HI 00825.110 Interpretation of Combined HIM and MBR Query Replies
A combined HIM/MBR query reply (see SM 00706.020) will accompany Forms CMS-2178. Items A and B below illustrate the information provided on both the MBR portion and the HIM portion of the query reply.
A. MBR Reply to Combined Query
Several possible replies can be received from the MBR.
When there is no record on the MBR for the individual but there is a cross-reference to an SSI record and the reply will consist of one line and will end with one of these legends: SSI ONLY;.
If a pending action on the orbit tape has not yet been applied to the MBR the reply will consist of only one line and will end with “PEN UPD ACT.”
If more than one pending action on the orbit tape has not yet been applied to the MBR, the query reply will consist of only one line and will end with the legend “SIM UPD ACT.”
If there is something wrong with the MBR record or the system so that a reply cannot be produced, the query reply will consist of only one line and will end with the legend “MBR STATUS.”
In each of these cases, the reply will contain the claim number and the beneficiary's name in addition to the legend.
The regular reply will consist of as many as seven lines in a fixed format:
The claim number (from the SSA-2467)
BIC (from the SSA-2467)
The surname (from the SSA-2467)
The Unit Identifier (from the SSA-2467).
This is a two position numeric or alpha entry. When a unit identifier is not input, the reply displays two zeros(00).
BIC NIF will appear at the end of the line if there is an MBR for the SSN but not for the claims symbol transmitted. Information will be given for all beneficiaries on that SSN.
A claims number appears at the end of the line whenever the DO transmitted the beneficiary's own SSN instead of his claim number. This number is the claim number on which he is receiving benefits. If applicable, one of the following legends will appear at the end of line 1: SSI ONLY.
The first line of the beneficiary's address on the MBR, and the ZIP code.
BIC— the subscript used to identify the type of beneficiary.
LAF— this field indicates the beneficiary's monthly benefit payment status.
DOB— Proof on DOB indication—In certain claims (HA, B2, C, and E), proof of age is not required at the time the individual comes on the benefit rolls. However, when these beneficiaries (other than HA's) attain age 65, proof of age is required. The MBR will show a P when proof of age is in the processing center. (All former B2's, C's and E's who attain age 65 must have this P indicator for health insurance benefits.)
DOD— Date of Death.
LAP— code (last action posted) date. This is a one digit entry (alphabetical or numerical) which represents the type of action posted.
A—Establishment of RRB jurisdiction for collection of premiums.
B—Manual actions. Used for actions which cannot be handled by a direct input computer program. May be a credit (stop payment) action, debit (start payment) action, benefit rate change, or other change. May also be an initial award.
C—SALT action. May be marriage, divorce, left or returned to U.S., annulment, deportation, CDB suspension, direct deposit, payment replacement, withdrawal of claim, representative payee action, or several other unusual events input by processing centers.
D—Change of address, payee, or name.
E—Student conversion. Initial annotation of ESY.
F—Subsequent student operations.
H—Communication with the SOBER system. Does not affect benefit payment.
I—Supplemental transcript debit. A debit (start payment) action which cannot be handled by a direct input program. Also initial awards, whether in payment status or not.
J—Returned check action.
M—Death termination. May include payment of lump sum and conversion of auxiliary benefits to survivor benefits.
N—Death termination based on a returned check.
Q—Termination due to attainment of age 18 or 22.
R—Addition of a new beneficiary who is dually entitled. Conversion from B to D of a dually entitled beneficiary.
S—Initial SMI enrollments, refusals, withdrawals, and cancellation of withdrawals. State buy-in processing. End-of-year reconciliation of premiums.
T—Termination of SMI for failure to pay premiums, and reversal of such terminations.
U—Annotations of state exchange data (BENDEX). Does not affect benefit payments.
V—Miscellaneous correction of data on the MBR which cannot be handled by a specific EDP program. Does not affect benefit payment.
W—Annotation of dual entitlement or *cross-reference information for a beneficiary who is already entitled to benefits.
X—Actuarial reduction factor adjustment (ARF) and delayed retirement credit.
Y—Disability attainments and denials (interim RIB-DIB cases).
Z—Automatic lump sum operations (ALSO).
1—Processing of work notices and annual reports. Reinstatement of age 72.
2—ROAR (recovery of overpayments) action.
3—Annual report enforcement operations. Does not affect benefit payment.
4—Awards or establishment of new PSC jurisdiction.
5—Military service input.
6—Start of payments after a period of deferred status.
7—Recovery of unpaid premiums.
8—Automatic recomputation (AERO).
#—Annotation of SSI, or RR data.
Run Date— this is the date (month and day) the last action was processed (see LAP code above).
Beneficiary's name— it will appear as the given name, middle initial (in some cases, the middle name), and surname.
Sex Code— A one letter designation of F—female; M—male.
Line 4 Part A Data
Part A Entitlement Date
Part A Option Code
C—No—Cessation of Disability
F—No—Invalid enrollment terminated
H—No—Not eligible (generally X-ref)
N—No—No response to enrollment solicitations
S—No—No longer renal disease
Premium Amount Collectible Part A
Amount Collectible—this monetary figure represents the currently determined premium rate. (If HIB is terminated, the amount shown is what the premium would be, according to current rates, ignoring any increase that would result from additional noncoverage months following the date of termination.)
Date of Termination Part A
Third Party Code Part A
S01-299—Group payer for Part A
S01-S65—Reserved for State group payment. (S replaces first digit of State code used for Part B.)
Third Party Entitlement Date Part A
This field shows the third party entitlement date. (The effective date of the most recent action by a third party to start or resume paying premiums.) However, this date may not reflect the entire period of third party premium payments. This date may also differ from the beneficiary's Part A entitlement date.
Third Party Termination Date Part A
This date indicates the effective termination date of the third party's payments. It is the last month of third party coverage.
Line 5 Part B Data
Part B Entitlement Date
Part B option code (refer to option codes as in Line 4 above).
Premium amount collectable Part B (refer to line 4 for identification).
Date of Termination Part B
Third party code Part B
A01-K99 Private third party
010-650 State buy-in
700 Civil Service
Third party entitlement date Part B
Third party termination date Part B— last month of third party payment.
There will be a separate cross-reference line (up to nine) for each cross-reference in the MBR.
CROSS-REFERENCE CODES—This field, which may not be shown on all cross-reference records, helps identify what type of cross-reference number is shown on the record.
C—Beneficiary's CSC number
D—Other SSN on which child is entitled in combined PIA cases
M—Additional SSN of beneficiary
O—Other number on which beneficiary is or may be entitled.
R—RRB number involving this beneficiary
S—SSN of beneficiary's spouse
U—SSN on which renal entitlement is based
V—2nd SSN for beneficiary
W—Beneficiary's welfare number, preceded by first two digits of state code HI 01001.205 for list of state codes.
CROSS-REFERENCE NUMBER—The type *of code above will help explain how the cross-reference number is related to the record.
CROSS-REFERENCE BIC—If the cross-reference symbol exists and has been provided to the MBR, it will appear here.
CROSS-REFERENCE SERVICING PSC—If the cross-reference claim number refers to a folder serviced by another program service center, that PSC's number will appear.
DUAL ENTITLEMENT INDICATOR—If the record has been identified in the MBR as a dual entitlement record, one of the following codes will appear:
X—The cross-reference number is the active number for premiums
R—The cross-reference number is the inactive number for premiums
Whenever a BIC A appears in the reply the A account number is the active number for premiums.
Line 7 Security Income Data (SID)
This field will appear whenever the SID is contained in the MBR file.
Position 1—Security Income File Type (SIFT) one alpha position.
A—aged individual or spouse
B—blind individual or spouse
D—disabled individual or spouse
T—essential person (ineligible spouse or parent)
Position 3-6—Security Income Entitlement/Termination Date (SIED) four numeric position (month and year).
This is the entitlement date for the SISC codes in position 6.
Position 8—Security Income Status Code (SISC) one alpha position.
C—conditional SSI payment—SIED date first month of payment
D—denied—SIED denial date
E—entitled—SIED indicates first month of payment
I—ineligible—SIED indicates date claim filed
L—denied after payment has been paid—SIED first month of nonpayment
N—terminated because of erroneous State conversion—SIED will be 12/73
P—pending SSI entitlement—SIED date claim was filed
S—entitled to SSI State Supplementation Payment only–SIED first month of payment
T—terminated for reasons other than X-Y-Z–SIED first month of nonpayment
V—T30 action pending—SIED effective date of T30 action
W—withdrawal of Federal Administered State-Supplementation Payments —SIED first month of nonpayment
X—terminated due to death—SIED first month after month of death
Y—terminated due to excessive income—SIED first month of nonpayment
Z—terminated due to excessive resources—SIED first month of nonpayment
Position 7-11—State and County Code of Residence (SCCR) five numeric positions. First two positions reflect the State code. The remaining three characters represent the county code of residence.
Position 10-14—Security Income Effective Date of Residence Change (EDRC) four numeric positions (month and year). Position blank if no residence change.
Position 16-19—Security Income Living Arrangement Code (SILAC) one alpha position.
A—Living in their own household
B—Living in another household
C—Living in parent's household
D—Living in title XIX institution
Position blank if—no computation has been done for SSI payment
—living in non title XIX institution
—living arrangement change is in process
The MBR reply to a HMQ is intended to provide information only for the claim number queried. If the query input data matches a record in the MBR system on the SSN, but does not match on a particular BIC within that SSN, the query reply will include data for all beneficiaries on that SSN. For example, if a HMQ is submitted on claim number 262-00-5327B and the MBR record on that number does not have a “B” BIC, but does have beneficiaries listed with BIC's of “A” and “D,” the MBR query reply will contain data for both the “A” beneficiary and the “D” beneficiary.
If the MBR contains information for more than one beneficiary, the data record display for the first beneficiary on the SSN will consist of as many as seven lines of information in exactly the same format as described above. The data display for subsequent beneficiaries will immediately follow and will consist of as many as six lines of information beginning with line 2 (address data). However, if a combined payment is being made (e.g., “A” and “B” beneficiaries receiving one, combined benefit check), display of data for subsequent beneficiaries in the combined payment will consist of as many as five lines of information beginning with line 3 (beneficiary data).
The query input claim number may not have matched a claim number in the health insurance master tape if the MBR query reply contains information for more than one beneficiary. In this case, a disposition code 52 will be received on the health insurance master tape reply.
Do not be alarmed if a HMQ results in a dispostion code 99 giving information from the health insurance master tape and an MBR reply containing information for more than one beneficiary. This may occur because the health insurance master tape contains both a beneficiary's current BIC and previous BIC while the MBR contains only the beneficiary's current BIC. For example, if a “B” beneficiary is converted to a “D” beneficiary, the health insurance master tape will contain both the “D” current BIC and the “B” previous BIC and will accept queries on both. The MBR will contain only the “D” BIC, and a combined query submitted under the “B” BIC will result in a reply being sent for all beneficiaries on that claim number.
For a sample MBR reply to a HMQ and a detailed explanation of the fields, see HI 00825.906.
B. * HIM Reply to Combined Query
Each reply starts with HH
HH Edit reject—the message was not transmitted correctly. An asterisk will appear after the erroneous or omitted data field.
HH REJECT HMQ EVHIR THOMAS, C
123456789 *DA 010177 PN UNAB
HH REPLY HMQ EVHIR THOMAS, C
123456789A DC52 PD060577 UNAB
A disposition code 52 indicates that there is no record in the HI system for the claim number queried.
A disposition code 99 supplies the information from the health insurance master tape on the claim number queried.
Line 1—Fixed Format
|REPLY||Final reply—disposition codes 52 or 99|
|HMQ||Type of query sent|
|EVHIR||DO routing indicator|
|Thomas, C||Beneficiary name and initial as queried|
|123456789A||Claim number and BIC as queried by the DO|
|PD060577||OCRO processing date|
|UNAB||Unit indicator—last two positions numeric/alpha or both|
Line 2—Fixed Format
Part A entitlement date and option code
Option Code for HI and SMI
C—No, terminated due to cessation of disability
D—No, coverage denied
E—Yes, automatic entitlement to Part A, no premium
F—Terminated, invalid enrollment
G—Yes, entitled under good cause provisions
H—No, not eligible for Part A
N—No, no election
P—Unknown, RRB has jurisdiction
R—No, beneficiary refused coverage
S—No, no longer under renal disease
T—No, coverage terminated due to nonpayment of premiums
W—No, beneficiary withdrew from coverage
Y—Yes, beneficiary has coverage, premiums are payable
|PBE0775Y||Part B entitlement and option code. If individual does not have SMI coverage, this position will be reflected as (PBE ).|
|DOB010101||Individual's date of birth|
Individual's buy-in status—if last position is
0—no third party involvement
7—third party (group premium payer)
|PCLYES||HI card preclusion—always yes or no|
|FRZYES||Part A record is frozen—FRZNO Part A record is not frozen|
|LAFS1||Individual ledger account file code see SM 10802.120 for LAF codes.|
Line 3 and subsequent lines supply additional information as indicated by the following trailers. These trailer lines will not be in a fixed format. Appearance of trailer depends on the presence or absence of circumstances within the individual master record. No line will contain more than two trailers.
|XCN||Cross-reference number. The claim number queried was the inactive half of a cross-reference claim number (an 00 disposition reply would have been received previously). The inactive claim number supplied by the DO appears in line 1. The cross-reference number is the claim number under which the individual's health insurance record is maintained.|
|CBN||Correct beneficiary name. This trailer always appears in the reply.|
|PAT||Current Part A termination date. The four numeric digits (month and year) indicate the last month of entitlement.|
| ||PATXXXX—indicates that the individual's Part A entitlement is questionable.|
|PBT||Current Part B terminated. The four numeric digits (month and year) indicate the last month of entitlement.|
| ||PBTXXXX—indicates the individual's Part B entitlement is questionable.|
|PPA||Prior Part A entitlement, termination and option code. The first four numeric digit represent the beginning prior entitlement date (month and year). The last four numeric digits represent the last month and year of prior entitlement. The last alpha digit represents the option code.|
|PPB||Prior B entitlement, termination and option code. The first four numeric digits represent the beginning prior entitlement date. The last four numeric digits represent the last month and year of prior entitlement. The last alpha digit represents the option code.|
Reason for entitlement. This trailer indicates the basis for entitlement to benefits. Example:
ENT 1 code description:
1 - The individual is entitled because of a disability.
2 - The individual is entitled because of chronic renal disease.
3 - The individual has, or had chronic renal disease but is currently covered by the disability provision.
4 - The individual is age 65 or over and is covered by Medicare as an uninsured or an insured old age or survivor, and has chronic renal disease.
8 - The individual has chronic renal disease and is covered under Part A premium payment provision.
9 - The individual is covered under Part A premium payment provision.
Date of death. The last four numeric digits represent the month, day and year of death.
Occasionally the disposition code 99 supplies the information from the health insurance master SKELETON record on the claim number queried. This occurs when the health insurance master tape has on record that the individual is dead and there has been no health insurance utilization for a year. The individual's record was purged from the health insurance master active file and added to the health insurance inactive (skeleton) file.
In this instance, the disposition code 99 supplies only the individual's claim number, BIC, name, date of birth, and date of death.
Beneficiary address or name and address of the representative payee. If an address is not listed, one of two possibilities exists: An auxiliary record has just come into the health insurance master file and the address is not available. After the monthly updating, the complete address should be available.
If the record in the health insurance master file is a temporary one, the reply, to the DO will show UNK 88000, UNK 8001, etc., instead of an address. Generally, a temporary record is followed by a permanent record from the MBR. If the address is necessary to assure positive identification, it should be obtained from some other source.