TN 2 (09-09)

DI 23540.015 Completing Notices and Routing Medicare for Qualified Government Employment (MQGE) Cases

A. Completing MQGE denial notices

The various form and model letters and paragraphs to be used are shown in the denial charts below. The notices are intended to supplement, but not replace, any requirements for personalized notices.

1. Notice Chart 1 - Disabled Insurance Beneficiary (DIB)

Enter in Item 22 Reg-Basis Code

Letter Number and Paragraph Numbers
Initial Claims (See Footnotes 124 and 5)
Recon Claims (See Footnote 3
)

Earnings Requirement Last Met on or After the Date of Current Decision

Earnings Requirement Last met Prior to Date of Current Decision

Earnings Requirements Last Met on or After Date of Current Decision

Earnings Requirement Last Met Prior to Date of Current Decision

F1

 

L443,851,409,920

 
 

F2

 

L443,852 (Date ER Last Met),409,920

H1

 

L443,850,409,920

 
 

H2

 

L443,859 (Date ER Last Met),409,920

J1

 

L443,850,409,920

 
 

J2

 

L443,859 (Date ER Last Met),409,920

E1

 

L443,854,409,920

 
 

E2

 

L443,859 (Date ER Last Met),409,920

E3

 

L443,853,409,920

 
 

E4

 

L443,859 (Date ER Last Met),409,920

M5

 

L443,876,409,920

 
 

M6

 

L443,876,409,913 (Date ER Last Met),920

L1

 

L443,877,409,920

 
 

L2

 

L443,877,409,913 (Date ER Last Met),920

M3

 

L443,870,409,920

 
 

M4

 

L443,870,409,913 (Date ER Last Met),920

M7

 

L443,870,409,920

 
 

M8

 

L443,870,409,913 (Date ER Last Met),920

K1

 

L443,872,409,920

 
 

K2

 

L443,872,409,913 (Date ER Last Met),920

Z1

 

L443,409,920

 

Z2

 

L443,859 (Date ER Last Met),409,920

 

1 Add the following after the first sentence on the SSA-L443, “Your claim for Medicare as a disabled individual is based on your employment with the Federal, State, or local government.”

2 In any situation where the SSA-L443 contains insufficient space for the fill-in paragraphs, combine the preprinted paragraphs from the SSA-L443 with the assigned paragraphs to form the notice.

3 The Reconsideration Letter Number is L928. On the SSA-L928, include “Medicare Coverage-Only” as a type of claim.

In concurrent recon affirmations of denials, use one SSA-L928 with each type of claim checked off. Place a copy of the letter in each folder and show the multiple claim numbers at the top of the letter.

4 Include Paragraph No. 267 as an attachment to initial notices.

5 See DI 90070.900 – Exhibit 5.

2. Notice Chart 2 - Disabled Insurance Beneficiary (DIB) Death Claim

Enter in Item 22 Reg-Basis Code

Letter Number and Paragraph Numbers

Initial Claims (See Footnotes 123 and 5)
Recon Claims (See Footnote 4)

Earnings Requirement Last Met on or After the Date of Death

Earnings Requirements Last Met Prior to Date of Death

Earnings Requirements Last Met on or After the Date of Death

 

H1
J1

 

L443,885, (WE's Name),409,920

 
 

H2
J2

 

L443,884 (WE's Name)(Date ER Last Met),409,920

F1

 

L443,892 (WE's Name),409,920

 
 

F2

 

L443,891 (WE's Name)(Date ER Last Met),409,920

E1

 

L443,887 (WE's Name),409,920

 
 

E2

 

L443,884 (WE's Name)(Date ER Last Met),409,920

E3

 

L443,886 (WE's Name),409,920

 
 

E4

 

L443,884 (WE's Name)(Date ER Last Met),409,920

M5

 

L443,888 (WE's Name),409,920

 
 

M6

 

L443,888 (WE's Name),409,920

M3
M7

 

L443,889 (WE's Name),409,920

 
 

M4
M8

 

L443,889 (WE's Name),409,920

K1

 

L443,890 (WE's Name),409,920

 
 

K2

 

L443,890 (WE's Name),409,920

1 Add the following after the first sentence on the SSA-L443, “Your claim for Medicare on behalf of (NH's Name) as a disabled individual is based on (NH's Name) employment with the Federal, State, or local government.”

2 In any situation where the SSA-L443 contains insufficient space for the fill-in paragraphs, combine the preprinted paragraphs from the SSA-L443 with the assigned paragraphs to form the notice.

3 If the W/E died within 5 months of AOD, refer to DI 23510.000 for processing. Make no entry in item 29.

4 The Reconsideration Letter Number is L928. On the SSA-L928, include “Medicare Coverage-Only” as a type of claim.

In concurrent recon affirmations of denials, use one SSA-L928 with each type of claim checked off. Place a copy of the letter in each folder and show the multiple claim numbers at the top of the letter.

5 Include Paragraph No. 267 as an attachment to initial notices.

3. Notice Chart 3 - Disabled Widow(er) Beneficiary (DWB)

Enter in Item 22 Reg-Basis Code

Letter Number and Paragraph Numbers
Initial Claims (See Footnotes 1235 and 6)
Recon Claims (See Footnote 4)

Prescribed Period Requirement Met on or After Date of Current Decision

   

F1

 

L443,868,409,864 (Last day of PP),919

 
 

F2

 

L443,869 (Last Day of PP),409,919

E1

 

L443,875,409,864 (Last Day of PP),919

 
 

E2

 

L443,869 (Last Day of PP),409,919

E3

 

L443,874,409,864 (Last Day of PP),919

 
 

E4

 

L443,869 (Last Day of PP),409,919

M5

 

L443,876,409,864 (Last Day of PP),919

 
 

M6

 

L443,876,409,864 (Last Day of PP),919

L1

 

L443,877,409,864 (Last Day of PP),919

 
 

L2

 

L443,877,409,864 (Last Day of PP),919

M3

 

L443,870,409,864 (Last Day of PP),919

 
 

M4

 

L443,870,409,864 (Last Day of PP),919

M7

 

L443,870,409,864 (Last Day of PP),919

 
 

M8

 

L443,870,409,864, (Last Day of PP),919

K1

 

L443,872,409,864 (Last Day of PP),919

 
 

K2

 

L443,872,409,864 (Last Day of PP),919

X3

 

L443,402,409,919

 
 

X3

 

L443,402,409,919

H1

 

L443,850,409,864 (Last day of PP),919

 
 

H2

L443,869 (Last day of PP),409,919

 

J1

 

L443,850,409,864 (Last day of PP),919

 

J2

 

L443,869 (Last day of PP),409,919

 

Z1

 

L443,409,864 (Last day of PP),919

 
 

Z2

 

L443,409,869 (Last day of PP),919

1 In Federal Medicare cases only, add the following after the first sentence on the SSA-L443, “Your claim for Medicare as a disabled individual is based on (NH's Name) employment with the Federal, State, or local government.”

2 In any situation where the SSA-L443 contains insufficient space for the fill-in paragraphs, combine the preprinted paragraphs from the SSA-L443 with the assigned paragraphs to form the notice.

3 Paragraph 864 should not be included in this notice when the widow is receiving mother's benefits and the ending date of the PP is in the future.

4 The Reconsideration Letter Number is L928. On the SSA-L928 include “Medicare Coverage-Only” as a type of claim.

In concurrent recon affirmations of denials, use one SSA-L928 with each type of claim checked off. Place a copy of the letter in each folder and show the multiple claim numbers at the top of the letter.

5 Include Paragraph No. 266 as an attachment to initial notices.

6 See DI 90070.900 – Exhibit 5

4. Notice Chart 4 – Childhood Disability Beneficiary (CDB)

 

Letter Number and Paragraph Numbers
Initial Claims (See Footnotes 1235 and 6)
Recon Claims (See Footnote 4)

Enter in Item 22 Reg-Basis Code

CDB (Both DIB and RSI) Applicant Age 22 or Older

CDB (Both DIB and RSI) Applicant Not Yet 22

F1

L443,855,409,865,920

L443,856,409,866,920

G1

L443,857,409,865,920

L443,858,409,866,920

E1

L443,854,(Omit last sentence)409,865,920

L443,854,(Omit last sentence)409,866,920

E3

L443,853,(Omit last sentence)409,865,920

L443,853,(Omit last sentence)409,866,920

M5

L443,876,409,865,920

L443,876,409,866,920

L1

L443,877,409,865,920

L443,877,409,866,920

M3

L443,870,409,865,920

L443,870,409,866,920

K1

L443,872,409,865,920

L443,872,409,866,920

F1, G1, E1, E3, M5, L1,
M3, or K1, or Z1

Medicare Model
Letter, “Q” (Last Day of Specified Period)

Medicare Model
Letter “Q” (Last Day of
Specified Period)

F2, G2, E2, E4, M6, L2,
M4, K2 or Z2

Medicare Model
Letter “R” (Last Day of Specified Period)

 

Z1

L443,409,865,920

L443,409,866,920

1 Add the following after the sentence on the SSA-L443, “Your claim for Medicare as a disabled individual is based on (NH's Name) employment with the Federal, State, or local government.” If another person filed on behalf of claimant, add “on behalf of John Jones” after “Medicare.” Write the personalized notice in the third person when an individual is filing on behalf of the child.

2 In any situation where the SSA-L443 contains insufficient space for the fill-in paragraphs, combine the preprinted paragraphs from the SSA-L443 with the assigned paragraphs to form the notice.

3 Delete “and the earnings requirement” from paragraph 920.

4 The Reconsideration Letter Number is SSA-L92