DI 45001.045 Establishing a Temporary HI Record

A temporary HI record will only be established by earnings reviewers in ODO. The temporary records will only be established as follows: congressional inquiry or mention of congressional contact is indicated, there is potential for adverse publicity (media contact), the application is at least 60 days old, specific procedure is shown elsewhere in DI 45001.000, or special instructions from ODO, OSS or OD are received.

The following is the procedure for establishing a temporary HI record for ESRD claims.

  1. Prepare Form HCFA-8063 (Internal Temporary HI Record), see DI 45001.106 and E., below for each ODO allowed ESRD claim (within the categories shown above) except (1) if the ESRD month of entitlement is the same as or later than the claimant"s month of entitlement to D-HI, Age 65-HI, or Premium-HI, or (2) closed period cases.

  2. Complete Form HCFA-8063 accurately and legibly as follows from the entries on the SSA-559 or SSA-101-U3.

    Care must be taken to print legibly and to make sure all items are completed accurately. Do not use slashes (/) or dashes (-) in any space since they will cause the input to except.

    Keep in mind that this form is used to prepare the HI tape record and the data entry operator must be able to readily decipher the information.

    • Item 1

      Enter SSN in spaces 1-9. In space 10, enter “A” if the patient is receiving a reduced primary benefit or DIB (do not use HA since this will cause the input to except) or the appropriate claim symbol if the claimant is entitled to auxiliary or survivors benefits, or “T” if the patient is not receiving monthly benefits. In space 11, be sure to enter the appropriate subscript (1, 2, 3, etc.) when the claimant is a child entitled to auxiliary benefits, e.g., space 10 would show “C” and space 11 would reflect the corresponding subscript (1, 2, 3, etc.). If the patient is insured based on federal employment for appropriate BIC (space 10) and subscript (space 11) entries.

      Item 2

      Enter first name - do not enter more letters beyond space 22. If the first name does not use the 10 spaces, leave remaining spaces blank.

      Item 3

      Enter middle initial.

      Item 4

      Enter surname. Do not leave any blank spaces between letters. For example, show “McCree” or “OBrien” rather than “Mc Cree” or “O"Brien.” If Jr. or Sr. is shown on the application, it needn"t be shown on the HCFA-8063, although the input will not except if Jr. or Sr. is included.

      Item 5

      Enter date of birth.

      Item 6

      Leave blank.

      Item 7

      Enter the month and year of R-HI entitlement.

      Item 8

      Enter the month and year of R-SMI entitlement. If patient did not elect R-SMI, leave blank.

      Item 9

      Enter “82D2.”

      Item 10

      Enter sex code.

      Item 11

      Enter “82D2.”

      Item 12

      Enter “2” in space 78. A numeric entry is mandatory or the input will except.

      Item 13

      Enter signature (see E., below).

  3. If the internal temporary HI Record (HCFA-8063) is prepared, complete two copies of the appropriate temporary notice (see DI 45001.077-DI 45001.080) advising the patient of entitlement to Medicare.

    File one copy of the notice on the right side of the folder and release the original to the mailroom.

  4. Route Form HCFA-8063 to 4 Phase Control, 3-D-20 North Building, Metro West, 300 North Green Street, Baltimore, Maryland 21201 by Optional Form 41.

  5. Since the Form HCFA-8063 is used as source information for the HI tape record, the person preparing the form must be duly authorized to provide the information. The authorization is obtained by completion of a Signature File Card (see DI 45001.107) which is submitted to CMS, Enrollment Section, Bay F-2, 1717 Equitable Building where it is maintained for verification of authorization of completed Forms HCFA-8063.

    Any HCFA-8063 completed by an unauthorized person or any substitute for HCFA-8063 will be returned to SSA as potential security breach for investigation and resolution. For example, completion of the Forms SSA-8063 or CO-8063 (predecessors to the HCFA-8063) will be returned to the issuing module division. The Form HCFA-8063 should then be properly completed and returned to CMS.

    Some of the earlier versions of the Forms HCFA-8063 instruct the preparer to print his/her name in item 13. However, that instruction was removed by a subsequent revision and all Forms HCFA-8063 must show the required signature (as shown on the Signature Fi