HI 00825.015 Premium Inquiries
It should be kept in mind that any delay in processing a complaint regarding premium payments may result in subsequent complaints thus creating duplicate handling of the claim. Therefore, it is imperative that the question raised be resolved as quickly as possible and where necessary the complainant notified of the action(s) being taken at the earliest possible time.
NOTE: Premium inquiries will be received directly from the enrollee or from the DO. When a premium problem is submitted by the DO, it must be on an overprinted SSA-5002 (Report of Contact). The overprinted SSA-5002 lists the various types of premium problems. The DO should include the BCM query and any proofs with the overprinted SSA-5002. When applicable, the “Reply Requested” block is checked. In replying to the DO inquiry, use the remarks portion and the reverse side of the SSA-5002. No folder documentation is required.
Due to the interrelationship of the SOBER operations and the various other operations performed in both program service centers and Central Office, all of which could involve the same record, it is possible for the problem causing the correspondence or the SSA-5002 to be corrected before the correspondence is received. However, it can never be assumed that the record has been fully corrected. Based on the nature of the complaint, an examination must be made of all available sources such as the BCM, MBR, unidentified remittance files in the Premium and Recovery Cash Collection Section, premium remittance microfilm, etc., to ensure that both the cause and result of the error, if one exists, has been corrected and the enrollee properly informed.
NOTE: Due to public relations considerations, proof of payment will be requested only after all other means of verifications have failed. A copy, including a photocopy, of receipt Form SSA-1395-BK is acceptable as proof of payment. If such evidence (SSA-1395-BK) is submitted for a payment not recorded on the BCM, enter a Form SSA-1592 immediately to credit the record with the amount shown on the receipt. If no PSC record of the Form SSA-1395-BK can be located, give the case to the Exceptions and Health Insurance Specialist who will contact the DO where the receipt was prepared to ascertain the facts of the matter and attempt to locate the apparently missing remittance.
The examples of complaint correspondence provided herein are not intended to be all inclusive. They are probably the most common of the types of complaints that will be received and are used to provide guidelines for processing the infinite variety of queries that will be received. In the following examples concerning an allegation of a payment having been remitted but not recorded, the search for the remittance should also include the film of unidentified remittances and those designated as recovery of overpayment remittances. If the remittance is located that has been identified as an overpayment recovery, a Form SSA-666 must be prepared to transfer the money amount from the FOASI trust fund to the FSMI collection account (see HI 01015.001 ff).
A. Allegation of Prior Premium Payment—Premium Notice Received
An enrollee may submit a statement that he or she has received a premium billing notice for months that have already been paid. This generally occurs when the payment was processed late in the operating month and was not recorded on the BCM in time to prevent the subsequent billing notice.
Obtain a BCM printout. If the payment in question was processed after the billing cutoff date and the CPDA is correct, no further action is necessary.
If the BCM shows an exception was made on the premium in question and no reentry has been attempted, obtain the exception informational and process it in accordance with SM 00711.000.
If no record of the remittance is found on the BCM, search all other sources of information (i.e., premium microfilm. SSA-1395-BK in file, unidentified remittance files, etc.). If evidence of the remittance is found on the premium microfilm or SSA-1395-BK, note the processing date. Give the information to the PRCCS Supervisor. The PRCCS will compare the RASIN and SMIRK totals for the processing date noted and for the subsequent 2 days to ascertain why transmission did not take place. The PRCCS will transmit the original premium card. If the payment is located in the unidentified remittance file, prepare a Form SSA-1592 to record the payment (using a RIC “3” to avoid duplicate trust fund deposits) and prepare a Form SSA-666 to transfer the money amount from the FOASI trust fund to the FSM collection account.
If no record of the remittance is located, request the DO (by Form SSA-5075) to request proof of payment and to inform the enrollee that if acceptable evidence of the payment is not furnished, we will be unable to credit the record. (SEE the NOTE above for the required followup action when the district office submits a photocopy of the Form SSA-1395-BK.)
B. Allegation of Premium Payment When Claim Filed—First Bill Did Not Reflect Payment
Although a premium payment is not solicited nor encouraged at the time a claim is filed, if it is offered, it is not refused. Under these circumstances, the payment is processed by the Premium and Recovery Cash Collection Section with a RIC “2” on a form SSA-1592. These as well as all other premium remittances received through a DO will be accompanied by a Form SSA-1395-BK (Receipt and Transmittal). The Premium and Recovery Cash Collection Section will retain a copy of this receipt for 6 months.
If a complaint that a remittance paid at the time of filing the claim is not reflected in the first billing notice, follow the steps in A. above. Particular attention should be given to the procedures regarding the use of RIC “2” and SSA-1395-BK, keeping in mind that a Form SSA-1395-BK or a photocopy of the DO copy of this form is acceptable as proof of payment.
C. Allegation of Premium Payment and Premium Deducted From First Check When Benefits are Reinstated
In most instances when a claimant has submitted a premium remittance and is subsequently placed in current payment status, the computer will automatically prepare a refund and a notice to the claimant within 3 months after benefits are reinstated. No further action is necessary when the computer-generated informational form is in the folder.
When the informational form cannot be located, ascertain if an exception has been generated since the computer, of course, cannot process a refund on an excepted item. Measures must be taken immediately in line with this manual to reintroduce the exception into the system.
There will be instances when an explanation to the beneficiary should be included in the reply. The following example illustrates such a situation:
A claimant is placed into conditional payment status on an initial award action effective 4/76 pending on a proper payee. He or she had submitted a $21.60 remittance in advance for the April-June quarter. On July 1, the Administration determines the correct payee. No additional remittance has been received. A reinstatement action is processed and $14.40 is withheld from the July check for July and August SMI premiums. Subsequently, the claimant"s payee protests indicating that since $21.60 was submitted, only $7.20 instead of $14.40 should have been withheld from the first check.
In the above example, the prior reinstatement action and the $14.40 deduction was correct. Send a short explanation to the payee advising that the $14.40 deduction was for July and August premiums and in the future only $7.20 will be withheld each month.
D. Allegation that Amount of SMI Premium Bill is Incorrect
An incorrect bill may be released to a claimant under certain circumstances. The most common instance occurs if there has been an exception. Due to the exception (either a debit exception or a premium exception), the amount of the premium was not annotated on the BCM and consequently a bill was released without taking the premium remittance into consideration. Examine all available exception information and immediately take action to reenter the excepted item into the system.
An incorrect bill can also be generated if the last post-entitlement action is incorrect even though an exception did not occur. In all cases, furnish an explanation to the claimant indicating that action is being taken to properly credit the record.
When an individual fails to submit the premium billing notice when paying the SMI premiums and indicates an incorrect claim number on the remittance, the payment data will usually result in a “CAN NIF” exception (see HIIM 760.05.A). However, occasionally, the erroneous number may involve another SMI enrollee in which case the payment will be credited to an incorrect record. After it is determined that an exception does not exist, check the premium microfilm to ascertain if an incorrect number was indicated on the remittance document. In these instances, immediately request a BCM for the correct record and the folder and BCM for the number shown on the premium microfilm. Unless there is evidence in either the folders or BCM informationals indicating a correction has been made, prepare Form SSA-1592 with a RIC “1” for the incorrect number and another SSA-1592 with a RIC “3” for the record which should have been credited. In effect, the two Forms SSA-1592 will adjust both records. Furnish an explanation to both claimants to explain the action and to avoid correspondence at a later date questioning the amount of a premium bill.
When examination of both the BCM informationals and the folders reveals one of the claims has been corrected, prepare Form SSA-1592 with RIC “1” or “3”, as applicable, for the record which has not been corrected. If both records have recently been corrected, no further action is necessary other than replying to the claimant.
There will be other instances in which the claimant will question the amount of a bill which is correct. After verifying that the bill is correct, furnish the claimant with a short explanation of the months covered by the bill. Indicate that the bill is correct and advise the claimant to forward the remittance immediately if he or she has not already done so.
E. Request for Monthly Billing
We will honor a request from an uninsured (including special age 72) claimant for monthly billing of his or her premium payment. To establish a monthly billing cycle, prepare Form SSA-1592 with a RIC “5”.
It should be kept in mind that an individual in arrears under the quarterly system at the time a monthly billing arrangement is requested will be billed for all premiums due. Obviously, this amount will be more than the regular monthly premium in arrearage situations. A claimant may question the amount of the bill after requesting monthly billing when the next bill is in excess of 1 month"s premium. Reply to the claimant indicating that the monthly bill will be in the monthly amount after the arrearage is paid.
Insured beneficiaries in suspense status are billed on a quarterly cycle. A request for monthly billing from insured individuals will not be honored. Advise the beneficiaries that we are unable to bill them monthly and that they are required to submit premium payments on a quarterly basis.
F. Request for Quarterly Billing
An uninsured individual (including special age 72) who was previously converted to a monthly billing cycle either automatically or upon request may indicate he or she wants to be billed quarterly. Upon receipt of a specific request, reestablish a quarterly billing cycle by preparing a Form SSA-1592 with a RIC “6”.
An individual in arrears under the monthly system at the time a quarterly billing arrangement is requested will be billed for all premiums due. An enrollee may question the amount of a bill which is in excess of the regular quarterly billing amount.
Reply to the claimant indicating the months included in the bill and advising that the quarterly bill will be in the regular quarterly billing amount after the arrearage is paid.
G. Request for Change in Quarterly Billing Cycle by Uninsured Enrollee
Situations may arise when an uninsured (including special age 72) claimant receiving bills on a quarterly basis (either calendar quarter or noncalendar quarter) wishes a change in billing cycle. Upon receipt of a specific request, establish a new quarterly billing cycle by preparing a Form SSA-1592 showing the appropriate RIC “A,” “B,” or “C” as indicated below.
|RIC||Quarterly Cycle Established|
|A||Bill sent in January, April, July, October.|
|B||Bill sent in February, May August, November.|
|C||Bill sent in March, June, September, December.|
The SOBER system will react to the type of RIC furnished by changing the billing cycle code (BCC) on the BCM record and will begin sending bills out in the months specified above. However, a claimant in arrears under the old billing cycle at the time the new cycle is initiated may be billed for all premiums due. In turn, the claimant may question the amount of the first change-in-cycle bill which is in excess of the regular quarterly billing amount.
Reply to the claimant indicating the months included in the bill and advising that the quarterly bill will be in the regular quarterly billing amount when the arrearage is paid.
H. Protest of SMI Termination
When a claimant has not paid SMI premiums by the end of the grace period, SMI coverage is terminated.
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 00820.140).
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.
I. Request for Immediate Refund of Excess Premium Payments or Deductions
We will honor a request for an immediate refund of excess premium payments or deductions for any enrollee on his or her own behalf or from a representative payee as shown on the SOBER record. When such a request is received and the BCM reflects an overpaid CPDA, prepare a SIC card. No reply is required to the correspondence unless the BCM does not reflect an overpaid CPDA.
If there is an overpaid CPDA and the request for refund of premiums is made by someone other than the enrollee or represntative payee, forward the case to the Claims Authorizer for a determination on whether payment should be made. Request the Claims Authorizer to forward the case to the Benefit Authorizer if refund is appropriate.
J. Allegation of Nonreceipt of SMI Premium Billing Notice
There will be instances when correspondence will be received alleging nonreceipt of a SMI premium billing notice. Determine if a notice should or should not have been sent. This can be done by securing a BCM printout for the record (and the claims folder for insured and special age 72 beneficiaries).
There are several reasons why a billing notice will not be issued: e.g., a pending third party buy-in (SAC 2 set on). If it is determined that a billing notice was issued after the correspondence was written or will be released within a few days, take no further action unless the nature of the correspondence requires a reply.
If it is determined that a billing notice is not in order or is not scheduled for release within the next few days, notify the correspondent accordingly. If a billing notice should have been sent but was not, prepare a bill manually via Form CMS-500, Notice of Medicare Premium Payment Due. The coverage period and amount to be shown for an uninsured individual (including a special age 72 claimant) must include all premiums due through the 3rd month following the month in which the billing notice is prepared. The coverage period and amount to be shown for an insured individual must include all premiums due through the current calendar quarter.
In those cases where a billing notice should have been sent automatically but was not, correct the problem which caused nonbilling.
Occasionally, a billing notice that was mailed will be returned and handled under the “Undeliverable SMI Premium Notices” procedures (see HI 00825.070). If a correct address is available from the correspondence, have a premium billing notice prepared as indicated above and take action to have the correct address applied to the MBR and BCM if it has not already been done.
K. Premium Remittance Correspondence Involving Transferred Claims
Correspondence pertaining to a claim which is currently being serviced by another PSC or by the Division of International Operations (DIO) should be forwarded to the appropriate processing center. However, care must be taken to furnish the other office with the pertinent information required to reply to the correspondence and/or take corrective action; all available sources of premium information must be examined prior to forwarding the correspondence. For example, if the cause for the complaint arose from a SOBER exception, reenter the exception or forward the exception to the servicing PSC and provide enough information for the servicing PSC to reprocess the premium remittance data. Advise the servicing PSC of the action taken to resolve the complaint or inform that office that no information was found regarding the record. In the latter situation, advise the servicing PSC of the specific attempts made to locate the source of the complaint.
L. Health Insurance Card Inquiries
Generally, an award of HI and/or SMI or a change in pertinent data (change of birth date, etc.) will trigger the release of a new health insurance card. Occasionally, difficulties arise and a claimant will inquire regarding the nonreceipt or loss of health insurance card or the receipt of an incorrect health insurance card. The steps to be followed for each type of health insurance card inquiry are reflected below.
1. Loss or Nonreceipt of Health Insurance Card Allegations
If loss or nonreceipt of health insurance card correspondence is received directly from a claimant, obtain a SSADARS MBR (see SM 00500.000). If unavailable, secure the claims folder. Where HI/SMI entitlement exists and no impediment to the issuance of a health insurance card is evident (see list of impediments below), prepare a Form SSA-2467 (Request For HI/MBR/SSR Information or HI Card) per SM 00706.035. SSADARS should be used to transmit the data on Form SSA-2467 for the Medicare card replacement.
If an impediment exists, either forward the claims folder to the Benefit Authorizer requesting necessary action or take appropriate MISCOR action per SM 00613.000. However, if corrective action for the MBR is required and if CMS has not previously handled the correspondence, photocopy the incoming correspondence and prepare a memorandum to CMS Transaction Processing Branch, requesting the same corrective action for the HIM and issuance of a new card.
The following list of impediments will not permit the issuance of a health insurance card and require that additional update actions be made on both the MBR and HIM.
An MBR LAF status of “T-O.” This LAF code indicates RRB jurisdiction and any correspondence must be processed in accordance with section HI 00825.020D.
An MBR LAF of “T-3,” “T-5,” or “X-5.” These LAF codes indicate that the enrollee is entitled under a different claim number. The award on the other claim number must be processed with the appropriate cross-reference date to remove the impediment.
An MBR LAF of “T-R.” This LAF code indicates the claim has been withdrawn and no entitlement exists.
An MBR LAF “T-1” or “X-1.” These codes indicate termination for death and only a reversal of the termination (reinstatement) can remove the impediment.
An MBR LAF “S-J,” “S-K,” or “S-L.” These codes are reflected in certain foreign residency cases and can only be removed based on a Claims or Benefit Authorizer"s determination.
The lack of proof of date of birth indicator for former HA"s, B2"s, C"s, and E"s prohibits the issuance of a health insurance card. The addition of the “P” (proof) indicator to the MBR and HIM date of birth field removes the impediment.
The lack of a correct (or the recording of an incorrect) dual-entitlement indicator prohibits the issuance of a health insurance card.
The SMI option code of “P” (RRB jurisdiction) will not allow the issuance of a card. Correspondence related to this code should be processed as in HI 00825.020D.
If no record of HI/SMI entitlement as alleged by the claimant is recorded in the claims folder or the MBR and the claimant has indicated that he or she filed for coverage during the initial mass enrollment period or one of the annual GEP’s follow the instructions to determine if a record of enrollment is housed in CMS. If the reply from CMS is negative or the claimant did not specify that the election took place during one of the enrollment periods cited above, forward all material and the claims folder to the Claims Authorizer for necessary development through the DO. If the reply from CMS indicates a record of enrollment was located, prepare an SSA-2467 to record the enrollment.
2. Incorrect Health Insurance Card Allegations
Allegations of incorrect health insurance card data must be verified against the folder and an MBR printout. Thereafter, based on the problems encountered, follow the same procedures outlined for processing Forms HCFA-2178 in HI 00825.095 District office notification is not required but CMS notification is required if corrective action is being initiated and if CMS has not previously handled the correspondence. To inform CMS of the corrective action, prepare a Form 41, Routing and Transmittal Slip to: Transaction Processing Branch
P.O. Box 17078
Baltimore, MD 21203
explaining the corrective action required for the HIM, that MBR correction is being accomplished, and that appropriate action should be taken to correct the HIM and issue a new health insurance card.
3. Subsequent Inquiries Concerning Health Insurance Cards
Subsequent inquiries about health insurance cards shall be handled as described above except that a photocopy of the incoming correspondence must always be sent to CMS, Transaction Processing Branch, under cover of Form 41 whenever a corrected health insurance card should be issued. The route slip should reflect the remarks “Subsequent inquiry about health insurance card received (see attached). Action has been taken to correct any erroneous MBR data recognized in the program service center. Please take appropriate action to issue correct health insurance card. We would appreciate receiving notification of your final action on this matter so that our controls can be cleared. The appropriate entitlement factors are as follows.” (List all appropriate HI/SMI entitlement factors on the Form 41 or an attachment.)
Control the folder via Form SSA-5015, Diary Slip, for 30 days awaiting the final reply. If no reply has been received by the end of the 30 days, send a followup.
4. Beneficiary Notification
After action has been taken to correct the information on the health insurance card, send letter SSA-L974 to inform the claimant of the corrections made. If the only action was the replacement of the Medicare Card through SSADARS, do not send a letter.
M. Inquiry Concerning SMI Premium Rate
Each GEP form HCFA-40D indicates the SMI premium rate the individual will be charged if he or she enrolls. This rate is computed based on SMI data contained in the HIM record. In past years this premium rate was part of the input data to the Post-Entitlement Premium Payment and Enrollment (PEPPER) program and was compared to the premium rate PEPPER computed based on information in the MBR: whichever rate was the lowest was the one actually charged the beneficiary.
Because the premium rate is not coded on the SSA-1598, PEPPER develops a premium rate based solely on MBR data and this rate is shown on the enrollment and premium rate notice HCFA-1585) or on the premium billing notice that is mailed to the beneficiary shortly before coverage begins.
If a beneficiary subsequently protests that the premium rate he or she is being charged is greater than that shown on the HCFA-40D, examine the HCFA-40D to see if the allegation is correct. If the rate shown on the HCFA-40D is lower, correct the premium rate on the MBR and refund any excess premiums deducted from monthly benefits. Any excess paid by an individual in direct billing status will be used to adjust the next billing notice.