Home: Medicare Secondary Payer Group Information Form: Forms

Medicare Secondary Payer Group Information Form 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 new directive, HealthPartners needs current your group size and Federal Tax ID Number. Find more information about this requirement. If your group size changes and results in you moving into a different category (as listed below), please notify HealthPartners throughout the year by resubmitting this form or notifying your HealthPartners sales executive. CMS requires that we maintain an accurate group size for each employer group insured through HealthPartners. Group size determines whether the group health plan or CMS is the primary payer of medical claims. The group size categories are: Under 20 employees 20 to 99 employees 100+ employees For these purposes, the definition of group size is the total number of employees (part- and full-time) within the employer's family of companies who worked every working day of at least 20 weeks within the current or previous year. Please fill out the following: Company Name: HealthPartners Group Number: Federal Tax Identification Number: Number of Employees (group size, example - 12): Size is current as of what date (example: MM/DD/YYYY): Contact: Contact Job Title: Contact Phone Number: Contact Email Address: