HI 00825.020 Correspondence Pertaining to State Buy-In, Group Payers, Civil Service, or RRB

Inquiries pertaining to various third party buy-in situations will be received from all sources. These inquiries should be broken down as to sensitivity for processing purposes. The sensitive correspondence category should include those items in which:

  1. hardship is alleged; or

  2. congressional involvement is present or anticipated, or

  3. public relations are in jeopardy; or

  4. sensitivity would normally be judged present under other procedures.

Once the degree of sensitivity has been established, determine the type of third party involved (State, civil service, or private group) and handle the inquiry as indicated below. Obtain an MBR printout for each case in accordance with SM 00500.000ff.

A. State buy-in correspondence

1. Sensitive inquiries

If a sensitive inquiry allegation agrees with MBR data and folder documentation, prepare a final reply to the correspondent. If the allegation does not agree with the MBR data and folder documentation, send a teletype to:

  • Centers for Medicare & Medicaid Services

    BPO, OPOP

    Division of Eligibility Systems

containing the following information:

  • Hardship or sensitive correspondence pending

    Identity of State or group

    Claim number

    Name of individual

    Address (if available)

    Any other claim number

    Allegation of the claimant

    Pertinent status reflected in claims folder.

    Name of person in PC to whom status reply should be sent.

CMS will inform the PC if the claim is reflected on the third party master record and is consistent with the allegation reported in the teletype.

If the folder documentation is consistent with the allegation but inconsistent with the MBR, forward the case to the Benefit Authorizer to record the State buy-in reflected on the MBR and prepare all required notices. However, if all data is inconsistent with the allegation, prepare a Form 41 in accordance with 2. below and send an interim reply to the correspondent informing him or her of our findings and that further development is being undertaken with the State.

2. Routine or nonsensitive inquiries

Examine the claims folder to see if the State buy-in is reflected on a Form SSA-1596-C1, Record Changes in Premium Deductions or Billing Status, or on a manually processed debit action (SSA-2795-U3 or SSA-2652-U2) and that the data shown is in agreement with that alleged and that on the MBR. If so, prepare a final reply to the correspondent.

If the MBR data and allegation are not in agreement and the folder contains no evidence of any State buy-in coverage, forward the correspondence to the appropriate DO for development. Acknowledge the referral except when the correspondence originated from the DO. Use a Form 41 (see examples below for the information to be given to the DO). No control is necessary.

Annotate the Remarks portion of the Form 41 as follows:

  • “Please review the attached correspondence and develop in accordance with HI 00815.088 and prepare any necessary reply because (insert (a) through (d) below or other explanation, as appropriate):

    (a)

    folder contains no evidence of buy-in coverage

    (b)

    folder contains evidence of buy-in coverage for the months      .

    (c)

    folder shows continuous buy-in coverage by the State of beginning.

    (d)

    Processing center has no record for this person under this claim number.”

To determine the DO to be contacted, see HI 01001.205. In most buy-in States, a specific DO has been established for handling buy-in issues.

If folder documentation is consistent with the allegation but inconsistent with the MBR data, forward the case to the Benefit Authorizer for action to record the State buy-in on the MBR and to prepare all required notices.

B. Correspondence relating to private group payers

1. Sensitive inquiries

Reply immediately to sensitive correspondence if folder documentation and MBR data agree with an allegation. If no agreement is evident, request CMS, BPO Division of Eligibility Systems, by teletype to furnish the claimant"s status giving them the information listed in A.2. above.

If, based on a reply to the teletype or current folder documentation, a private group payer has bought-in for the claimant, establish the buy-in on the MBR and reply to the correspondence.

If the MB response is negative, inform the correspondent that our records indicate that the private third party has not bought-in for the claimant and that the claimant should contact the third party for further information.

2. Nonsensitive inquiries

If a nonsensitive allegation agrees with folder documentation and the MBR data, write a final reply to the correspondent. If the allegation agrees with folder documentation but is in disagreement with MBR data, forward the folder to the Benefit Authorizer for the necessary action to establish the buy-in on the MBR and reply to the correspondence.

If no agreement is evident, forward the correspondence via a Form 41 to:

  • Centers for Medicare & Medicaid Services

    Group Premium Audit and Billing Section

    P. O. Box 11977

    Baltimore, MD. 21207

CMS will take all appropriate action on the correspondence and no reply is required from the PC.

C. Correspondence relating to civil service annuitants

When correspondence relating to premium collection from civil service annuitants is received, the appropriate action depends upon the specific type of inquiry. Forward the following types of correspondence with a current MBR printout (Furnish the annuitant"s name and civil service annuity number) to:

  • Centers for Medicare & Medicaid Services

    Premium Processing Branch

    P. O. Box 11977

    Baltimore, MD. 21207

    1. The following complaints will be processed by CMS, and CMS will prepare the final reply:

      1. complaints regarding failure to deduct the premium from the civil service annuity when the MBR reflects a 700 billing code; and

      2. complaints regarding nonreceipt of health insurance cards or receipt of incorrect cards; and

      3. complaints about continued deduction of premiums from civil service annuity after withdrawal or voluntary termination regardless of MBR status; and

      4. complaints about duplicate premium payments (i.e., deductions from civil service annuity and also deduction from RSDI or RR benefit or by State buy-in); and

      5. any other complaints not covered below.

    2. The following types of correspondence must be processed and answered by the PC:

      1. complaints involving questions of entitlement (forward to the Claims Authorizer requesting resolution of the inquiry and final reply); and

      2. complaints involving a failure to deduct SMI premiums from the civil service annuity check or continued direct billing when premiums should be deducted from the annuity check (verify with the MBR and if the MBR reflects a status inconsistent with the individual"s alleged status (billing code is other than 700), even if no folder documentation of civil service involvement was previously indicated, forward the claims folder and all material to the Benefit Authorizer requesting that all appropriate actions be taken to reflect the civil service data on the MBR, is appropriate); the new letter produced as a result of that action should be responsive to the pending complaints and no reply is required from the Exceptions and Inquiries Examiner (EIE). If the allegation is consistent with the MBR data, forward the correspondence to:

        Centers for Medicare & Medicaid Services

        Premium Processing Branch

        P. O. Box 11977

        Baltimore, MD. 21207

D. Correspondence related to RRB

When correspondence is received indicating that a beneficiary has been enrolled for Medicare by both SSA and RRB (i.e., he or she has received health insurance cards from both agencies or has had dual premium deductions or billing from both agencies), refer the correspondence to CMS central office for a determination of agency jurisdiction.

All RR related correspondence should be sent directly to RRB:

  • Railroad Retirement Board

    Medicare Programs Section

    11th Floor

    844 Rush Street

    Chicago, Illinois 60611

No further action need be taken on these cases by the Health Insurance and Inquiries Examiner. Once the agency jurisdiction is resolved, CMS will notify the Claims Authorizer of their findings.


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HI 00825.020 - Correspondence Pertaining to State Buy-In, Group Payers, Civil Service, or RRB - 08/06/2013
Batch run: 08/06/2013
Rev:08/06/2013