When a claimant has not paid SMI premiums by the end of the grace period, SMI coverage
When an individual alleges he or she made a timely payment and submits evidence (e.g.,
a cancelled check, a DO receipt, etc.) supporting the allegation, the termination
action must be reversed. However, it is imperative that the exception listings are
checked prior to reentering the premium data to avoid crediting the record with the
same premium payment twice. When there is no indication that an exception exists or
that the premium payment has been credited based on a previous inquiry or that a prior
action corrected the record, reenter the data based on the supporting evidence by
means of Form SSA-1592 (see HI
When an exception is found indicating the premium payment was not accepted for annotation
to the BCM, expedite the processing of the exception. Inform the claimant that the
termination notice was erroneous and that SMI coverage has been reinstated.
When an individual alleges he or she made a timely premium payment and does not submit
proof of payment with the allegation, check all available sources to ascertain if
a record exists of the remittance. When a record is found, reinstate SMI coverage
immediately by either reentering the data or resolving the exception, as applicable.
When no record of the remittance is found, request the DO by means of Form SSA-5075
to secure proof of payment. Keep in mind that due to the public relations problems
which can arise, the request for proof of payment should be made only after all records
and sources have been thoroughly checked and no record is found.
When an enrollee submits proof of a timely payment, reinstate SMI coverage in accordance
with HI 00820.135. The original postmark date must be shown. If the individual is insured or a special
age 72 claimant, a debit and credit should be processed in accordance with HI 00820.140 to reinstate SMI coverage due to the receipt of a timely remittance.
When the individual advises he or she cannot furnish proof of payment, direct the
claims folder to the Reconsideration Branch by means of a SSA-559 route slip. Advise
the Reconsideration Branch that since proof of payment cannot be verified, the case
is being forwarded for their determination. Include an explanation on the route slip
regarding attempts made to locate a payment.
If an enrollee does not allege payment of SMI premiums before the end of the grace period but nevertheless
feels that SMI coverage should be reinstated, direct the request to the DO requesting
development per HI 01001.300.
When a claimant protests the termination of SMI coverage and alleges an inability
to pay the premiums, send a copy of the protest to the DO via Form SSA-5075 requesting
the development of a premium payer per HI 01001.225.