HI 00825.105 Miscellaneous Issue

Miscellaneous issues will be handled in accordance with the instructions pertaining to the various situations indicated below.

A. All Available DO Information Indicates Another Individual Is Entitled On This Account Number

The DO has information that indicates that two different individuals (entitled to HI and/or SMI) are using the same social security number, that one of these individuals actually should be entitled on another number or not entitled at all, and that the wrong individual is reflected on the MBR for the number in question. They will explain what they believe are the facts in the case in the “Reason for Referral” portion of the referral form and attach any available proofs, etc. Upon receipt of the CMS-2178, the claims folder must be obtained and examined.

1. MBR IS INCORRECT

If folder examination indicates that a clerical error in the claim number was made and it is evident that the facts presented by the DO are accurate, complete the “Reviewing Office Reply” portion of the CMS-2178 to reflect all pertinent entitlement data for both claimants. The pertinent entitlement data consists of claim number, name, address, dates of entitlement to HI and/ or SMI, date of birth, sex, and option code for each claimant. Send the blue original to the DO and file the yellow copy on the right side of the folder. Once the CMS-2178 has been appropriately routed, forward the folder to a Benefit Authorizer requesting the necessary corrective action.

2. MBR IS CORRECT

If folder examination reveals that the data on the MBR is correct and the DO allegation is incorrect, explain the findings in the “Reviewing Office Reply” portion of the referral form. Send the blue original to the DO and file the yellow copy on the right side of the folder.

3. CLAIMS AUTHORIZER DETERMINATION IS NECESSARY

When folder examination reveals that the data on the MBR is suspect but a final determination cannot be made by the Exceptions and Inquiries Examiner, prepare an interim reply to the DO and forward the folder to a Claims Authorizer for a final determination. Request that the Claims Authorizer expedite the determination and return the folder to the Exceptions and Inquiries Examiner immediately after the determination is made.

Depending upon the Claims Authorizer's determination, take appropriate action as reflected in 1. or 2. above.

B. All Other Miscellaneous Issues

Almost all miscellaneous issues on the Form CMS-2178 may be completely processed by the Exceptions and Inquiries Examiner by following the instructions in this manual and in SM 00613.000 ff. Basically, the principle behind PSC completion and routing of the Form CMS-2178 remains the same as in all situations listed above.

If corrective action to the MBR and HIM is required, complete the “Reviewing Office Reply” portion of the CMS-2178 defining the data to be corrected. Send the blue original to the DO and file the yellow copy on the right side of the folder.

If no corrective action can be accomplished due to lack of proofs or an inaccurate allegation by the DO, explain the findings in the “Reviewing Office Reply” portion of the CMS-2178. Send the blue original to the DO and file the yellow copy on the right side of the folder.

If a final determination on the issue cannot be made by the Exceptions and Inquiries Examiner, prepare an interim reply to the DO and forward the folder to the appropriate module specialist for a determination. Request that person to expedite his/her determination and return the folder to the Exceptions and Inquiries Examiner after the determination is made. Depending upon the determination, follow the above instructions for completing and routing the Form CMS-2178.

In nearly all cited miscellaneous issues (items 2, 3, 4, and 8 of the Form CMS-2178), the MISCOR program may be used to correctly update the MBR. The rules set down in SM 00613.000 ff. should be used to effectuate each correction. The appropriate coding sheet should be prepared by the Exceptions and Inquiries Examiner and forwarded to the Data Entry operator per local instructions.

If full corrective action cannot be accomplished by using MISCOR, send the folder to a Benefit Authorizer and request that all required corrective action be taken. When the DO is requesting the status of an uninsured (T or M) claim refer to a Claims Authorizer for handling.

A very general key to the specific MISCOR change coding sheet to be used to effectuate changes requested via the CMS-2178 is shown below. Again, MISCOR can only be used when full correction can be accomplished by using that program.