TN 10 (01-24)

HI 00630.150 Inquiries Requesting Payment for Noncovered Hospital or Medical Services Furnished Outside the United States

After making photocopies for the folder, the modules (or whichever DIO component receives it on the freeze) will forward the inquiry and any bills or receipts by HEW-30 to:

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  Office of Direct Reimbursement

  Room 1705 Equitable Building

Make sure the claimant"s complete name and address are clearly shown on the material forwarded. Also, if any of the material to be forwarded is in a foreign language, have it translated before forwarding. Under “Remarks” on the OF-41 show the following:

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  “Attached is a claim received for (hospital and/or medical) expenses incurred in (country). Please send a copy of your reply to Division of International Operations, Attention: Mod No.    , and in remarks indicate "Please Drop File in Folder." ”

Annotate the file to show the action taken and answer any other questions raised by the claimant. If it is necessary to write to the claimant on some other issue, inform them that their claim has been referred to the Centers for Medicare & Medicaid Services for a formal decision.

Send only actual requests for payment to CMS. If the writer simply wants program information, the request should be answered in the modules.