HI 00630.050 Processing Forms CMS-1739 and CMS-40F
A. Description of CMS-1739
The CMS-1739 will be computer generated and will have the claim number and the last month of the initial enrollment period; i.e., April 1986, May 1986, etc., shown at the top of the card. A numeric code will indicate the month in which the card was prepared; i.e., “1” for January, “2” for February, etc.
Mailroom personnel will date stamp all forms received on the face; i.e., CMS-1739's and all types of CMS-40's. DO NOT STAPLE, PUNCH HOLES OR OTHERWISE MUTILATE THEM. Any correspondence received with the form should be sent to the module HI-SMI clerk, and should be attached to the form with a paper clip. If folders are needed, they will be requested by the HI-SMI clerk.
The prepunched forms CMS-40F received each month from OCRO will be kept in a holding file in the mailroom. The mailroom will screen the forms CMS-1739 against the CMS-40F holding file. Send the CMS-40F, SSA Publication No. 05-10014 and a return envelope to the beneficiary if: (1) a United States address is not shown, and, (2) the CMS-1739 contains no notations or is not accompanied by correspondence, other than a letter of transmittal. To ensure that the CMS-40F is not returned prior to the beginning of the beneficiary's initial enrollment period, do not mail it sooner than 5 days before the start of the enrollment period.
If a change of address is received with a Form CMS-1739, prepare a new CMS-40F to show the new address since addresses on computer-prepared CMS-40F's cannot be corrected. Send the CMS-1739 and any correspondence to the module so action can be taken to correct the address on the MBR. Destroy all unused computer-generated forms CMS-40F not removed from the holding file, in the month after the end of the initial enrollment period.
Since the CMS-1739 may serve as a protective filing it should be retained for 60 days after the last month of the enrollment period. If the CMS-40F is returned, both forms should be forwarded to the module HI-SMI clerk. The CMS-1739 should be destroyed if the CMS-40F is not returned and 60 days have passed beyond the end of the enrollment period.
C. Special handling required
|SITUATION||ACTION TO TAKE|
|CMS-1739 received and enrollment period has ended or no SSA-40F is located. (Absence of the SSA-40F is an indication that the enrollment period has ended for computer generated forms CMS-1739.)||For other than Mexican, Greek, Canadian, and Philippine addresses, write in red “CDB—enrollment period ended” on the CMS-1739, or other correspondence, and send it to the module for folder association and referral to CDB. CDB should send an informal disallowance on this type of case.|
| ||For Mexican, Greek, Canadian, and Philippine addresses, write in red “Module—enrollment period ended” on the SSA-1739, or other correspondence, and send it to the appropriate module. A claims authorizer should send an informal disallowance on this type of case.|
|The enrollment period has not ended but the CMS-1739 contains a notation or is accompanied by correspondence.||If the beneficiary definitely disclaims any interest in enrolling, destroy the SSA-40F and CMS-1739. If correspondence is received with the form, annotate the correspondence showing the action taken, and send correspondence to the module for any action necessary based on the correspondence.|
|The SSA-1739 shows a U.S. address.||Forward CMS-1739 to the appropriate module.|
| ||The modules will take the following action:|
| ||(1) Folder in DIO —If this is a COA—beneficiary returning to U.S.—photocopy material pertaining to SMI and send to the servicing DO under cover of form HEW-30 stating “Develop SMI enrollment. Send development to ( name ) PSC. Note CMS-1739 cannot be used to establish a filing date. Use as inquiry only.” Take N/A to transfer folder to PSC based on COA. Annotate correspondence that CMS-1739 sent to DO (name) for SMI enrollment contact.|
| ||However, if the individual states he definitely wishes to enroll, proce|