TN 33 (01-06)

GN 00502.181 Other Contacts to Evaluate Payee Applicant's Suitability

A. Policy - General

An applicant's concern and responsibility for the beneficiary must be verified with the beneficiary or custodian. It is essential to verify concern when the applicant does not have custody of the beneficiary. An applicant who does not demonstrate concern for the beneficiary is a very poor choice for a payee, and every effort should be made to find a more suitable candidate.

B. Policy - Beneficiary Interview Criteria

An interview with the beneficiary is always required in the situations listed in GN 00502.181B.1. and GN 00502.181B.2. The type of interview required depends on the particular situation.

1. Either Face- To-Face or Telephone Interview

Although the interview should generally be conducted face-to-face, a telephone interview is permissible when:

  • the beneficiary lives alone, or

  • the beneficiary is a child who is:

  • away at college,

  • in the armed forces, or

  • in the job corps or has otherwise established independence from parental authority.

NOTE: Beneficiaries in these situations may be better served by direct payment. (See GN 00502.070.)

2. Face-To-Face Interview Required

The interview with the beneficiary must be a face- to-face interview when:

  1. The applicant is an agent for a Medicare/Medicaid certified facility that has been cited by HHS/court or the media for abuse or substandard conditions.

  2. The applicant is the owner of a private, for profit facility and the FO either:

    • has not visited the facility in the past year, or

    • has obtained information in the past year that shows the facility is unlicensed or substandard.

      NOTE: You need not conduct yearly visits of private, for profit facilities solely for waiving the requirement for beneficiary interviews. Further, you may wish to note the dates you visit private, for profit facilities for any reason in the Make Note screen of the eRPS (MS INTRANETERPS 015.002 and MS INTRANETERPS 015.003.B).

  3. Unresolved questions exist about the applicant's interest in or responsibility for the beneficiary.

C. When To Use an SSA-788

The SSA-788 (Statement of Care and Responsibility for Beneficiary) is the form used to obtain information from the beneficiary's custodian about the applicant's concern and responsibility for the beneficiary.

An SSA-788 (or equivalent information which can be shown in the Make Note or View Notes screens of the eRPS or on an SSA-5002, Report of Contact) is required in all cases where the payee applicant does not have custody of the beneficiary except where:

  • The beneficiary is in a facility and is expected to return to the payee applicant's custody within 90 days.

  • The custodian has also filed an SSA-11-BK which reflects the needed information.

  • The custodian refuses to provide the information.

  • The beneficiary lives alone. (Contact with the beneficiary is required in this situation. See GN 00502.181B.1.a.)

D. Procedure

If a payee applicant does not have custody of the beneficiary, mail an SSA-788 to the custodian to verify the applicant shows concern and responsibility for the beneficiary.

EXCEPTION: In any situation where a question about the applicant's concern has been raised, conduct a face-to-face interview with the custodian to verify the applicant's concern.

STEP

ACTION

1

If the custodian cannot furnish the information requested on Form SSA-788 within 30 days, process the claim without the information.

NOTE: You can obtain the SSA-788 information over the telephone if the custodian is slow to respond.

2

Do you believe the applicant demonstrates concern for the beneficiary?

  • If yes, document the file that the SSA-788 is being secured post-adjudicatively; diary the case for 3 months to follow up f