HI DAL00815.073 Field Office (FO) Assistance to the Texas Health and Human Services Commission
See HI 00815.073
Since August 1983, Texas Health and Human Services Commission (THHSC) has directly contacted servicing FOs for assistance by using THHSC Forms 7375 and 7376.
THHSC primarily uses the form 7375 in the following situations:
The SDX lists an individual who is entitled to SSI and Medicaid and who is apparently eligible for buy-in of Part B but who does not have a Medicare claim number;
The Medicare carrier denied a claim with the explanation that the individual was not entitled to Part B coverage during the month(s) in which services were rendered. The physician or supplier subsequently filed a Medicaid claim with the National Health Insurance Company (NHIC), but NHIC cannot pay the claim because the Medicaid eligibility file indicates that the individual was entitled to Part B and that the State was paying the premium under its buy-in agreement for the month(s) in question.
Form 7376 is used in the following situation:
THHSC will send a letter to the FOs when SSA has deleted an individual’s buy-in coverage as a result of death information reported through the SSA system, but the State’s records show the person is still alive or show a date of death that differs from the date of death on SSA records. The FOs will verify the correct date of death, enter that date of the letter, and return to TDHS.
The THHSC Forms 7375/7376 are designed with check blocks and fill-ins so the FO can reply to THHSC on the form itself. If an interim reply is necessary (e.g., the FO is treating the 7375 as a lead for a Part B application), the FO should photocopy the Form 7375/7376, annotate the status information on the photocopy, and send it to THHSC in Austin. The FO should send a final reply to THHSC once action has been completed.
If a FO does not reply to THHSC within 60 days of the initial request, or if the FO provides a reply which is unresponsive to the needs identified in the request, THHSC will issue a follow-up in writing. If a reply is not received within 60 days after the written follow-up is issued, THHSC will contact the servicing FO by telephone. After 14 days, if additional follow-up is required, THHSC will contact the Area Director for assistance. The Area Director staff will establish a control and assume the responsibility to ensure that THHSC receives a definite reply.
The information on the revised THHSC Form 7375 appears on Exhibit 1. Exhibit 2 includes the revised THHSC Form 7376 and Exhibit 3 covers frequently asked questions and answers from the 7375/7376 process.
Exhibit 1 – 7375 (FRONT SIDE)
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EXHIBIT 2 – 7376 (FRONT SIDE)
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EXHIBIT 3 – FIELD OFFICE PROCESSING OF TDHS FORMS 7375/7376
1. What can our office do to prevent receipt of so many 7375s?
While all FO and Teleservice Center (TSC) employees must be alert to the need to establish Part B entitlement for claimants when appropriate, Title II employees have the primary responsibility for the HI/SMI entitlement workload. Service Representatives (SRs) and Teleservice Representatives (TSRs) should be alert to claimants who might be eligible for Part B, and Title II Claims Representatives (CRs) must process Medicare Attainment and Lead (HI 00810.010) cases in a timely manner.
In addition, Title XVI CRs play a particularly important role in the State buy-in process. We recommend that managers remind Title XVI CRs that Part B entitlement should be established for all SSI aged applicants in conjunction with their SSI aged applications. In addition, during redeterminations (and other SSI Postentitlement [PE] activities), SSI CRs should:
Refer disabled SSI-only recipients within 4 months of age 65 to Title II CRs for Part B applications; and/or
Advise disabled SSI-only recipients who are not within 4 months of age 65 to file for Part B shortly before age 65.
Following these procedures not only provides the best service to the customer, but an SSI initial claim or redetermination also presents the best opportunity to ensure the recipient’s cooperation and avoid receiving a 7375.
2. Can we provide information to THHSC without the beneficiary’s consent?
Yes, this is allowed as a routine disclosure to a State and local income and health maintenance program. The information allows the State to pursue enrollment for individuals under section 1843 of the Social Security Act.
3. How should the FO respond to THHSC?
FOs can reply to some requests immediately by furnishing Part B entitlement information on the reverse of the Form 7375/7376 and returning it to THHSC or attaching a TPQY which provides the necessary information. Employees should enter their name, position, phone number and extension on the back of the form. Please ensure your name is legible. However, some requests take longer to process (e.g., lead for a Part B application), and the FO should always send an interim reply on a photocopy of the 7375/7376. When the Part B or ESRD application is adjudicated, the FO should send a final reply.
In some cases, the FO employee may find it helpful to call the THHSC worker to discuss the request.
A general response such as “This individual is not eligible for Medicare” is never appropriate. The FO employee should either verify the Part B or ESRD entitlement or provide specific information on why the claim was disallowed and consider whether the individual should now file a new Part B or ESRD application (e.g., the individual was previously denied for not meeting the requirement for 5 years’ continuous residency, and the individual now meets that requirement).
NOTE: Prior to sending a TPQY as a response, the FO employee must review the TPQY to ensure that it will provide an appropriate answer. For example, if the MBR shows an “026” denial for an individual who is eligible for but not yet entitled to Medicare, the FO employee could send a TPQY as an interim response but should annotate the 7375 or the TPQY to show that the FO is treating the 7375 as a lead for a Part B application.
4. THHSC sent us a 7375/7376 regarding an individual who no longer lives in our service area. What is the proper action?
If the FO is unable to verify Part B entitlement, the 7375/7376 should be treated as a Part B application lead for the time period the individual lived in the State of Texas, even if the individual now lives outside the State or outside the U.S.:
If the individual now lives in another FO’s service area, forward the 7375/7376 to that FO as a lead for a Medicare claim but send an interim reply on a photocopy to THHSC to provide the individual’s new address and the address of the new servicing FO. Ask the servicing FO to notify your FO when entitlement is established and if there is any earlier Part B entitlement months while in Texas as shown in item 8 below; or
If the individual now lives outside the U.S. and the FO is unable to locate the individual and/or the individual does not cooperate, process the 7375/7376 following the instructions for an individual who fails to cooperate (see item 5). (See HI 00815.045 and HI 00815.048)
5. Should an FO take any special action on 7375s/7376s which are leads for Part B and ESRD applications?
Informal studies have shown that over 60 percent of 7375s/7376s are application leads. While control of application leads is essential (see HI 00815.073B), the method of control is a local management decision. Some FOs establish an appointment on the Leads/Protective Filing System; others set up an MDW.
To prevent a THHSC follow-up on a lead, send THHSC an interim reply including a reasonable expected “Final Reply” date. Be sure to provide a final reply once the action has been completed.
6. How can an FO establish Part B entitlement for an SSI recipient who will not cooperate?
HI 00815.048 provides instructions on how to handle this very common situation. It seems that many SSI recipients see no reason to apply for Part B because their medical needs are already covered by Medicaid. It may help to send a notice explaining the importance of filing for Part B (establishing HI and SMI to coordinate with Medicaid to provide health care coverage) and providing the opportunity to again review the individual’s potential eligibility for SSA monthly benefits. NOTE: This notice should not include language about suspending SSI payments if the individual fails to apply for Part B; SSI’s “filing for other benefits” requirement does not apply to Part B because it does not result in an “additional benefit which could affect the individual’s SSI eligibility or payment amount (SI 00510.001C.1.)” See Example 1 for a sample notice.
If the individual fails to contact the FO, the CR can complete the Part B application on the SSI recipient’s behalf, sign it “DO PROCESSED PER HI 00815.048,” and process it to an award or disallowance based on evidence of age, citizenship, and residency readily available in SSA’s records (i.e., the FO is not required to obtain an SSI folder outside the FO to search for such evidence). If SSA does not have all necessary evidence, the State must submit the evidence as shown in HI 00815.045A and HI 00815.045C. If the State cannot or does not furnish necessary evidence, the FO should disallow the Part B claim. (The Dallas Regional Office, RSI Staff, has established a precedent with THHSC, Austin showing that Texas Medicaid offices do not maintain such evidence for SSI recipients.)
We recommend that the FO notify THHSC of the disallowance by attaching a TPQY to the THHSC Form 7375 and annotating it to show what evidence was necessary. If the State later furnishes the evidence, the FO can reopen the application.
For instructions about processing a Part B claim for a non-SSI recipient (e.g., a recipient of Temporary Assistance to Needy Families [TANF]) who fails to cooperate, see HI 00815.045.)
7. How can the FO establish Part B entitlement for a deceased individual?
HI 00815.051 provides instructions on how to handle this situation. Again, the State is required to submit necessary evidence (including proof of death). Basic processing is similar to that in question 6 for an SSI recipient who fails to cooperate.
8. We processed a Part B claim for an SSI recipient and have now received another 7375 asking us to approve an earlier Date of Entitlement to SMI (DOES). What do we do?
Sometimes when coding the buy-in data on the HICL screen, the CR fails to code the earliest DOES possible because on the most recent SSI record was reviewed or an earlier buy-in based on TANF eligibility was not considered. For example, the CR reviewed SSI Record 2, but SSI Record 1 was T30-ed after the recipient became age 65 and prior months of SSI eligibility are shown on SSI Record 1.
To provide an earlier DOES, follow instructions located in the Entitlement Problems section of the Field Office Teleservice Center Program Service Center Medicare Trouble Shooting Desk Guide which the San Francisco region maintains on its website and is located at:
http://sfnet.sf.ssa.gov/wnpsc/attach/GuideforResolvingMedicareProblems.htm or accessed through the T2 or SR Resource Kit. The FO will send a CMS-1957 to the Centers for Medicare and Medicaid Services (CMS) Central Office (CO) to request correction of the Third Party System (TPS) record. Provide an interim reply to THHSC advising them to allow three