Rising Financial Solutions
325 N LaSalle St, Ste #475
Chicago, IL 60654
Tel: 877.MSA.4404 / Fax: 877.259.7473
Email: msaadmin@risingfs.com
Medicare Set-Aside (MSA) Administration Scorecard REQUIRED FIELDS are denoted with an asterisk (*)	WWW.RISINGFS.COM
Instructions:
Please complete the information below regarding the MSA. The system will then calculate a recommendation for administering the MSA settlement funds – either Professional Administration or Self-Administration. If applicable, the system will also calculate a recommendation for a Medical Custodial Account for any settlement funds intended to pay non-Medicare covered, future medical expenses that fall outside of the MSA.
Claimant Name (Last, First):
*MSA allocation based on:	Charges/UCR State Fee Schedule
*Jurisdiction state of claim:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
*$ Amount of MSA Allocation:
$ Amount of non-Medicare covered future medicals, not included in MSA:
Claimant has Guardian/Conservator?	YesNo
Claimant has been declared incompetent by a court?	YesNo
Claimant has a designated representative payee?	YesNo
Payer has a Reversionary Interest?	YesNo
Claimant representation:	Pro Se Represented
Claimant education level:	Below High School High School Diploma Associates or 2 Year Degree College - 4 Year Degree Above College Degree Unknown
Claimant employment:	Insurance Professional Legal Professional Medical Professional Other
Claimant has a traumatic brain injury?	YesNo
Claimant physical functional level:	High Medium Low Unknown
Apportionment on the file?	YesNo
Denied or disputed treatment or injuries on the file?	YesNo
Claimant on Medicaid?	YesNo
MSA Admin Recommendation:
MSA Prof Admin Required?
Prof Admin of Medical Custodial Account Recommended?
State Reporting/Bill Review License Required by the state?
Points:
Recommendation:	Point Range
Self-Administration	0 to 14 points
Self-Administration Support	15 to 49 points
Professional Administration:	50 and above
Rising's MSA Prof Admin Bill Review Savings:	(estimated)
MSA Allocation Amount that Offsets Prof Admin Fees:
Disclaimer: This scorecard is a tool developed by Rising Financial Solutions. Point values are based upon Medicare requirements, state-specific Workers’ Compensation regulations, and impacting factors identified by Rising. This scorecard tool will be adjusted when Medicare and state regulations change, or as deemed appropriate by Rising. Final determination regarding how settlement funds are administered should be made using facts and circumstances related to the specific case and through discussions with all parties to the settlement.
To obtain further assistance or to refer a case to Rising for MSA Professional Administration, Medical Custodial Account Professional Administration, or MSA Self-Administration Support, please fill out our online services request form or contact us at 877.MSA.4404 or msaadmin@risingfs.com.
© Rising Financial Solutions, Inc.