MES Solutions - Medicare Services Referral

Medicare Set-Aside Services

Workers' Compensation Medicare Set-Aside

Medical Cost Projection

Liability Medicare Set-Aside

CMS Submission

Apportionment Medicare Set-Aside

Conditional Payment Services

Medicare Conditional Payment (Dispute/Appeal/Final Demand)

Medicare Advantage Conditional Payment (Research/Negotiation)

Medicare Conditional Payment (Research/Negotiation)

Insurance Information

Insurance Type*

Workers' CompensationLiabilityAuto/No-Fault

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Jurisdiction*

StateUSLH(Longshore)DBAFELAJones Act

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Claimant Information

Claimant/Plaintiff Name

Phone

DOB

Gender

Address

City

State

Zip

Claim 1 #

Claim 2 #

Claim 3 #

Date of Injury 1

Date of Injury 2

Date of Injury 3

Referring Party

Insurance CarrierTPASelf-InsuredExcess CarrierOther

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Name

Contact

Phone

Fax

Address

City

State

Zip

Involved Parties

Employer

Name

Contact

Phone

Fax

Address

City

State

Zip

Defense Attorney

Name

Contact

Phone

Fax

Address

City

State

Zip

Plaintiff Attorney

Name

Contact

Phone

Fax

Address

City

State

Zip

Structured Settlement Broker

Name

Contact

Phone

Fax

Address

City

State

Zip

Claim Information

Injury

ICD 9/10 Codes

Proposed Settlement Amount

Special Handling / Additional Information