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