Upon receipt of the request, the FO will review the MBR, paying particular attention
to the potential SCC discrepancy. The FO will then take one of three actions:
If the SCC (of residence) and/or address are incorrect on the MBR, the FO employee
should correct the appropriate fields(s) on the MBR. The FO is not required to notify
the MA Plan of its corrective action. The MA Plan will monitor correction of the SCC
through CMS reports and will notify the CMS Regional Office if corrections have not
been made by SSA timely (within 30 days of receipt). The CMS Regional Office will
follow-up with SSA Regional Office on these cases.
NOTE: If the FO employee changes the address on the MBR, allow 2 days for the address
correction to pass to the HIQR.
You may identify some cases in which the mailing address (which was also the residence
address) on the MBR is correct but the system apparently derived an incorrect SCC.
Please notify the RSI Team of such cases, and we will ask Central Office to make any
necessary systems changes.
If the MBR and HIQR are correct (i.e., the SCC of residence and address on the MBR
and HIQR agree with the beneficiary's statement), no further action is necessary.
If the SCC on the HIQR is incorrect, the FO should forward the case to the following
Attn: Managed Care
Colorado State Bank Building
1600 Broadway, Suite 700
Denver, Colorado 80202
Upon receipt, the CMS Regional Office will review and correct its records.
NOTE: There will be few cases of this type. FO employees should not routinely mail all
SCC forms to the CMS RO.
ATTN: Health Insurance Coordinator
From: Medicare Advantage Plan
Name of MA Plan Contact: ________________________
Contact Phone Number: ________________________
SUBJECT: REQUEST FOR ADDRESS CORRECTIONS, MA PLAN INVOLVED—ACTION
CMS uses the State and County code from the MBR to verify that a MA Plan member lives
in a county in which a MA Plan is certified to operate; therefore, the State and County
code should always match the beneficiary's residence address. When a MA Plan enrolls
a beneficiary who resides outside its service area according to the State and County
code on the MBR, CMS questions the enrollment and requires the MA Plan to resolve
the residence address with the Social Security Office.
Please correct any erroneous information on the MBR with the verified information
attached for the Medicare beneficiaries. In many cases, only the State and County
code needs to be corrected on the MBR.
Address Verification Form
MEDICARE CLAIM NUMBER: __________________________
My MAILING ADDRESS is: __________________________
(where I receive my mail) __________________________
My Permanent RESIDENCE ADDRESS is: ________________________
(where I actually live) ________________________
Effective Date: _______________________
My COUNTY OF RESIDENCE is: _______________________
(the county in which I live)
My PHONE NUMBER is: _______________________
If the mailing address is different from the residence address, please indicate why
(for example, "I prefer to have my mail delivered to my daughter's mailbox which is
behind a security gate."):