Medicare Set-Aside Services Referral
MSA Department - 440 E. Swedesford Road, Suite 1000, Wayne, PA 19087 - Fax: 866-860-8612

Line of insurance (Please select a box):     Workers’ Compensation  Liability  No Fault
Services Requested (check all that apply)

STANDARD MEDICARE SET-ASIDE ALLOCATION 

ZERO ALLOCATION MEDICARE SET-ASIDE 

MEDICARE SET ASIDE ALLOCATION WITH NON-MEDICARE COVERED EXPENSES

RUSH MEDICARE SET-ASIDE ALLOCATION 
REVISION MEDICARE SET-ASIDE ALLOCATION 
BASIC MSA- LIABILITY ONLY
MINI MSA ALLOCATION
	
MEDICARE SET-ASIDE SUBMISSION TO CMS
SOCIAL SECURITY DISABILITY and MEDICARE STATUS 
CONDITIONAL PAYMENT SEARCH/ANALYSIS
CONDITIONAL PAYMENT DISPUTE/APPEAL 
PEER TO PEER REVIEW
NURSE TASK ASSIGNMENT 
PHARMACY REVIEW	

                      Claimant Information                                                 Claim Information
Claimant Name:	Date of Injury:	
DOB:	Claim Number:	
SSN:                        Medicare ID:	Claim Jurisdiction:	
Address:	Covered Conditions/Injuries:
	
City:	Non-Covered Conditions/ Injuries:	
State:	Settlement Broker Preference: 	
Zip:                          Phone No.:	Is Claimant Receiving SSDI or Medicare: Y N 
UNKNOWN   MEDICARE ENTITLEMENT DATE: 	

Key Contact and Billing Information
Adjuster Name:
	Adjuster Email:	Adjuster Phone:	
Employer:	Employer Address:
	
Insurance Carrier:	Insurance Carrier Address:
	
Third Party Administrator:	Third Party Address:
	Third Party Phone:	
Defense Attorney/Firm:
	Defense Address:	Defense Phone:	
Applicant Attorney/Firm:
	Applicant Attorney Address:	Applicant Attorney Phone:	
Party Responsible for Billing:
	Billing Address:	
Provide Copies of the MSA to the following:  Adjuster     Defense Attorney     Applicant Attorney    Other: 

Special Instructions: 	

ELECTRONIC REFERRAL SUBMISSION 
Email the attached referral form with the required documentation to msadirect@genexservices.com. An email confirmation will be sent once the referral has been processed. For questions or additional information, please contact the MSA Department at 1-877-674-5175 or your local Genex Area Sales Manager.