HI 00825.115 CMS-1725 (Program Service Center Referral)

The CMS-1725 originates in the CMS, Group Premium Payment Branch (GPPB) in Central Office. Miscellaneous health insurance information and/or correspondence is received in the GPPB from carriers and intermediaries. When a discrepancy is noted or it appears a program service center action is necessary, an CMS-1725 is prepared and sent to the PSC.

The appropriate PSC component, Mail and Direct Input personnel, a Benefit Authorizer, or an Exceptions and Inquiries Specialist will review the folder in conjunction with the CMS-1725 and any attachments. If, based on such review, an adjustment to the MBR is in order, corrective action must be taken. If the CMS-1725 and the MBR are in agreement, no action is necessary. A reply to CMS, GPPB is required only if the PSC disagrees with the information furnished (either on the CMS-1725 or the attachments).

Please note, the receipt of the CMS-1725 only indicates the folder should be reviewed to insure the MBR is correct. It does not mean something is definitely wrong on the MBR.

The CMS-1725 has been revised to meet current needs. See HI 00825.912 for a sample of the revised form.

In some instances, a Health Insurance Printout (HIPO) will accompany the CMS-1725. This printout will assist the reviewer in recognizing possible discrepancies between the Health Insurance Master (HIM) and the MBR. See HI 00825.913 for a sample HIPO and an explanation of pertinent data contained thereon.