HI 00930.020 Beneficiary Dually Entitled to B and D4 Benefits

To determine which claim number is the active health insurance claim number, send a HMQ query (see SM 00706.005) on both claim numbers and observe the following when the query replies are received.

A. B Claim Number Active

The MBR reply on the B claim number has a LAF code of C (current pay) with full HI/SMI entitlement data. The MBR reply on the D4 claim number reflects the combined payment status by having a LAR code of AD.

B. D4 Claim Number Active

The MBR reply on the D4 claim number reflects the separate payment status by having LAF code other than AD (LAF code will probably be C) and shows full HI /SMI entitlement data.

The instances of finding the B claim number as the active number are diminishing. Present policy is to make the D4 the active claim number in all cases. Prior to this policy decision, however, HI/SMI entitlement was awarded on either the B or D4 depending on the payment of benefits.

If the beneficiary has a health insurance card under both the D4 and B claim numbers, the health insurance card under the inactive claim number should be recovered in accordance with HI 00901.185. The query reply on the inactive SSN, determined from the MBR reply as described above, should have a cross-referenced (XCN) followed by the active number. If the health insurance master reply shows that the B and D4 claim numbers are not properly cross-referred, refer the problem to BSS/HCFA.


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HI 00930.020 - Beneficiary Dually Entitled to B and D4 Benefits - 09/25/2012
Batch run: 09/25/2012
Rev:09/25/2012