TN 4 (01-06)

HI 00930.005 Revised Form CMS-2178 U2 (HI/SMI Entitlement Problem Referral)

The information contained in this section comes from Emergency Message (EM) 00175. We are placing the contents of the EM here pending revision or deletion of HI 00930.010 through HI 00930.080.

A. Background

In December 1998, CMS changed the way Medicare problem cases are processed. Many cases are now handled by the CMS Regional Office (RO) staff instead of staff in CMS Central Office (CO).

CMS has redesigned the Form CMS-2178 U2 to correspond to the processing changes. The new forms are available to SSA field offices (FOs), teleservice centers (TSCs) and processing centers (PCs) using regular distribution lists. All the old CMS-2178 U2 forms dated prior to 09/06 should be destroyed and new ones requested.

The new CMS-2178 U2 is a two-page self-carbon form consisting of a referral and a FO control copy. The initial referral of the form remains the same; all follow-ups are made using photocopies of the FO control copy and annotating the appropriate time frame on the photocopy. Please ensure that the control copy and photocopies are legible.

The redesign was done to aide the user in identifying the problem and determining the appropriate referral action.

The Form CMS-2178 U2 is not to be used for the following:

  • State Buy-in problems. (Use Form CMS-1957) See EM-00-077.

  • Medicare Premium problems. (Use Form SSA-5002 Overlay) See HI 01001.375.

  • Medicare +Advantage problems (e.g., Managed Care enrollments and disenrollments). See HI 00208.073.

B. Completion of Form CMS-2178 U2, HI/SMI Entitlement Problem Referral

Section 1.

Check the block indicating where to send the CMS-2178 U2 and circle the correct program service center (PSC), Office of Disability Operations (ODO), Office of International Operations (OIO), CMS Regional Office (RO) or CMS Central Office (CO).

Complete the date.

Section 2.

Complete the appropriate items:

  • TSC Code

  • FO Code (to be completed in all cases no matter where the form originated)

  • PSC (Circle One) and MOD

  • Contact Name

  • Unit

  • Telephone Number

  • Ext

  • FO Address

Section 3.

Complete all items:

  • Beneficiary’s Name

  • Beneficiary’s Telephone Number

  • Claim Number

  • Cross Reference Number

Section 4.

Check whether this is an Original or Follow-up request.

Section 5.

Determine whether the referral is to be made to SSA, the CMS RO or CMS CO:

Section 5A:

  • If both the Master Beneficiary Record (MBR) and the Enrollment Data Base (EDB) are incorrect, the CMS-2178 U2 referral is to the PSC, ODO or OIO. When both records are incorrect, the correction must be made to the MBR. The EDB will not be corrected independently of the MBR and all CMS-2178 U2s referred to CMS when the MBR is incorrect will be sent to a PSC, ODO or OIO as appropriate. The MBR correction will automatically update the EDB so no separate action (or CMS-2178 U2) is necessary to correct the EDB.

  • Check the block(s) which best explains the problem.

  • If the original referral was to a PSC, ODO or OIO, all follow-ups should be made to that office. Check the appropriate follow-up time frame.

The final follow-up is to be made to the appropriate SSA RO, not CMS RO.

Since the referral is being made within SSA, a Modernized Development Worksheet (MDW) should be used instead of a CMS-2178 U2 to refer the problem. Remember that the MDW cannot be used if this form has to go to CMS.

  • If the MBR has been corrected but the EDB still contains incorrect data, prepare a new CMS-2178 U2 and send to CMS CO. Check the “other” block and explain the problem in Section 6.

Section 5B:

  • If only the EDB is incorrect and the problem is not one of the three specified in Section 5C, the CMS-2178 U2 should be referred to the appropriate CMS RO. (The CMS ROs and their service areas are listed at the end of this message.)

  • Check the block(s) which best explains the problem.

  • If the original referral was to the CMS RO, the first follow-up is to the CMS RO. For the second follow-up, see the following bullet.

  • If there has been no response to the first follow-up, the second follow-up is to CMS CO. Check the block indicating a 45-day follow-up and send the CMS-2178 U2 to the address shown for CMS CO in Section 1.

Section 5C:

  • If the EDB problem is one of the three specific situations listed in Section 5C, the CMS-2178 U2 must be sent to CMS CO.

  • If the original referral was to CMS CO, the follow-up is to CMS CO.

Section 6:

If the check block in Section 5 does not fully explain the situation, use the space in Section 6 for a detailed explanation of the problem(s) and/or correction(s) needed.

Section 7:

Check whether or not a reply to the FO is requested.

Section 8:

  • This is for the PSC or CMS to complete if the FO requested an explanation.

    NOTE: CMS will not respond to the beneficiary directly.

  • Note: Some CMS ROs will reply with an electronic Administrative Message to the SSA FO.

C. CMS RO and CO Addresses

NOTE: CMS ROs service the same States as SSA ROs.

REGION I.

CMS

Beneficiary Services/Contractor Operations Branch

RM 2375 JFK Federal Building

Boston, MA 02203

REGION II.

CMS

Beneficiary Services and Providers Branch

26 Federal Plaza Room 3800

New York, NY 10278

REGION III.

CMS/DBHPP

Public Ledger Building, Suite 216

150 South Independence Mall West

Philadelphia, PA 19106

REGION IV.

CMS DBS BSB

61 Forsyth St. SW Suite 4T20

Atlanta, GA. 30303-8909

REGION V.

CMS

Beneficiary Services Branch

233 N. Michigan Ave. Suite 600

Chicago, IL 60601

REGION VI.

DHHS, CMS

Beneficiary Services Branch

1301 Young St. Room 833

Dallas, TX 75202

REGION VII.

CMS/Division of Beneficiary Services

601 E. 12th St. Room 242

Kansas City, MO 64106

REGION VIII.

CMS/Customer Relations Branch

Colorado State Bank Building

1600 Broadway Suite 700

Denver, CO 80202-4367

REGION IX.

Health Plan & Provider Operations

90 7th Street

Suite 5-300 (5W)

San Francisco, CA 94103

REGION X.

CMS/Customer Relations Branch

Suite 1600/M/S RX 300

701 Fifth Avenue

Seattle, WA 98104

Central Office

CMS

Attn: CBC, MEAG, DEEP

C2-12-16

7500 Security Blvd

Baltimore, MD 21244-1850


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600930005
HI 00930.005 - Revised Form CMS-2178 U2 (HI/SMI Entitlement Problem Referral) - 05/16/2016
Batch run: 05/16/2016
Rev:05/16/2016