Medicare Secondary Payer (MSP) Form

Available For: Part B

Part B users may submit MSP adjustment requests for:

  • Not related to no-fault, workers' comp, liability, and Medicare Set-Asides
  • Medicare paid primary or secondary in error
  • Incorrect MSP type (2-digit) submitted on previously processed claim

Do NOT use this form for the following:

  • Refund Checks
  • Requesting a Redetermination on an MSP claim for a reason unrelated to MSP
  • New claim submissions/CMS-1500 claim form
  • Situations that involve the Veteran's Administration, PACMED or USFHP (US Family Health Plan)

To submit an MSP adjustment request:

  • Perform a Claim Status Inquiry on the Claim Status tab to find the claim.
  • Choose the "View Claim" link.
  • Choose the "MSP Form" link under the Related Inquires section of the Claim Status Details page.

Step 1 - Complete MSP Form

Select all applicable reasons for request:

  • Not related to no-fault/worker's comp/liability/Medicare Set-Asides
  • Medicare paid primary in error
  • Medicare paid secondary in error
  • Incorrect MSP type submitted on previously processed claim
  • Other

In the "Additional Information" text box, add a narrative for the reason for the request.

Enter Primary Insurance Information

  • Insurance Name
  • Address
  • City
  • State (Select from drop-down)
  • Postal Code
  • Subscriber Name
  • Subscriber Relationship
  • Policy Number
  • Effective Date
  • Term Date
  • Injury Date
  • Injury Diagnosis Code (Up to 5 codes may be entered if applicable)

Enter Provider Information

  • Provider Name (Auto-populated)
  • NPI (Auto-populated)
  • PTAN (Auto-populated)
  • TIN (Auto-populated)
  • Address
  • City
  • State (Select from drop-down)
  • Postal Code
  • Phone Number

Add Documents

Select the "Add Document" button. Supporting documentation must be submitted. Ensure all medical records contain the correct beneficiary's name and date of birth.

  • Document Name - Limited to 40 characters
  • Selected File - Browse and upload

Upload Requirements:

Maximum File Size: 70 MB

Supported Formats: GIF, JPG, JPEG, TIF, TIFF, DOC, DOCX, XLS, XLSX, PDF

Tip
If multiple documents are required, combine them into a single file (if under 70 MB) to avoid multiple uploads.

Once all documentation is attached, select Continue.

Step 2 - Review Details

The details of the MSP adjustment request will display. Carefully review to ensure all information is accurate and complete. If changes need to be made, choose the "Back" button to return to Step 1. If all information is correct, choose "Submit"

Step 3 - Confirmation

A confirmation message will display. This message will contain your confirmation number and the documents that were attached to your request. Noridian has 45 calendar days to respond to your inquiry. You may contact the Provider Contact Center with questions, concerns or status inquires.

Last Updated Jun 19 , 2026