HI 00820.125 PEPPER Processing of Withdrawals
AUDIENCE: BA, BATA, ER, LCC, RECOVR, EHS, EIE, IES
The PEPPER program has the capability of processing SMI and premium-HI voluntary withdrawals. The program will update the MBR, adjust the benefit amount (when applicable), accomplish trust fund accounting, refund excess premiums (when applicable), notify related systems such as the health insurance system and SOBER, and generate the appropriate beneficiary notification.
A. Completed actions
The resultant computer output from a completed withdrawal action will be the Forms HCFA-L325/325A and HCFA-L326/326A for SMI and HCFA-2688/2688A for premium-HI. These forms are in two parts printed simultaneously by the computer when the action is processed. The Forms HCFA-L325, 326, and 2688 are the notices sent to the enrollee advising him of the action. The Form HCFA-L325 is used for all insured beneficiaries in current payment status who have terminated their SMI coverage. The Form HCFA-L326 is used for uninsured claimants and insured beneficiaries not in current pay status who have terminated their SMI coverage. The Form HCFA-2688 is used for all enrollees terminating their premium-HI coverage. The other half of these Forms (HCFA-325A, 326A, and 2688A) are used for folder documentation and contain the required debit information such as the computer run number, ABN, date of termination, etc. Only one form will be printed for combined payment (PIC O) cases. The Division of International Operations (DIO) will receive Forms HCFA-L327/327A and HCFA-L328/328A which are the equivalent of the domestic HCFA-L325 and 326 forms. The processing of a withdrawal action will cause the MBR and BCM option codes (SOC and EOC) to be changed to “W.”
Except for those forms designated for review, the Forms HCFA-L325A and HCFA-L326A (and matching source documents) will be prongfiled by the Records Analysis Clerk, who will also forward the Forms HCFA-L325 to the mailroom for release to the beneficiary.
B. Review of output
To help insure the continuing integrity of the PEPPER program, the Exception and Inquiries Examiner in all offices will review all of the processed forms HCFA 2688/2688A (premium-HI) output. The review will be performed as described below.
The Great Lakes and Mid-America Program Service Centers and ODO will be responsible for the validation of the Forms HCFA L325/325A and HCFA-L326/ 326A (SMI coverage) produced by the PEPPER program. This program will select a limited number of these cases for the Great Lakes and Mid-America Program Service Centers and ODO and annotate the output as “SAMPLE REVIEW CASE.”
The basic purpose of this review is the early detection of possible program errors such as incorrect termination dates, payment amounts, premiums, etc. All such errors should be brought to the immediate attention of the Director of Operations (ODO should notify the Operations Support Staff) who will notify, as soon as possible, Office of Claims and Payment Requirements, Division of RSDI Postentitlement Systems, Health Insurance, Correspondence, and Critical Case Branch by telephone or memorandum.
The output will reflect the following data:
The name and address of the claimant whose entitlement has been terminated will be shown.
The date of preparation will be shown.
The claimant's claim number will be shown.
Folder Location Indicator
The folder location indicator will be displayed on the folder documentation only.
Date Entitlement Ended
Forms HCFA-L325 and 326 will show the last day of the last month and year of coverage; e.g., January 31, 1977.
Form HCFA-2688 will show the month and year of the last month of coverage; e.g., December 1976.
Premium Amount Due (Forms SSA-L326 and 2688 only)
The amount of unpaid premiums through the last month of coverage will be shown.
The computer run (processing) date.
This is the month and year the action was recorded on the MBR.
The last debit action block number from the MBR.
The new ABN assigned by the PEPPER program as a result of this action. The number always has four digits.
Payment Discontinued (Date and Amount, HCFA-L325A Only)
For insured beneficiaries in current pay status, these entries will reflect the credit month (date) and the monthly benefit amount that was being paid.
CMA-THRU (Date and Amount, HCFA-L325A Only)
The month and the amount of the CMA check being paid for claims in current pay status.
Payment Change (Date, Old MBP HCFA-L326A Only)
For insured beneficiaries in nonpayment status, these entries reflect the update month and the adjusted monthly benefit payment amount prior to the withdrawal action. The appropriate BIC will be printed in front of the money amount.
The BIC of the claimant whose coverage has been terminated.
The current MBA will be shown for all insured cases. The block will be blank for uninsured cases.
For insured cases only, the MBP will be increased to the MBA amount.
Additional Processing Data
A remark will appear if the individual's premiums were paid beyond the last month of coverage and the program generated a refund (for SMI coverage) or a refund is due (for premium-HI coverage). The program will always pay a SMI refund in a separate check. The program will never generate a premium-HI refund.
NOTE: If a premium-HI refund is indicated as being due and the review verifies that the remark is correct, process a Special Indicator Card with an Action Indicator of “A”.
C. Exception and Alert Processing
Due to the timelag between the point of initial processing and the effective date of the withdrawal (2 to 6 months), there are two points in time when the systems may reject an item. The first is when the withdrawal is initially entered for annotation of the future termination date on the MBR. A non-processable item at this point will result in an “edit” exception rather than an annotation on the MBR. The second point is when the action is selected at maturity for the actual termination of coverage. If a Form HCFA-L325, 326, or 2688 cannot be generated at that time, a maturity (termination) exception will result.
Those pertaining to premium-HI and SMI withdrawals are as follows.
1. No master record (00)
If the wrong social security number was used on input, complete a Form SSA-1598 to reprocess with the correct number. If a review of the folder indicates the record should be on the MBR, reenter the SSA-1598. Annotate the input form “second attempt.” If the second attempt excepts again for this reason, bring the case to the attention of the Exceptions and Health Insurance Specialist. If the record should not have been on the MBR (for example, the prior update record was not through the PE system when the withdrawal was processed), prepare a credit/debit action to process the prior action and the withdrawal.
2. Invalid TOA (01)
The reason for this exception is an invalid type of action (TOA) code on the input. Prepare an SSA-1598 using the correct TOA.
3. No record of BIC (02)
This occurs either because of an incorrect BIC on input or because the BIC was not located on the MBR. If the former is true, prepare an SSA-1598 with the correct BIC. If the latter is the case and the folder indicates that the BIC should have been on the MBR, reenter the SSA-1598. Annotate the form “second attempt.” If the item rejects a second time, bring the case to the attention of the Exceptions and Health Insurance Specialist.
4. Intervening actions (14)
This occurs when some other action was in the system at the same time as the PEPPER action. Attempt to determine from the folder what kind of action was being processed. If it had no bearing on the PEPPER action, reenter the SSA-1598. If the intervening action did have a bearing on the HI/SMI annotation or withdrawal, take action on the withdrawal as dictated by the facts of the case.
5. Invalid MBR DATA (18)
This exception will occur when a withdrawal is processed for a disabled adult child and the MBR shows there are two or more children included in the same PIC. Process a credit/debit action at the proper time to record the withdrawal and place the disabled child in his or her own PIC. In some instances, this will require the preparation of a control diary when the effective date is in the future.
When a withdrawal action encounters a premium billing code of 006 or 800 on the MBR, the MBP plus the premium amount does not equal the MBA, and the MBP and MBA are not equal, process a credit/debit action at the proper time to record the withdrawal.
When PEPPER detects a nonnumeric date or money field in the input date when those fields are necessary for processing, prepare a new SSA-1598 or a credit /debit action in order to record the desired HI and/or SMI status.
6. Enrollment and withdrawal input on same CAN (28)
Use the dates of the source documents plus the MBR data shown on the informational form to determine which type of action is in order and process accordingly.
7. HI notified to correct option (31)
This informational is produced to verify that the input option and the MBR option are identical and that a record has been forwarded to the Health Insurance System to correct its recorded option, if necessary, and to insure a new health insurance card. The Records Analysis Clerk will prongfile the form.
8. Withdrawal-not in HIB status (35)
This exception is produced if the MBR for an uninsured individual contains an HOC other than “Y” and the input is a premium-HI withdrawal.
The Exceptions and Health Insurance Specialist will determine if the pertinent option code that should be reflected on the MBR is other than “Y” and take appropriate action.
If the proper HOC on the MBR is other than “Y,” forward the source document to the district office for a personal contact in order to clarify the request. No diary control need be maintained.
9. Withdrawal annotated (36)
This informational is produced for documentation purposes only. The Records Analysis Clerk will prongfile the form.
If the remark “Second Termination” appears on the form, the Records Analysis Clerk will staple it to the source document (a withdrawal notice) and give it to the typist for preparating of an HCFA-L351 (see NL 00703.000. Annotate the informational Form “HCFA-L351 sent.” Give the form and source document to the Records Analysis Clerk for filing and send the letter to the mailroom.
10. Withdrawal reversed (37)
This informational is produced whenever the request to reverse a prior withdrawal request is processed and the MBR is so annotated. The Records Analysis Clerk will prong file the form.
11. Withdrawal—master not located (38)
Reconcile as outlined in No Master Record (00) above.
12. BIC NIF (39)
If the BIC on the SSA-1598 coding sheet does not agree with the BIC on the informational form, resubmit the coding sheet with the next batch of Group II items being sent to the Data Preparation Section. If the BIC on the coding sheet does agree with the BIC shown on the informational form, determine the proper BIC from the folder.
13. Withdrawal—not in SMI status (40)
The exception form, source document and claims folder will be given to the Exceptions and Health Insurance Specialist who will determine if the option code that should be reflected on the MBR is other than “Y,” or its equivalent, or if the beneficiary is in advance filing status for SMI. After this determination, take the following action.
If the pertinent option code on the MBR is properly other than “Y” or its equivalent, return the source document to the district office for a personal contact in order to clarify the request. Return the folder to files.
if the proper SMI option code is “P,” forward the withdrawal request to RRB. Notify the claimant that the request has been forwarded to the RRB as that agency has jurisdiction concerning his or her medical insurance coverage.
If the SMI option code on the MBR is not proper (nonprocessed election located in file), the “yes” election must be processed in accordance with HI 00830.020 and the withdrawal processed 30 days later.
If the beneficiary is in advance filing status for SMI, prepare an SSA-1598 to cancel the initial election of SMI if the request is filed within the first 3 months of his or her enrollment period. An election filed in the GEP can be cancelled any time up to the month in which the SMI coverage becomes effective (i.e., the following July). Enter an option code of “R” on the SSA-1598.
14. Withdrawal—current state buy-in (41) (SMI only)
See HI 00820.130C.
15. Withdrawal—prior state buy-in (42) (SMI only)
This reject occurs as a result of the presence of a State buy-in indicator recorded on the MBR and a TTDS entry showing a deletion month within 3 months of the withdrawal filing date. Insured beneficiaries making such a request within this time period may withdraw their SMI coverage immediately upon the end of 3 months following the deletion month rather than the end of the quarter following the quarter in which the request was made. Prepare a credit /debit action to effect the earlier termination. (See HI 00820.130C.)
16. Withdrawal—duplicate notice (43)
This informational is produced whenever a request for withdrawal is received and the MBR already contains a withdrawal annotation. It will be prongfiled by the Records Analysis Clerk.
17. Reversal—nonproc after withdrawal updated (44)
This reject is produced whenever a reversal of a withdrawal request is entered too late to void the withdrawal action. Consequently, any valid reversal (i.e., one with a filing date prior to the withdrawal date) must be processed by a MADCAP or MISCOR CIP R action to reestablish coverage. Invalid reversals require a notice explaining why the request cannot be honored.
Treat a reversal request received after the withdrawal is effective as a GEP enrollment if the filing date is within a GEP. Prepare an SSA-1598 to process the reenrollment and send HI/SMI exhibit (NL 00703.000) to the beneficiary.
18. Withdrawal—nonnumeric or improper date in notice (45)
If the date of filing of the withdrawal is prior to April 2, 1968, for SMI, or January 1973 for premium-HI, or it is later than the computer run date into which the item was entered, this exception will be produced.
Process the withdrawal through MADCAP or MISCOR CIP R if the withdrawal filing date is prior to April 1968 or January 1973.
If the filing date, as shown on the source document and SSA-1598, is all numeric and is not later than the computer run in which the item was entered, reenter the coding sheet with the next batch of Group II items being sent to the Data Preparation Section.
19. Withdrawal—invalid MBR LAF (46)
This exception occurs whenever a request for withdrawal or reversal of a prior withdrawal annotation is received and the MBR LAF is “A-D,” “A-F,” “A-8,” “X-5,” “X-8,” “X-F,” “S-8,” “T-3,” or “T-5.” Examine the folder to determine the present status of the requested and take whatever action is necessary to resolve the exception situation. If the folder has been transferred to an office outside the program service center, forward the exception form and source document to that office.
20. Reversal—no prior withdrawal (47)
Examine the folder to ascertain if a withdrawal request is in the folder. If so, and the reversal was filed prior to the date the withdrawal would have been effective, NAN and file the reversal request in the folder and return it to files. For example, withdrawal filed on August 10, 1976, would have an effective SMI termination date of January 1, 1977. If the reversal is filed between August 10, 1976, and December 31, 1976, inclusive, there would be no change in the SMI status of the beneficiary.
If there is no indication of a withdrawal in file, return the reversal source document to the DO via form SSA-5075 to ascertain what the beneficiary is requesting.
21. Reversal—filing period expired (48)
If the date of filing of the reversal is within a GEP, the notice should be treated as a GEP enrollment. HI/SMI exhibit 6 (see NL 00703.606) should be sent to the beneficiary. If the date of filing is not within a GEP, HI/SMI exhibit 7 should be sent to the beneficiary.
22. “P” option in MBR (51)
23. Cessation—HI/SMI term (DATE) annotated (52)
Although these are not exceptions, they will be forwarded to the Health Insurance and Inquiries Examiner for corrective action when an HI/SMI termination action has been taken against the wrong record. Remove the HI/ SMI termination from the incorrect claim number via credit/debit and process the correct record via the PEPPER program. If the action taken on the wrong claim resulted in a change in the benefit check, notify the beneficiary of our error.
24. Cessation—HI/SMI term, not annotated (53)
This exception occurs if the BIC is not A, D, or E or if the HOC and SOC of record are not “E” and “Y,” respectively. If the BIC's are not valid, do not reprocess as the attempted action is not proper; i.e., the beneficiary cannot be a deemed DWB. If the HOC and SOC are not “E” and “Y,” the HI/ SMI is not in force and the attempted action is erroneous. If there is nothing in file to indicate that the BIC is not proper or the HOC and SOC are not correct, reenter the SSA-1598. Mark the form “second attempt.” If the action rejects again for the same reason, bring the case to the attention of the Exception and Health Insurance Specialist.
25. Cessation—HI/SMI term, nonprocessable (54)
This occurs when the HI/SMI termination was attempted against a record on which the LAF was “T.” This means that HI/SMI may already have been terminated as a result of benefit termination or that the HI/SMI termination was taken against the wrong record. The subsequent handling of this exception must be guided by what is evidence from the folder. That is, whether reprocessing is in order or the informational should be NAN'd.
26. Cessation—nonannotated—age 65(55)
This exception is generated when the date of termination of SMI on the input is equal to or later than the month in which the disability beneficiary attained or will attain age 65. In this case, the beneficiary should not have HI/SMI terminated as entitlement to HI/SMI should continue on the basis of age. The Records Analysis Clerk will dispose of the informational and input document.
27. Withdrawal over state (60) (SMI only)
This exception is produced whenever the withdrawal item has matured and the MBR billing code is 010 through 650, indicating State involvement or a withdrawal is processed and the decision code of G is not included on the SSA-1598. It will be prongfiled by the Records Analysis Clerk.
28. Not in SMIB status (61)
This informational occurs whenever the withdrawal item has matured and the MBR option code is not “Y” or “G.” The Records Analysis Clerk will prongfile the item.
If the legend “RR INV” appears on the form, the Records Analysis Clerk sends the form, source document, and claims folder to the Claims Authorizer with a covering Form SSA-559 annotated “Please determine if RRB has jurisdiction. Return to Exceptions and Inquiries Examiner.”
29. Questionable withdrawal (62)
This exception is produced when a pending withdrawal has matured but the termination date in the FWTD field on the MBR is either blank or contains nonnumeric data; or the date is more than 1 month after the current operating month. Examine the claims folder to determine whether a withdrawal is in order. If so, determine the proper month and prepare an SSA-1598 with the proper withdrawal date.
When the withdrawal action is for SMI only and the MBR indicates that entitlement to HI is on a premium paying basis, examine the source document to ascertain if the individual had requested withdrawal for both HI and SMI. If so, prepare a new SSA-1598 showing the proper data. If not, send the source document to the servicing district office with an SSA-5075 requesting development of the individual's intent, since withdrawal from SMI automatically terminates entitlement to premium-HI. Ask the DO to return the original source document if withdrawal is in order so that the original filing date can be used. Do not prepare a control diary.
30. Unacceptable LAF (63)
This exception is generated whenever the LAF is other than “C,” “S,” “D,” or “U,” or when another beneficiary on the record has a LAF other than that of the withdrawing claimant. A manual action is required to process the termination. (See HI 00820.130).
31. Pac is zero (66)
This exception is produced when the premium amount collectible (PAC) is recorded as “00” (zero). Since the premium is either unknown or nonexistent, an arrearage/overage (PDA amount) cannot be electronically derived. Examine the claim to ascertain the proper PAC and PDA (if entitlement exists) and process the withdrawal through MADCAP or MISCOR CIP R. If entitlement does not currently exist, send the claimant a notice to explain why the withdrawal request cannot be honored.
32. Sober intervening action (67)
This exception will be produced when a matured withdrawal is being processed and there is a simultaneous action being processed in the BCM. Enter the item via SSA-1598 in the next available run.
33. SOBER NIF (68)
This exception will occur when a matured withdrawal is being processed and there is no SOBER record, or there is no matching BIC in the SOBER record.
Compare the BIC to that in the claims folder to determine if the input record contained the correct information. Also, entitlement may have been transferred to another record (e.g., “B” to “A,” etc.) which was not properly annotated to the BCM. If it is determined that the withdrawal should be processed under a different BIC, or that entitlement has been transferred, prepare an SSA-1598 with the correct BIC and/or claim number and enter it in the next available run.
In some rare instances, the BIC and claim number on the input record will be correct, but there is no SOBER record. Determine from information in file, if possible the individual's premium status and process the withdrawal action through MADCAP or MISCOR CIP R. If the folder examination reveals that coverage has been terminated for nonpayment, no further action will be necessary
34. PDA arrearage (69)
This exception is produced when a withdrawal request is processed, the LAF is “C” and there is a current premium arrearage recorded on the BCM. Secure a BCM printout to determine the arrearage. In some instances, the arrearage recorded on the BCM may be in error. In most situations, however, due to the SOBER adjustment concept, it is possible to have a current arrearage when the beneficiary is in current payment status.
If it is determined that the arrearage is proper, process a MADCAP action to effect the withdrawal. MADCAP will automatically withhold any arrearage due through the last month of coverage. Record the appropriate HI/SMI coding on the Form SSA-2795-U3 to update the SOBER record. Send a notice to the beneficiary to explain the adjustment of premiums. If it is determined that the arrearage shown on the BCM printout is not valid, process a MADCAP action to effect the withdrawal and enter an “A” amount to offset the incorrect amount MADCAP will deduct based on the CPDA. Also, prepare an SSA-666 showing an amount equal to the “AA” to transfer that amount from the FSMI collection account to the FOASI trust fund.