The CMS-2178-U2 (see Exhibit HI 00930.090) is a one page, fillable form that the FO or TSC can use to notify the PC and/or CMS, of needed corrections to both the MBR and the health insurance record. It is also used to effect all changes on the Health Insurance card (CMS-1966). These include misspelled given names or surnames and incorrect sex, if direct input cannot be used (see HI 00901.245). You can use the CMS-2178-U2 for entitlement issues, which cannot be correct by direct input, but not for routine premium issues.

Before using the form CMS-2178-U2 process, you should consider the use of direct input facilities such as the Post Entitlement Online System (POS).

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  If the sex codes or name on both the MBR and HI Master are incorrect, it can be corrected by updating the information via the POS. This action will subsequently update the Enrollment Data Base (EDB).

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  Date of Death – If the MBR and HI Master are incorrect, it can be corrected by updating the information via the Death Information Processing System (DIPS

Also, if a state buy-in problem exists do not use Form CMS-2178-U2. Instead, use Form CMS-1957, (See HI 00815.088.)

A fillable form CMS-2178 U2 is available by clicking on the PDF document below:

1. 1. 

   If both MBR and HI records are incorrect, attempt to correct the address via POS or send a CMS-2178-U2 to the PC of jurisdiction via paperless. If HI record only is incorrect, send a CMS-2178-U2 to CMS via email to 2178Mailbox

2. 2. 

   “From” block: Enter the complete FO mailing address, including the ZIP code. Enter the FO code in space provided. Indicate name and phone number (include area code) of person in FO to be contacted if additional information is needed. Also, annotate the office email address and phone number.

3. 3. 

   In the appropriate space in the upper left hand corner, enter the date you email the form to CMS.

4. 4. 

   Enter the beneficiary’s claim number, and, if applicable, any related RRB or SSA claim number.

5. 5. 

   Enter the beneficiary’s name, address, and telephone number in the spaces provided.

6. 6. 

   Check whether the CMS-2178-U2 is an “Original Request” or “Followup.”

7. 7. 

   Reason for Referral:

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     Attach any documentation, e.g., SSA-250, establishing the fact and date of filing of the CMS-40B

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     Be sure to consider the direct input capabilities which exist for name, sex code, and death corrections (HI 00930.080A). Failure to use direct input when possible will delay the correction process unnecessarily.

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     Attach screen shots of pertinent MBR and HI printouts for all numbers involved.

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     Use the space provided to explain the problem situation as precisely as possible.

8. Correction Needed:

State clearly what the final result of the correction should be, i.e., how the MBR and HI record should look if accurate entitlement information is entered. Attach the documentation available to support any change.

Use the form CMS-2178-U2 to refer all Medicare entitlement problems to the PC or CMS. It should be used to report date of death problems when direct input cannot be used. Do not use the SSA-5002 to report needed death corrections. For inquiries that pertains to Railroad Retirement Board Medicare Issues, contact MedicareGroupMailbox.

1. 1. 

   When initially referring the form, check the appropriate block in the “Routing of Referral” section and the address section. Send form via Paperless to the PC or email to CMS, as appropriate. Maintain a copy in NDRED. For referrals to CMS Central Office uses 2178Mailbox. For referrals to CMS Regional Offices, use the appropriate email from the list below:

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     Region 1 (Boston)OPOLE_IFM_BOS

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     Region 2 (New York)OPOLE_IFM_NY

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     Region 3 (Philadelphia)OPOLE_IFM_PHI

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     Region 4 (Atlanta)OPOLE_IFM_ATL_Inq

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     Region 5 (Chicago)OPOLE_IFM_CHIKCGP

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     Region 6 (Dallas)OPOLE_IFM_DALDENGP

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     Region 7 (Kansas City)OPOLE_IFM_CHIKCGP

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     Region 8 (Denver)OPOLE_IFM_DALDENGP

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     Region 9 (San Francisco)OPOLE_IFM_SF

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     Region 10 (Seattle)OPOLE_IFM_SEA

2. 2. 

   The PC or CMS will send a response back to the email address(es) you annotated on the form.

3. 3. 

   When follow-up referrals to the PC or CMS are necessary (HI 00930.080D), send a follow-up to PC via Paperless, or in the case of a follow-up to CMS, send a second email with the proper follow-up blocks checked.

4. 4. 

   When referral to the CMS Associate Regional Administrator for Program Operations is necessary (HI 00930.0870 D), email a copy of the form to document actions previously taken. For appropriate CMS RO email addresses, please reference the list above..

5. 5. 

   For inquiries that pertains to Railroad Retirement Board Medicare Issues, contact MedicareGroupMailbox.

INCLUDE CURRENT MBR AND HI QUERY REPLIES WITH ALL REFERRALS (INITIAL AND FOLLOWUP).