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:
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:
“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
him that his 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.