Effective Dates: 10/13/2023 - Present Previous | Next

TN 4 (10-23)

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.

B. Mailroom

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 they definitely wish to enroll, process the enrollment request per HI 00630.130 and annotate the correspondence “SMI enrollment processed (date).” Transfer folder to PSC as above.
​ (2) Folder Transferred —If the enrollment period has not ended, send the SMI material to DO as above. If enrollment period has ended, send material to PSC under cover of Form SSA-1597 (Out-of-Area Route Slip). In remarks indicate “CMS-1739 is an inquiry regarding SMI. It cannot be used to establish a filing date. Appears enrollment period has ended.” However, if correspondence is a definite request for enrollment, send to HI branch in the PSC for processing.

 

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HI 00630.050 - Processing Forms CMS-1739 and CMS-40F - 10/13/2023
Batch run: 10/13/2023
Rev:10/13/2023