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:
hardship is alleged; or
congressional involvement is present or anticipated, or
public relations are in jeopardy; or
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:
containing the following information:
Hardship or sensitive correspondence pending
Identity of State or group
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:
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:
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:
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:
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.