HI 00815.076 SSA DO/BO Action Upon Receipt of HI/MBR Status Query (HMQ) Reply
The replies will show the current status of both the MBR and Health Insurance Master (HIM) for the claim number queried. A comparison between the query replies received and the information on the State"s request form should enable the DO/BO representative to determine what the problem is, which record(s), (MBR, HIM, DO/BO or State Data) need correcting and what action to take to accomplish the corrections. Refer to SM 00706.020 and SM 00706.265 for explanations and samples of the HIM and MBR replies to the HMQ. If 70 days have not elapsed since forwarding of the claim for development, see Item 8 below.
B. DO/BO Action Based Upon HMQ Reply
1. MBR and HIM Identifying Information in Agreement with State Records
If the MBR and HIM name and age agree with State records, advise the State accordingly and tell the State to accrete the item under code 62.
2. MBR - NIF (Not in File); HIM -CODE 52 (NO RECORD)
If the MBR reply is NIF and the HIM reply is code 52 (i.e., no record), the case has not been processed by the program service center. Prepare an CMS-2178 (HIB/SMIB Entitlement Problem-PRIORITY) according to HI 00930.080. Check item 6 under “Reason for Referral.” Enter the following in the “Correction Needed” section: “Claim forwarded (date) . Neither MBR nor HIM established. Please locate and process.” Attach the MBR and HIM replies to the CMS-2178 and send the form and replies to the appropriate program service center. Wait for the reply from the program service center (HI 00930.080D). If the reply indicates action has been taken to establish the MBR and HIM, advise the State to accrete under code 62. If additional development is required, complete it and send the development to the reviewing office. Requery every 30 days until a good MBR and HIM are received, then advise the State to accrete under code 62.
3. MBR - Established; HI - CODE 52 (No Record)
If the MBR reply shows the individual is eligible for SMI and the HIM code is 52 (i.e., no record), the problem is either one of timing or an exception in the MBR/HIM exchange. Prepare an CMS-2178 according to HI 00930.080. Check item 6 under “Reason for Referral.” Enter the following in the “Correction Needed” section: “Establish HIM according to information on the MBR.” Attach the MBR and HIM replies to the CMS-2178 and send to CMS, OMB, OAS, DMOS, Transaction Branch, P.O. Box 17078, Baltimore, MD 21203. Requery every 30 days until a good MBR and HIM is received. Then advise the State to reaccrete under code 62.
4. Name Difference Between State Records and SSA Records
If the entitlement information on the MBR and HIM is in agreement but a name difference exists between State records and SSA records, determine which name is correct. If the SSA name is correct, ask the State to accrete under code 62 using the SSA name. If the State name is correct, secure a statement from the individual requesting name correction in SSA records.
Prepare an CMS-2178 according to HI 00930.080 as the transmittal. Check item under “Reason for Referral.” Enter the following in the “Correction Needed” section: “Correct name in SSA records according to the attached statement of the beneficiary.” Attach the statement and the MBR and HIM replies to the CMS-2178 and send them to the appropriate program service center. Requery every 30 days until the query replies reflect the correct name. Advise the State that its name was correct and to accrete under code 62.
5. HI Disposition Code 00 (i.e., Number QUWRIED is Inactive and is Cross-Referred to Another Number)
If the HIM reply is disposition code 00 (i.e., number queried is inactive and cross-referred to another claim number), wait for the subsequent HIM code 99 response with a trailer code K on the claim number queried. The trailer code K will normally be in the second line of the response and shows the active claim number. Entitlement date for the active claim number is shown on the first line of the response in the normal position. Compare the identifying information on this response with the State information and process as appropriate. The DO/BO should also correct its records.
6. Individual not Entitled to Medicare
If the MBR reply shows the individual is not yet 65 and is not entitled to Medicare based on SSA disability benefits or end stage renal disease, and the HIM reply response is code 52 (i.e., no record), advise the State it cannot accrete due to the age shown on SSA records, and that the State may wish to help the individual establish that he is older or disabled or has Medicare based on end-stage renal disease.
7. Disabled Individual not Yet Entitled to Medicare
If the MBR reply shows the individual is entitled to a disability benefit but has not been eligible to the benefit long enough to be entitled to HI/SMI, advise the State as to what date he is potentially eligible so that the State can annotate the record for future accretion purposes.
8. Claim Forwarded to PSC Less Then 70 Days Ago
If the DO/BO records show that the claim (or last development) was forwarded to the program service center within the last 70 days, do not send the HMQ. Advise the State to accrete under code 62 and give the date the claim was forwarded.