TN 1 (07-04)

DI 45001.324 Processing ESRD Medicare Claims With Railroad Retirement Board Involvement

A. Insured status

Follow the instructions in HI 00801.235G in developing cases where insured status is based on RRB involvement.

B. Determining how to process an award

1. General

If the claimant meets the requirements for entitlement to ESRD Medicare, it is then necessary to determine whether or not the claimant is currently entitled to Medicare under a Railroad Retirement Number (RRN). A claimant can have Medicare under an RRN only if he or she:

  1. is age 65 or over, or

  2. has been receiving a disability benefit from RRB for 24 months.

If neither of these conditions exists and LAF code on the MBR is not “E,” process an award per the instructions in DI 11052.000. In most cases, the claimant’s ESRD Medicare will be established under his or her own SSN with a BIC of T. He or she will be billed for SMI premiums by SSA. This is true even when the claimant is receiving a monthly benefit from RRB, but is not yet entitled to Medicare. The only time SSA will not collect premiums is if the claimant is already entitled to Medicare under an RRN or if the LAF code on the MBR is “E.” (See section DI 45001.324D.)

2. Determining if Medicare exists under an RRN

A Medicare record may be established if an RRB claimant is age 64 and 8 months old or in the 20th month of disability benefit entitlement.

Secure MBR and ESQ (entitlement systems query, i.e., health insurance record) printouts on the claimant’s own SSN or any other SSN’s involved, such as those indicated in the answer to item 9(c) of the HCFA-43. If the claimant supplies a Railroad Retirement Number secure an ESQ on the RRN.

Review the printouts to determine whether:

  1. Hospital Insurance Option Code (HOC) and/or Supplementary Medical Insurance Option Code (SOC) for the claimant is “P” on the MBR and LAF code indicates an allowance; or

  2. The ESQ on the RRN shows Medicare entitlement for the claimant; or

  3. The XCN field of the ESQ on the claimant’s SSN shows a cross reference to a Railroad Number (six or nine digit number preceded by one, two, or three alpha characters, e.g., WA xxxxxx; A xxxxxxxxx).

C. Award processing—Medicare record already established under RRN

If any of the conditions in DI 45001B.2. apply, the claimant already has a Medicare record. The following actions are required:

  1. Complete form SSA-892-U3.

  2. Determine which of the following situations exists and take the processing actions indicated:

    1. Beneficiary is Entitled to HI/SMI on MBR and HOC/SOC is “P,” LAF code is not “E.”

      Do not request a change in HOC and SOC.

      Do not prepare an SSA-101-U3.

      Check block 2.1. of Form SSA-3601 and complete the “Remarks” section with the following:

      Route to Benefit Authorizer for Processing.

      ESRD CLAIMANT.

      Change HENC and SENC to “K.”

      Enter HI eff.         and SMI eff.         (only if ESRD dates are more advantageous than dates on MBR).

      See SSA-5002 in file for notice information.

      Send SSA-3103 to “RRB.”

    2. Beneficiary is Entitled to HI/SMI on MBR and HOC/SOC is Not “P.” (ESQ shows beneficiary has Medicare under an RRN.)

      Do not prepare an SSA-101-U3. (Beneficiary is already on MBR.)

      Check block 2.1. of SSA-3601 and complete the “Remarks” section with the following:

      Route to Benefit Authorizer for Processing.”

      ESRD CLAIMANT.

      Change HENC and SENC to “K.”

      Change HOC and SOC to “P.”

      Enter HI eff.         and SMI eff.         (only if ESRD dates are more advantageous than dates on MBR).

      See SSA-5002 for notice information.

      Send SSA-3103 to “RRB.”

    3. No Record of Claimant on MBR (ESQ shows claimant has Medicare under an RRN.)

      Prepare an SSA-101-U3 on beneficiary’s own SSN with a BIC of “T.” Show SEC of “K.” In remarks, (item 11) show HOC and SOC of “P.”

      Check block 2.1. of SSA-3601 and complete the “Remarks” section with the following:

      Route to Benefit Authorizer for Processing.”

      See SSA-5002 in file for notice information.

      Send SSA-3103 to “RRB.”

  3. Notifying RRB (Medicare record already established under RRN)—in all cases in which a Medicare record has been established under an RRN, the benefit authorizer in ODO will complete Form SSA-3103 (SSA Certification of Title II Monthly Benefi