HI 00820.140 Reversing an Erroneous Termination
AUDIENCE: BA, BATA, ER, LCC, RECOVR, EHS, EIE, IES
Findings have indicated that some SMI terminations will be improper based on information in the claims folder which is not reflected in the master records. When this occurs, corrective action is required to restore the SMI coverage. This situation may occur in both insured and uninsured records.
These terminations can represent withdrawal from coverage, termination based on cessation of disability, termination based on cessation of renal disease eligibility, termination based on the equitable relief provisions, or termination for nonpayment of HI and/or SMI premiums.
When reinstating coverage for any reason, except nonpayment of premiums, a MADCAP debit will be needed for insured cases; and a MISCOR CIP R action will be needed for uninsured cases.
There are three methods of reversing or reinstating premium-HI or SMI coverage erroneously terminated for nonpayment of premiums. The use of each process depends on whether:
a BCM record already exists for the terminated record (which always will for all uninsured and premium-HI cases), and
any factors other than a simple reversal for nonpayment of premiums are involved, and
the claimant is insured or uninsured.
The three methods are REVTER, MADCAP, and MISCOR CIP R. (REVTER derives its name from the special batch code of that name and is not an actual program; it is a reversal of a termination entered via the PEPPER program.)
NOTE: The applicability of equitable relief must be considered in all reinstatement actions (see
This is the easiest and most efficient means of reversing a termination of premium-HI and/or SMI coverage caused by the nonpayment of premiums. This method cannot be used if:
the coverage was withdrawn, or
no BCM record exists, or
any type of third party payer (civil service, State, or private group) must be established, or
any other factors are being changed (i.e., DOES, DOEH, etc.).
If all that is necessary is to change the HOC/SOC from “T” to “Y,” remove the DOTH/DOTS, and resume either billing or deduction on any case already established on the BCM file, REVTER can be used for insured, uninsured, or special age 72 claims. A BCM record must already exist because this method is entered via the premium process to the SOBER system through PEPPER to the MBR. If no SOBER record exists, the premium amount entered would be refunded.
To accomplish a REVTER reinstatement, prepare a Form SSA-1592TC with the following special entries:
The amount entered must be sufficient to reduce the CPDA or CPDHA to less than 2 month's premiums.
This field must be left blank if an actual remittance is involved in a reversal of SMI only. If no actual remittance (trust funding is not required) is involved, the RIC must be “3” for SMI cases. The RIC must always be “F” for premium-HI reinstatements. Prepare a Form SSA-666 to adjust the trust funds, if necessary.
Enter a date that is at least 1 month earlier than the DOTH and/or DOTS.
Always enter “REVTER.”
NOTE: Two Forms SSA-1592TC must be used if both premium-HI and SMI are to be reinstated.
This method of reversal is accomplished under the following time frames. Please note that each “DAY” is a process day and any weekends or “dark” days will extend the actual calendar days involved. For example, if Day 1 is Friday, DAY 2 represents the following Monday. In addition, DAY 1 is the day the data entered on the SSA-1592TC is actually transmitted to Central Office; therefore, the process is also extended by the time it takes to get the form from the process module, onto tape, and into transmission.
The time frame for either premium-HI or SMI reinstatements is as follows:
DAY 1-Action transmitted to Central Office.
DAY 2-Action enters the SOBER system and effectuates the reversal on the BCM, except for an event history. The SOBER system sends a record to the health insurance master (HIM) record and to the PEPPER programs.
DAY 3-Action enters the HI system and the reinstatement is recorded on the HIM. The PEPPER program records the reinstatement on the MBR, prepares a history record to be returned via PESO, to the BCM.
DAY 4-Event history is recorded on the BCM. When reinstating both premium-HI and SMI, this schedule presumes that the Forms SSA-1592TC prepared to reverse both terminations are entered into the transmission to Central Office in the same run. The SMI reinstatement follows the same timing as when only HI or SMI is being reversed. The HI action is placed in orbit on DAY 2 because at this time the SMI still shows terminated and the HI cannot be present if SMI is terminated. The HI action reenters the system on DAY 3 and then updates on the BCM and follows a day behind the SMI reversal through PEPPER to the MBR and to the HIM.
Because of this scheduling, it is possible to receive an MBR on DAY 3 that does not show the reinstatement when the BCM having the same date shows active coverage. In addition, when both HI and SMI are being reversed on an uninsured record, the BCM record will show the SMI reversal on DAY 2, the HI reversal on DAY 3, but the LAF will not change from “X7” to “U” until the history record is returned from the MBR on DAY 4.
If the reinstatement is processed on an insured record and REVTER cannot be used because either new entitlement factors (i.e., new DOES, DOEH, etc.) or a third party payer must be established or any other action requiring a debit (address change, work notice, etc.) is also being processed, MADCAP must be used.
Enter in RID 6 whatever changed data is necessary. In all cases, the BIC, SOC, and DES must be entered to cause the reversal. Do not enter a pound sign ( ) in the DTS field when reversing a termination.
D. MISCOR CIP R
The Form SSA-2652-U2 must be prepared, if an uninsured claim is involved and you are also recording a third party payer of any kind.
E. Beneficiary Notification
Regardless of the method used to manually reverse the termination, the claimant must be informed of the reversal action. Send the general “check box” notice (see NL 00703.629) with the 3rd block checked to the individual.
This section contains the following exhibits:
Exhibit 1 - CMS-1763 (Request for Termination of Premium Hospital and/or Supplementary Medical Insurance) See HI 00820.901.
Exhibit 2 - CMS-L457 (Acknowledgement of Request for Medical Insurance Termination) See HI 00820.902.
Exhibit 3 - CMS-L458 (Acknowledgement of Request for Premium Hospital Insurance Termination) See HI 00820.903.
Exhibit 4 - Notice to R-HI Beneficiary about Termination Because of Transplant. See HI 00820.904.