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 DO. HI 00825.110 explains the interpretation of the combined EDB/MBR query reply which will accompany
the form CMS-2178.
In all cases, check the issue cited on the CMS-2178 against the MBR response to the
EDB/MBR query to verify that the allegation is in conflict with the MBR data. If the
MBR and allegation are in agreement, the DO should not have referred the issue to
the PC and the entire CMS-2178 package should be returned to the DO explaining the
reason for return. If a conflict exists between the MBR and the allegation, handle
the matter as described in the appropriate section below.