Effective Dates: 01/19/2024 - Present Previous | Next

TN 7 (01-24)

HI 03040.100 Appeal Establishment

CITATIONS:

20 CFR §418.3605 - §418.3680

A. Policy

When an individual disagrees with an initial determination, we will establish an appeal in the Medicare Application Processing System (MAPS).

However, we may not take an appeal on our own motion, i.e., establish an appeal without any indication from the individual that they disagree with the initial determination.

See HI 03050.045. for the policy on fixing errors.

B. Procedure

1. Establishing the Appeal

The Appeal Application screens in MAPS, or form SSA-1021 (Appeal of Determination for Help with Medicare Prescription Drug Plan Costs) are used to obtain the following information:

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    Applicant's Name and Social Security Number (SSN)

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    Medicare Number (this number is printed on your Medicare card)

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    Spouse's Name (if spouse lives at same address as applicant) and SSN

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    Spouse's Medicare Number (this number is printed on your spouse's Medicare card)

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    The reason for the disagreement

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    Whether or not the individual will be submitting additional information

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    Whether the individual prefers a case review or a telephone hearing

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    Whether the individual wants a telephone hearing sooner if scheduling permits (at least 20 days is provided between date of request and date hearing is scheduled). Make it clear the Subsidy Appeals Unit (SAU) will schedule the appointment and send the appointment notice.

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    Whether an interpreter is needed and whether the individual is hearing impaired

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    Whether or not a conference call is needed if the hearing is to be via telephone (i.e. whether the individual will be represented, or will include another party in the hearing)

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    Claimant’s statement explaining good cause for late filing of appeal

NOTE: 

When multiple applications are in MAPS, due to a systems limitation, an appeal can only be established on the most recent application.

Establish the appeal on the current application.

Include a Report of Contact (DWRC) screen stating: the appeal is established on the current application due to a systems limitation; show the date of the application being appealed; and state that this is the date that should be used for the appeal determination.

a. Applicant Requests an Appeal via 800# or in Field Office (FO)

The SSA employee will:

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    Conduct a brief interview with the individual or the person acting on the individual's behalf. Make it clear to the individual that the SAU will schedule the appointment (if hearing by telephone is requested) and send the individual an appointment notice.

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    Determine whether the individual is requesting an appeal, requesting an explanation of a determination, reporting a subsidy changing event (marriage, divorce, death of spouse, separation, annulment, separated spouses living together again, or spouse newly enrolls for subsidy) or reporting another event that may change the subsidy determination. There is more information on subsidy changing events and other reporting events in HI 03050.025. Also, in HI 03050.025C., there is a chart for handling calls within and outside the appeal period.

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    If a request for appeal is mailed to the FO, review the appeal information to make sure it is complete and readable. Contact the individual to obtain clarification on any items before entering information on the Appeal screens in MAPS. Make two attempts to phone the individual before submitting the appeal to the SAU. Document attempts on the DWRC screen in MAPS (date, time, and phone number).

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    Establish the appeal by completing the Appeal Application screens in MAPS. See MS 03207.001.

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    Document the MAPS DWRC screen with additional information. Accept any reasonable allegation (e.g., lower income due to loss of job). Destroy paper copies of additional documentation and return original documents to the individual.

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    Document the reason for late filing on the Good Cause for Late Filing screen in MAPS. Accept any reason the individual gives.

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    If a recent change of address or phone number is indicated, enter the new address/phone number on the appeal screens in MAPS. This entry will not update the MBR/SSID records, so you must also follow change of address instructions in HI 03050.020E.

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    For applicants with foreign addresses, record on the MAPS APIS screen (Section titled: "Please explain why you disagree with our decision") the following information: the applicant’s mailing address and telephone number, and the field office code of the office establishing the appeal.

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    Do not ask the caller for two preferences for the date and timeframe (morning or afternoon) for the hearing appointment and do not enter any preferences to MAPS. Make it clear to the caller that the SAU will schedule the appointment and send an appointment notice.

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    Submit the request to the SAU.

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    For telephone hearing, the SDR schedules the appointment (not the 800 # agent or the FO) and sends the appointment notice. For case review, the SDR sends the acknowledgment notice.

b. Applicant Requests an Appeal via Mail to WBDOC

The SSA employee will:

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    Establish the appeal in MAPS.

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    Attempt two phone contacts with the individual to obtain clarification on any items that are incomplete or unreadable or to determine the reason for late filing, if applicable.

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    Document the DWRC screen or the Good Cause for Late Filing screen in MAPS. Accept any explanation the individual gives.

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    Fax any additional or supporting information that accompanied the appeal request to the SAU. At the end of each day, batch additional/supporting information and send to the SAU. Determine SAU by following instructions in HI 03040.001C. Include the SSN on all supporting information. Document on DWRC, additional information faxed to (fill-in jurisdictional SAU).

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    If a recent change of address is indicated, enter the new address on the appeal screens in MAPS.

    IMPORTANT: This entry will not update the MBR or SSID, so you must follow change of address instructions in HI 03050.020E.

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    For applicants with foreign addresses, record on the MAPS APIS screen the following information: the applicant’s mailing address and telephone number. This information should be entered in the section titled “Please explain why you disagree with our decision.”

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    Submit the request to the SAU. Once the appeal request has been established, the paper form may be discarded. Ensure all information has been input in MAPS before destroying the appeal form.

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    For telephone hearing, the SDR schedules the appointment and sends the appointment notice. For case review, the SDR sends the acknowledgment notice.

2. Handling a Subsequent Application

a. First Application Is Denied and Subsequent Application Is Received Within 60-Day Timeframe

If the initial application was denied and the subsequent application is received within 60 days of initial denial notice, the Claims Specialist (CS) will compare the applications. If the subsequent application represents a change, establish an appeal. See HI 03010.010F. for procedures on subsequent applications.

b. First Application Is a Subsidy Award and Subsequent Application Is Received Within 60-Day Timeframe

If the initial application resulted in a subsidy and the subsequent application is received within 60 days of the initial application, then the two applications will be compared to determine whether an appeal will be taken. See HI 03010.010F. for instructions on subsequent applications.

NOTE: Starting January 1, 2024, the Inflation Reduction Act (IRA) provides all Extra Help beneficiaries full subsidy. A partial subsidy determination can only be made on an Extra Help case that has a coverage start date before January 1, 2024.

c. Processing Subsequent Applications with Subsidy Changing Event Indicator or Outside Appeal Period

Follow the instructions in HI 03010.010F.2.

d. Canceling Subsequent Application While Appeal Pending on First Application

The subsequent application will be transferred to the jurisdictional SAU when an appeal is pending on the first application. The SAU will use the information from the subsequent application in their decision, list the subsequent application as evidence, and address the subsequent application in their notice. The SAU will cancel the subsequent application in MAPS.

3. Referrals to the Subsidy Appeals Unit (SAU)

a. Inquiries from individuals

You may receive inquiries from individuals who wish to contact the SAU directly (e.g., to confirm that they received the additional information they sent to support an appeal or to reschedule appointments). Handle these requests as follows.

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    Provide the individual with the toll-free number for the SAU: 866-865-5311.

b. Requests for the Mailing SAU address

You may also receive requests for the mailing address of the SAU (e.g., the caller has an appeal pending and would like to submit additional information to support the appeal). Handle these requests as follows.

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    Provide the caller with the mailing address for the SAU.

    Social Security Administration

    Medicare - Subsidy Appeals Unit
    P.O. Box 17720

    Baltimore, MD 21235-7720
To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0603040100
HI 03040.100 - Appeal Establishment - 01/19/2024
Batch run: 10/03/2024
Rev:01/19/2024