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)
EXHIBIT 2 – 7376 (FRONT SIDE)
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
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;
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
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 TPS update cycles (at least 90 days) prior to further follow-up.
Request that the response be returned to the FO so you can notify THHSC. The correction
will not be reflected on the MBR because the MBR maintains the earliest buy-in date
and the current buy-in State; however, you can review the SMI Third Party Query (STPQ)
to check for the correction.
9. On some 7375s THHSC asks us to review the SSR for an SSI recipient and provide a manual Medicaid certification
for a specific time period. Why do they need this information, and why don’t they have it already?
This situation often occurs when SSI checks are not paid timely; e.g., an ALJ reversal
case. THHSC needs evidence of SSI eligibility to document its records for Buy-in purposes
when a prior manual Medicaid certification was not submitted. Follow instructions
in SI DAL01730.009 to have a member of the SSI staff complete the necessary certification. Be sure to
return the manual Medicaid certification to THHSC at the address shown on the 7375.
EXAMPLE 1 – SUGGESTED NOTICE LANGUAGE
We would like to talk with you about your eligibility for Medicare benefits.
Because you are an SSI recipient who is at least 65 years old or will soon attain
age 65, you may be eligible for medical insurance coverage under Medicare.
Medicare benefits are in addition to Medicaid benefits you already have and will work
with Medicaid to pay your medical expenses. Because you receive SSI and Medicaid,
the State of Texas will pay your Medicare premiums.
In addition to discussing Medicare, we will review your possible eligibility for Social
Please contact our office by (date) so we can help you file for these benefits. When you contact us, please have this
letter with you, and ask for (CR’s name). The telephone number is shown above.
If you plan to visit our office, you may call ahead to make an appointment. This will
help us serve you more quickly.