TN 7 (07-09)

HI 00825.100 Entitlement Issue

Resolve entitlement issues following the instructions pertaining to the various situations indicated in this section.

A. Entitlement to a current period of HI or SMI coverage is not shown

The field office (FO) receives an allegation of Health Insurance (HI) or Supplemental Medical Insurance (SMI) entitlement but no record of such entitlement is on the master beneficiary record (MBR) or the enrollment database (EDB).

The FO explains the facts of the case in the “Reason for Referral” portion of the form CMS-2178, HI/SMI Entitlement Problem Referral. The FO faxes the CMS-2178 to

  • program service center (PSC) of jurisdiction via the dedicated paperless fax number based on the MBR, or for

  • Medicare eligibility issues for End-Stage Renal Disease (ESRD) fax to PSC 7 regardless of MBR PSC, or for

  • Medicare eligibility issues for the Disabled Working Individual (DWI) – Section 6012 – fax to PSC 7 regardless of MBR PSC.

The faxed document is scanned and converted to an image for electronic (paperless) processing and directed to a Benefit Technical Examiner (BTE). The BTE should check for:

  • An image in paperless,

  • A Processing Center Action Control System (PCACS) or Paperless Read Only Query System (PPL ROQS) item,

  • T2 exception on the Transaction History Query (THIS),

  • A Daily Update Master Accounting System (DUMAS) exception,

  • A Manual Adjustment Credit and Award Process/ Manual Adjustment Credit and Award Data Entry System (MADCAP/MACADE) exception, etc., (in case the enrollment action processed after the FO sent the CMS-2178).

If necessary, the BTE requests the Information Retrieval Group (IRG), via PCACS for a review of the claims folder. If the folder review reveals

  • an unprocessed general enrollment application in file; or

  • The claimant is entitled to HI or SMI as alleged but the award form A-101 (or the electronic form 101, EF-101) has not been processed.

The reviewer should fax the documented proof to the requesting technician for processing. After processing, the technician should send an interim reply to the FO using District Office Telephone Procedures (DOTEL), PCACS, or the Modernized Development Worksheet (MDW).

If the folder review reveals a processed manual action or computer output reflecting HI or SMI entitlement as alleged, compare the processing dates of the folder document with the MBR update month reflected on the MBR query reply, attached to the form CMS-2178 (scanned documents). When the MBR update month on the query reply is earlier than the intended MBR update of the folder document, obtain a current MBR printout to verify that the action on the folder document actually updated the MBR. If the MBR is updated with the current information, notify the FO via DOTEL, PCACS, or the MDW.

If the MBR does not reflect the entitlement factor in the later MBR update month, an exception or some other problem has occurred and the BTE should reprocess the final action and notify the FO via DOTEL, PCACS, or the MDW.

If the folder review reveals no record of HI or SMI, as alleged on the CMS-2178, determine if any inconsistencies may have occurred which would prevent the MBR from being updated . If so, send an interim reply to the FO as noted in HI 00825.095. If a record of enrollment was located, use MACADE/ MADCAP to process the enrollment. Notify the FO of the final findings as noted in HI 00825.095.

If the entitlement factors do not coincide with one of the prior enrollment periods, notify the FO regarding the findings via DOTEL, PCACS, or the MDW.

NOTE: Attainment of age 65 or 25 months of entitlement to disability benefits by an insured beneficiary automatically entitles that claimant to free HI coverage.

If the folder contains correspondence, which could be an implied request for HI/SMI entitlement, the Claims Technical Examiner (CTE), makes a determination.

  • If the claimant is not entitled to HI or SMI, notify the FO of the findings via Dotel, PCACS, or the MDW.

  • If the claimant is entitled to HI or SMI, notify the FO as noted in HI 00825.095. Take action to have the entitlement recorded on the MBR.

See Detail

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

B. Entitlement to a prior period of HI or SMI coverage is not shown

The FO receives an allegation of HI/SMI entitlement, which is prior to a current period of HI/SMI coverage, but no record of a prior period of coverage is on the MBR or EDB (CMS database). The FO explains the facts of the case in the “Reason for Referral” portion of the referral form. Upon receipt of the CMS-2178, review the claims folder and take the following actions if

  1. Prior period of coverage exists. If a prior period of HI/SMI coverage exists, annotate the prior period of entitlement to the MBR via MACADE. Notify the FO of the pertinent HI/SMI entitlement data via DOTEL, PCACS, or the MDW.

    NOTE: The MBR contains up to 20 occurrences for SMI and 10 occurrences for HI. If the beneficiary becomes entitled to a new period of coverage and this exceeds the maximum number of occurrences, the earliest occurrence drops and the new occurrence is added to the MBR.

  2. Prior period of coverage does not exist. If no prior period of HI/SMI coverage exists, document the file and notify the FO via DOTEL, PCACS, or the MDW.

C. HI or SMI entitlement dates appear to be incorrect

The FO receives an allegation that the HI/SMI entitlement dates on the MBR or EDB are incorrect. The FO explains the facts of the case in the “Reason for Referral” portion of the referral form and attaches any available proofs. Upon receipt of the CMS-2178, review the claims folder as shown in section A. Take the following actions if the folder examination reveals:

  1. EDB and MBR are incorrect. If the entitlement date(s) reflected on the MBR and EDB are incorrect, take corrective action, and advise the FO accordingly, (i.e., date of entitlement to SMI and date of entitlement to HI).

  2. MBR is suspect. If the data on the MBR is suspect have the CTE, determine the correct entitlement dates and prepare an interim reply to the FO. If the CTE verifies that the MBR date(s) is incorrect, take appropriate action from item 1. If the CTE determines that the MBR and EDB dates are correct as posted, take appropriate action in item 3.

  3. EDB and MBR are correct. If the data on the MBR and EDB are correct and the allegation on the CMS-2178 is incorrect, inform the FO and request proofs to support the original allegation if the enrollee still disagrees with the MBR data.

D. SMI termination or withdrawal data appears incorrect

The FO receives an allegation that the SMI termination or withdrawal data on the MBR and EDB is incorrect. The FO explains the facts of the case in the “Reason for Referral” portion of the form and attaches any available proofs.

Upon receipt of the CMS-2178, review the claims folder as shown in section A.

Take the following actions if the folder examination reveals:

  • a protest to a SMI termination action for nonpayment of premiums is questioned, the FO should not to use the Form CMS-2178 to transmit their determination on the protest. If the FO makes an error of this type, return all copies of the CMS-2178 and request the FO to follow HI 01001.375 in handling this type of situation.

  • a potentially erroneous date of termination, withdrawal, or protest of a withdrawal action, handle the case as follows:

    1. MBR is incorrect. When the SMI termination or withdrawal date on the MBR is incorrect and the allegation on the CMS-2178 is correct, take corrective action.

    2. MBR is correct. When the termination or withdrawal date on the MBR is correct and the allegation on the CMS-2178 is incorrect, explain the findings to the FO.

    3. MBR is suspect. When the data on the MBR is suspect, the CTE makes the final determination and takes the following action

      • If the MBR data is correct, follow the instructions in item 2 , or

      • If the MBR data is incorrect, follow the instructions in item 1.

See Details


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600825100
HI 00825.100 - Entitlement Issue - 02/11/2016
Batch run: 02/11/2016
Rev:02/11/2016