TN 4 (05-09)

DI 13050.070 Expedited Reinstatement (EXR) and Medicare Termination

A. Policy – EXR denials effect on Medicare

1. When to deny an EXR request

We may deny an expedited reinstatement (EXR) request for:

  1. Not meeting the technical requirements (see DI 13050.001 for EXR requirements);

  2. A “not same as or related” determination (shown on the SSA-832/833 as a code of 28 for Title II cases and a code of 61 for Title XVI - see DI 28057.015C for medical criteria and DI 28057.020 for coding information); or

  3. Not meeting the medical improvement review standard (MIRS) due to medical improvement (shown on the SSA-832/833 as a MIRS denial code - see DI 28085.012 and DI 28086.012 for MIRS denial codes).

2. Determining if Medicare ends when denying an EXR request

When we deny the EXR request, Medicare entitlement may or may not terminate depending on the basis of Medicare entitlement (see HI 00801.165).

  1. If the only basis for Medicare entitlement is the provisional benefit period, Medicare will terminate the earlier of:

    • the last day of the 6th month of the provisional benefit period, or

    • the last day of the month following the month the unfavorable decision notice is mailed.

  2. Medicare based on end-stage renal disease (ESRD) or age will not terminate when the provisional period ends, or when we deny an EXR request.

  3. Extended Medicare will continue, unless the DDS determines that the individual has medically improved (MIRS denial). If the individual has medically improved, coverage will end the last day of the month following the month the notice of the unfavorable decision is mailed.

NOTE: If the individual is working, and has not medically improved, he or she may be eligible for Premium HI under the Disabled Working Individual (DWI) provision, see (SM 00850.525 and HI 00801.170). If the individual chooses to elect Premium HI, the field office (FO) will send a high priority message (HP2560) using the modernized development worksheet (MDW) to OCO to establish Premium HI entitlement. If you need assistance on how to complete an MDW, follow instructions found in the National Toolkit: MDW Instructions .

3. Procedure when Medicare ends due to EXR denial

The FO will identify the reason for the EXR denial, and determine the Medicare termination month. If Medicare terminates, the FO will send a HP2560 using the MDW to OCO/PC with instructions to input the correct termination month and prepare the termination notice.

4. Medicare termination notice used in EXR denials

OCO/PC prepares and releases the appropriate Medicare termination notice. If Medicare was based solely on the provisional benefit period, the beneficiary will not have appeal rights with this termination (see HI 00801.165).

B. Procedure - Medicare language in denial notices

When the FO prepares the denial notice, they will include the appropriate Medicare language, based on the type of denial and type of Medicare coverage. The chart below shows the appropriate notice language (known as a UTI in DPS) to use when constructing the denial notice. In some situations, there won’t be Medicare language inserted. Examples of these notices are contained in DI 13050.105, Exhibits 6, 7 and 8.

Basis for Denial

Type of Medicare Coverage

Impact on Medicare

EXR Denial Notice Issued

UTI/POMS Reference

Technical Denial

Part of provisional payments and did NOT have Premium HI

Medicare Ends

Technical Denial

HIB158

DI 13050.105F--

Exhibit 6, Sample Title II MIRS Denial Notice

Technical Denial

Received Provisional Payments and had Premium HI

Medicare continues only if Premium HI is reinstated See HI 00801.164B.3.

Technical Denial

HIB 174

DI 13050.105H – Exhibit 8, Sample Title II Technical Denial Notice

Technical Denial

Extended, Premium HI, ESRD, MQGE, or Aged

No impact on Medicare

Technical Denial

HIB159

DI 13050.105H – Exhibit 8, Sample Title II Technical Denial Notice

Technical Denial

No Medicare coverage

N/A

Technical Denial

Do not include Medicare language in Notice

“Not Same as or Related” Denial

(Form 833 Item 11 shows code of 28)

Part of provisional benefits and did NOT have Premium HI

Medicare Ends

MIRS Denial

HIB158

DI 13050.105E--

Exhibit 6, Sample Title II MIRS Denial Notice

“Not Same as or Related” Denial

(Form 833 Item 11 shows code of 28)

Extended, ESRD, MQGE or Aged

No impact on Medicare

MIRS Denial

HIB159

DI 13050.105H – Exhibit 8, Sample Title II Technical Denial Notice

“Not Same as or Related” Denial

Premium HI

Medicare continues only if Premium HI is reinstated See HI 00801.164.3

MIRS Denial

HIB 174

DI 13050.105H – Exhibit 8, Sample Title II Technical Denial Notice

MIRS Denial

Part of provisional payments

Medicare ends

MIRS Denial

HIB158

DI 13050.105F--

Exhibit 6, Sample Title II MIRS Denial Notice

MIRS Denial

Extended Medicare

Medicare Ends

MIRS Denial

HIB167

DI 13050.105F--

Exhibit 6, Sample Title II MIRS Denial Notice

MIRS Denial

Premium HI

Medicare ends

MIRS Denial

HIB168

DI 13050.105E-

Exhibit 6, Sample Title II MIRS Denial Notice

MIRS Denial

ESRD

No impact on Medicare

MIRS Denial

HIB169

DI 13050.105F--

Exhibit 6, Sample Title II MIRS Denial Notice

MIRS Denial

Aged Medicare

No impact on Medicare

MIRS Denial

HIB172

DI 13050.105F--

Exhibit 6, Sample Title II MIRS Denial Notice

MIRS Denial

MQGE

Medicare Ends

MIRS Denial

HIB173

DI 13050.105F--

Exhibit 6, Sample Title II MIRS Denial Notice

MIRS Denial or “Same as or Related” Denial

No current Medicare coverage

N/A

MIRS Denial

Do not include Medicare language in notice

Reconsideration Denial

Extended Medicare, Premium HI, ESRD, Aged

No impact on Medicare

Recon Denial

HIB159

DI 13050.105F--

Exhibit 6, Sample Title II MIRS Denial Notice

Reconsideration Denial

No current Medicare Coverage

N/A

Recon Denial

Do not include Medicare language in notice

C. References

HI 00801.164 - Medicare Entitlement during the Provisional Benefit Period – Expedited Reinstatement of Disability Benefits

HI 00801.165 - Medicare Termination When the Provisional Benefit Period Ends

HI 00801.166 - Favorable Medical Decisions


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http://policy.ssa.gov/poms.nsf/lnx/0413050070
DI 13050.070 - Expedited Reinstatement (EXR) and Medicare Termination - 08/03/2011
Batch run: 08/03/2011
Rev:08/03/2011