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 FO 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 PSC via the Paperless process. This routing is necessary because
the DO has no knowledge of any final determination handled in the PSC on the HI/ SMI
entitlement.
In communicating an apparent MBR/EDB data problem to the PSC via a Form CMS-2178-U2,
the FO will attempt to break the problem down into the specific error(s). For more
information on form CMS-2178-U2, please see the PDF document below:
Priority should be taken with Forms CMS-2178-U2 since a problem can prelude the beneficiary
from receiving health insurance reimbursement until you correct the MBR and EDB.
In the subsequent sections, the description of the problems being relayed by the FO
relays will be used to differentiate the kinds of handling required by the Benefit
Authorizer (BA) in the module. Although these Form CMS-2178-U2 procedures may not
be all inclusive, FO can handle the majority of inquiries with the guidelines prescribed
below. In all FO inquiry situations related to HI/SMI, a final or interim reply is
sent to the inquiring FO within 20 days of receipt of the CMS-2178-U2 in the PSC.
The PSC procedure for replying to the FO is below.
The BA in the module receives the Form CMS-2178-U2 via the paperless process. A 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 PSC.
Forward the form to FO so they may determine the action taken on the issue previously
presented.
If a final determination on the issue reflected on the form CMS-2178-U2 cannot be
made within the 20 days referred to above, an interim reply must be sent to the appropriate
FO (otherwise, the FO will send a 30-day follow-up status request). If the situation
warrants an especially quick interim reply, prepare an email to the FO, referring
e to the Form CMS-2178-U2 dated (MM/YYYY), and explaining why you are not sending
a final reply . The email should reflect the claim number and the name of the enrollee
as shown on the Form CMS-2178-U2.
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 CMS 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-U2 must be maintained with
the objective of correcting the MBR immediately upon the receipt of the FO referral.
The final reply to the FO should must be sent immediately after you make a determination
on the issue presented on the form CMS-2178-U2. The MBR corrective action begins after
the above notification been sent to the FO.
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 accompanying the form CMS-2178-U2.
In all cases, check the issue cited on the CMS-2178-U2 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 agree with each other, the FO should not have referred the
issue to the PSC return the entire CMS-2178-U2 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.