TN 54 (02-23)

HI 01001.260 District Office Procedure in Complaint or Problem Cases Relating to Group Billing Arrangement

Individuals who are included in group premium accounts may continue to receive premium bills or may receive termination notices. In some cases, this is a temporary situation caused by the time required to process data to appropriate SSA records. In other cases, it is a result of the group or the individual not following procedures, or the result of SSA processing errors.

In handling group payer problem cases, take the following actions:

1. A. 

   Verify that the individual is eligible for third party group coverage. An individual who is included under a State buy-in agreement, or receiving SSA, CSC, or RRB benefit checks is in eligible for coverage by a third party group. Inform the individual if it is determined that the individual is ineligible.

2. B. 

   Verify that the individual has not been recently accreted to a formal third party group. This can be determined if, within the last month, the individual has received a form HCFA 1626, Notice of Group Billing Arrangement (see HI 01010.805). Receipt of this form is sufficient evidence to show that the individual is included under a group account on the Third Party Master record and all other appropriate SSA records. The individual should no longer make direct remittances to SSA. If any payments were made for a period while the individual was included on the group account, they will receive an automatic refund from SSA within 4 months. If the HCFA 1626 has not been received:

3. C. 

   Verify that the allegation concerns a formal group. The list of formal third party groups appears in HI 01010.809. Please note that all possible agency codes begin with the letters “A”, “J” , B, “K”, or “X” and are followed by a two digit number (examples: A02, J81, B03, K71, X71). If the organization involved is not a formal group, suggest to the individual that they contact their organization to determine the details of their premium payment program. If the organization is a formal group:

4. D. 

   Ascertain that the individual followed the proper procedures for becoming a group member. This means that the individual gave the group a signed authorization and their premium notice cards.

5. E. 

   If you determine that the individual could be a member of a formal third party group, send an overprinted RC to BSS along with a current MBR and any available proof that the allegation is correct. It is mandatory that the involved group's agency code and proper name be included on the form (see HI 01010.809 for the list of formal groups and their codes). BSS resolves the issue and informs the individual of the resolution action. Indicate on the RC if a reply to the DO is desired. See HI 01001.375B and HI 01001.375D for a detailed explanation of the use of the overprinted RC for group payer inquiries.