HI 00815.091 State Agency and Parallel DO Processing of CMS-1957

A. State Agency Processing of CMS-1957

  1. The State takes the following action when it receives the CMS-1957:

    1. It completes Part III (Report of Buy-In Status by Welfare Department) of the CMS-1957 or reviews Part III for correctness if arrangements coordinated through the CMS and SSA regional offices call for Part III to be completed by the DO/BO from information it obtains from the local welfare office.

    2. It reviews the accuracy of the information in the Identification Block on the upper right-hand side of the form.

    3. It completes Part IV (Information from State"s Records or Actions Being Taken by State), on the CMS-1957 based upon information contained in the State"s records and the latest billing record received from CMS. NOTE: If the State has checked the block stating that it will submit an action to CMS in a future data exchange, it will diary the case to insure that the action is taken.

    4. It signs, dates and returns the completed form to the parallel DO.

  2. If the State receives an inquiry on an item which requires an adjustment of the accretion or deletion date, for example, the State may explain the problem in Part IV of the CMS-1957 and request a correction or adjustment.

B. Parallel DO Response to CMS-1957 Completed by the State Agency


If the completed CMS-1957 indicates that action has been initiated to resolve the problem or that there no longer is a problem, return both copies of the CMS-1957 to the servicing DO/BO.

Examples of this type of response are:

  1. Individual has never been eligible for State buy-in.

  2. State will submit a buy-in accretion or deletion action.

  3. Any response which verifies the correctness of the Third Party annotations on the MBR and the HI.


  1. If the State response to the problem identified on the CMS-1957 indicates that corrective action is required by CMS Central Office, forward the first copy of the CMS-1957 together with current MBR and HI printouts to the address contained in HI 00815.088.C.3.

  2. Annotate the second copy of the CMS-1957 with the data furnished by the State agency. Annotate the top of the form “Case referred to CMS Central Office on   (date)   .” Return the annotated copy of the CMS-1957 to the servicing DO/BO.

C. Examples of unresolved problems:

  1. Part B claim denied due to lack of Part B entitlement for same period in which CMS-1957 shows buy-in coverage.

  2. Part B premiums are being withheld from individual"s check or individual is in direct billing status and State alleges ongoing buy-in coverage.

  3. Complex case described in narrative portion of CMS-1957.

  4. Any other situation in which it is apparent that the master records are in conflict.

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HI 00815.091 - State Agency and Parallel DO Processing of CMS-1957 - 08/17/2005
Batch run: 01/27/2009