Findings have indicated that some SMI terminations will be improper based on information
in the claims folder which is not reflected in the master records. When this occurs,
corrective action is required to restore the SMI coverage. This situation may occur
in both insured and uninsured records.
These terminations can represent withdrawal from coverage, termination based on cessation
of disability, termination based on cessation of renal disease eligibility, termination
based on the equitable relief provisions, or termination for nonpayment of HI and/or
SMI premiums.
When reinstating coverage for any reason, except nonpayment of premiums, a MADCAP
debit will be needed for insured cases; and a MISCOR CIP R action will be needed for
uninsured cases.
There are three methods of reversing or reinstating premium-HI or SMI coverage erroneously
terminated for nonpayment of premiums. The use of each process depends on whether:
-
1.
a BCM record already exists for the terminated record (which always will for all uninsured
and premium-HI cases), and
-
2.
any factors other than a simple reversal for nonpayment of premiums are involved,
and
-
3.
the claimant is insured or uninsured.
The three methods are REVTER, MADCAP, and MISCOR CIP R. (REVTER derives its name from
the special batch code of that name and is not an actual program; it is a reversal
of a termination entered via the PEPPER program.)
The applicability of equitable relief must be considered in all reinstatement actions
(see HI 00830.020).