HI 00930.030 Health Insurance LAF Codes and Health Insurance Impediments
The LAF code on the health insurance master tape can preclude HI and SMI entitlement and can prevent the issuance of health insurance cards.
If there is a PCL YES (HI card preclusion) on line 2 or there are impediment indicators “XXXX” following HI and/or SMI termination fields, e.g., PAT XXXX on the health insurance reply, the proper course of action can depend on the LAF code shown in line 2.
The LAF codes and what they can preclude are listed below. If only the health insurance master tape contains one of these LAF codes refer the problem to BSS/CMS for correction.
However, if both the MBR and health insurance master tapes contain one of these LAF codes, it will first be necessary to undertake development to determine if the LAF code is correct. If the LAF code is not correct then refer the problem to the appropriate processing center (see HI 00930.050).
Generally, LAF codes which appear in the MBR will appear in the HI system. However, the following LAF Codes are peculiar only to the HI system:
EW-Part B termination because of elected withdrawal.
NP-Part B termination because of non payment of SMIB premiums.
RN-Part B has been reinstated.
PC-A Temporary record has been established in the HI system.
ZZ-Entitlement was previously established in error on this claim number. Impediment indicators (XXXX) will follow F trailers and T trailers.
NOTE: There may be a number of instances in which the LAF code on the MBR and health insurance master do not agree. However, if the LAF code on the health insurance master is not one of those listed below, do not refer the case to either BSS/CMS or the processing center for correction. Any LAF codes other than the ones identified do not preclude HI and SMI entitlement and do not prevent the issuance of a health insurance card.
A. LAF Codes Preventing HI Card Issuance:
SJ-Suspended under alien provision. Develop according to current procedures.
SK-Suspended because of deportation. Refer the problem to DIO.
TO-(XO)-Benefits paid by another agency (e.g., RRB), Refer the problem to RRB (see HI 00901.165).
TI (XI)-Death of beneficiary. Determine whether the beneficiary is alive (see HI 00930.050).
B. LAF Code Precluding HI Entitlement:
T3-Divorce, marriage, remarriage, (e.g., B to T case).
C. LAF Code Precluding HI Entitlement and Preventing the Issuance of a Health Insurance Card:
T4-Last entitled child attains 18 (22)
T5-Entitled to equal or greater benefits on another account.
T6-Last entitled child"s marriage or death.
T7-Last entitled child adopted prior to 10/72.
D. LAF Codes Precluding HI and SMI Entitlement and Preventing the Issuance of a Health Insurance Card:
SL-Living in barred payment country. Determine the date of the beneficiary"s return to the United States and notify the appropriate reviewing office.
T&-Withdrawal of claim.
TA-Termination prior to entitlement.
X&-Withdrawal of SMI in SMI only case.
The following do not necessarily cause impediments in the health insurance master but do present problems requiring resolution.
E. LAF Code T9-X9
Miscellaneous termination. Check the microfiche (see HI 00900.020) for a possible other claim number. If a claim number is located, prepare a HI/MBR Status Query (HMQ) and when the replies are received follow HI 00930.001. If no other claim number is located, refer the problem to the Health Insurance Inquirers Examiner of the appropriate reviewing office (see HI 00930.050). For Age 115 Termination, see SM 03020.380.
F. Dual Entitlement Code on MBR
Send a HMQ on the cross-reference claim number, and when the replies are received, forward the replies to BSS/CMS (see HI 00930.050). If the query had been submitted under the inactive number, supply the carrier or intermediary with the active claim number.
G. HI and SMI of P Option on MBR
Examine the microfiche (see HI 00901.020) for an RRB claim number for the beneficiary.
1. HI CLAIM
If the problem is a HI claim, advise the intermediary to requery under the RRB claim number.
2. SMI CLAIM
If the complaint involves a SMI claim, advise the carrier or the beneficiary to submit the claim to Travelers using the RRB claim number (see HI 00920.045).
3. HEALTH INSURANCE CARD ISSUANCE
If the problem concerns the issuance of the health insurance card, refer the inquiry to RRB.
4. ERRONEOUS P OPTION
If the microfiche does not show an RRB claim number for the beneficiary, and/ or the beneficiary alleges no new entitlement, refer the problem to the reviewing office to initiate correction action. The processing center will remove the erroneous P option and establish entitlement for the beneficiary under his SSA claim number.
H. None of the Above
Forward the problem and the query replies to the appropriate reviewing office (see HI 00930.050).