HI 00825.095 Form CMS-2178, HIB/SMIB Entitlement Problem — Priority

The Form CMS-2178, HIB/SMIB Entitlement Problem - Priority (see HI 00930.005 ) was designed to provide a coordinated and efficient method of effectuating appropriate entitlement corrections (i.e., for reflecting HI and/or SMI coverage or noncoverage, whether prior or current, etc.) to both the Enrollment Data Base (EDB) and/or MBR by means of referral from the DO to the PC and/or CMS, OMB.

To preclude an incorrect referral, all DOs have been given a query facility into both the EDB and MBR records. Therefore, whenever a DO receives a complaint relating to HI and/or SMI entitlement issues (including health insurance card issues) the EDB and MBR systems are queried. Based on the data available in both master records, the following steps are taken by the DO to have the issue resolved:

A. HIM Incorrect

If the HI/SMI information on the MBR is correct based on the allegation but the EDB data is incorrect, it is apparent that any action produced from the EDB would reflect the alleged incorrect data. Since the EDB causes health insurance cards to be issued and is relied upon to pay HI/SMI benefits, that record must be corrected. CMS, OMB has the means of accomplishing corrective actions to the EDB which are consistent with data contained on the MBR. Therefore, appropriate action is taken between the DO and CMS, OMB to correct the EDB record without contacting the PC.

B. MBR and EDB Incorrect

If both the EDB and MBR reflect apparently incorrect HI/SMI entitlement factors or no HI and/or SMI entitlement factors at all and the DO has information which disputes the data (or lack of data) in both records, a Form CMS-2178 with copies of the MBR and HIM are sent to the PC via the Paperless process. This routing is necessary because the DO has no knowledge of any final determination on HI/ SMI entitlement which may have been made in the PC.

In communicating an apparent MBR/EDB data problem to the PC via a Form CMS-2178, the DO will attempt to break the problem down into the specific error(s).

Priority handling must be given to Forms CMS-2178 since the beneficiary is precluded from receiving health insurance reimbursement until the correction of the MBR and EDB is made.

In the subsequent sections, the description of the problems being relayed by the DO will be used to differentiate the kinds of handling required by the Benefit Technical Expert (BTE) in the module. Although these Form CMS-2178 procedures may not be all inclusive, it is expected that the majority of such DO inquiries can be fully handled with the guidelines prescribed below. In all DO inquiry situations related to HI/SMI, a final or interim reply must be sent to the inquiring DO within 20 days of receipt of the CMS-2178 in the PSC. The procedure for reply to the DO is also explained below.

The form CMS-2178 will be received by the BTE in the module via the paperless process. The yellow copy of the form is to be retained for folder documentation once the appropriate action to be taken on the issue is determined by the PC.

The original copy (blue) should be returned to the DO so they may determine what action is being taken on the issue which they presented.

If a final determination on the issue reflected on the form CMS-2178 cannot be made within the 20 days referred to above, an interim reply must be sent to the appropriate DO (otherwise, the DO will send a 30-day follow-up status request). If the situation warrants an especially quick interim reply, prepare a memorandum to the DO, making reference to the Form CMS-2178 dated (MM/YYYY), and explaining the reason a final reply is not being sent. The memorandum should reflect the claim number and the name of the enrollee as shown on the Form CMS-2178.

Use Form SSA-3339-U2, “Interim Reply to HIB/SMIB Problem Referrals.” To send the interim reply (See HI 00825.908.). Once the interim reply is forwarded, the final reply must be made within 30 days after mailing of the interim.

If the problem is not corrected within 90 days (of the initial DO referral), the DO will refer the problem to the Health Insurance Regional Office who in turn will contact central office. Subsequently, central office will contact the PSC. To limit the necessity for such contact, maximum control over the form CMS-2178 must be maintained with the objective of correcting the MBR immediately upon the receipt of the DO referral.

The final reply to the DO must be accomplished immediately after determination is made on the issue presented on the form CMS-2178. The MBR corrective action can begin after the above DO notification has been sent.

HI 00825.100 defines the procedures to be used in resolving the issues presented by the