payer
during the 30-month coordination of benefits (COB) period. Medicare is the secondary payer during this time. At the end
of the COB this will reverse, with Medicare becoming primary and the EGHP will be secondary.
Medicare based on ESRD ends with:
The last day of the 36th month after the month the individual receives a kidney.
Transplant or the last day of the 12th month after the month in which an individual stops dialysis, most generally for return
of kidney function.
Mail to: Cerner HealthPlan Services, PO Box 165750, Kansas City, MO. 64116-5750
Fax to: Cerner HealthPlan Services (816) 571-6994
Email to: ClientS[email protected]
Call the Contact Center, toll-free at 1-877-765-1033
Your signature_______________________________________________ Date:_______________________________
This Section Pertains to Medicare Coverage Only
ESRD Medicare Questionnaire
ESRD Effective Date
