HI 00910.040 Resident District Office Procedure

Check the office records including the pending files and proceed as follows:

A. No RSDI Claim Filed

If eligibility apparently exists for monthly or health insurance benefits, obtain a claim. If the request refers to HI benefits, retain the request until the requirements for a temporary notice are met, and then follow C. below. If the request refers to SMI, clear the request showing “No eligibility for SMI” since no claim filed now can provide retroactive coverage unless a welfare recipient in a buy-in State is involved.

B. No RSDHI Entitlement

If the individual is not entitled, or if no claim will be filed, notify the requester and provide the reason. However, if nonattainment of age 65 is procluding health insurance benefits, merely state “not eligible.”

C. Claim Pending or Recently Forwarded

If the claim is pending, or was recently forwarded to the processing center (less than six weeks ago), and the requirements for a temporary notice are met, notify the requester of the claim number, the date(s) of entitlement to HI and/or SMI and the date the temporary notice teletype was transmitted to CMS, BSS, OHPS, TPB.

D. Claim Forwarded Six or More Weeks Ago

If it is a claim number request, supply the claim number and return it to the requester. If a code 52 is involved, send a HMQ (SM 00706.005) and when the replies are received, follow HI 00930.001.

E. Unable to Locate

If no local record can be located and the search was conducted because of a:

1. Code 52

Send a HI/SMI Status Query (HMQ) (see SM 00706.005 and when the health insurance master tape and MBR replies are received, follow HI 00910.050.

2. Claim Number Request

Contact the beneficiary"s home to ascertain whether a claim was filed. If HI benefits are involved in welfare buy-in States, check whether the individual is a welfare recipient. Secure the claim number or sufficient identifying information so that a claim number can be located.

If a claim number is secured, report it to the requester. If only identifying information is obtained.

3. RRB Involvement

After the intermediary has exhausted all available means of identification, and the provider has been contacted to have their records rechecked for a possible correction of name and/or claim number, and no new data is obtained, refer the case to the local RRB office for their investigation. RRB will resolve the problem and notify the intermediary.

If the DO receives a code 52 reject allegation from an intermediary for a prefix claim number, return the correspondence to the intermediary, with an an explanation that this is a RR claim number and should be directed to the local RRB office.

NOTE: If an intermediary or beneficiary indicates a previous contact has been made with RRB to resolve a problem and RRB has not responded or the problem still exists do not forward the case to RRB. Instead refer it to the Medicare Bureau RO with the explanation that RRB has been previously contacted. The CMS RO refers the case to CMS, BPO, Entitlement Systems Branch to be handled similar to a critical case.

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HI 00910.040 - Resident District Office Procedure - 11/23/2001
Batch run: 09/25/2012