HI 00815.070 State/Carrier/Intermediary/CMS/SSA Coordination on Problem Cases Involving HI Query Codes 42, 44, or 56
When querying the Health Insurance System for Medicare status on a Part B claim, an intermediary or carrier may encounter a situation in which the HI system replies with a disposition code 42, 44 or 56. The codes are explained in the following paragraphs.
B. Code 42/Code 44
The code 42 states that the individual does not have Part B coverage. The code 44 states that the individual once had Part B coverage but the coverage has terminated. If the intermediary or carrier has reason to believe that the individual has welfare involvement (Medicaid), Part B coverage can be established through the State buy-in process. Use of the procedure is optional with the State agency and the intermediary or carrier. (See HI 00815.070E below).
C. Code 56
The code 56 states that the individual resides in an auto-accrete State, is eligible for SSI benefits, and the Social Security Administration will initiate development of a claim for Medicare benefits. The intermediary or carrier will diary the case and requery in 60 days. If the intermediary or carrier receives a second code 56, it refers the query to the SSA DO/BO on the form HCFA-1980, Carrier or Intermediary Request for SSA Assistance. The form will be annotated “Second Code 56 After 60 Day Diary.” (See D below).
D. SSA DO/BO Involvement - Claim for Part B Benefits Denied
A welfare recipient whose claim for Part B medical expenses has been denied, may contact the DO/BO for assistance. If appropriate, the DO/BO may treat the inquiry as a lead for an SMI application or it may need to investigate a buy-in problem case as described in HI 00815.079. HI 00810.010 describes the procedure the DO/BO should follow to obtain an application for SMI if the individual resides in an auto-accrete State. This process is referred to as HIMEXC, Attainments, and Leads.
E. CMS RO Involvement
Frequently, local procedures have been established under the direction of the CMS RO to assist the State and the intermediary or carrier in establishing the individual"s Part B entitlement. The CMS RO will assist in coordinating procedures if its assistance is required. The details of implementation are worked out on the local level.