HI 00930.080 Completion and Use of the CMS-2178-U2 (HIB/SMIB Entitlement Problem — Priority)

A. Use of the CMS-2178-U2

The CMS-2178-U2 (see Exhibit HI 00930.090) is a two page form which the FO uses 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 (HCFA-1966). These include misspelled given names or surnames and incorrect sex, if direct input cannot be used (see HI 00901.245). The CMS-2178-U2 should be used for entitlement issues which cannot be corrected by FO direct input, and not for routine premium issues.

Before using the form CMS-2178-U2 process, consideration must be given to use of the following direct input facilities:

  1. Form SSA-3709 (MBR corrections)—To correct name/sex/day of death data in the MBR. This action will subsequently update the HIM. (See SM 00706.075-SM 00706.080.)

  2. Form HCFA-3274 (HI corrections)—To change or remove date of death data in the HI system only. (See SM 00706.090.)

  3. Form SSA-2467 (Request for HI/MBR/SSR Information or HI card)—To request replacement HI card issuance. (See SM 00706.035.)

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

B. Completing the CMS-2178-U2

  1. Use a ball point pen or typewriter to insure that all copies are legible.

  2. Check the appropriate address box. If both MBR and HI records are incorrect, send to PC having jurisdiction of folder. If HI record only is incorrect, send to CMS.

  3. “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.

  4. In the appropriate space in the upper right hand corner, enter the date the form is forwarded to the PC or CMS.

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

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

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

  8. Reason for Referral:

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

    • 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.

    • You check C block 2, attach MBR and HI printouts for all numbers involved.

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

  9. 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. Also, attach current HI and MBR queries.

C. Routing of the CMS-2178-U2

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.

  1. When initially referring the form, check the appropriate block in the “Routing of Referral” section and the address section. Send the blue original and yellow copy. Retain the DO Followup Copy (pink) and the DO Control Copy (white).

  2. The PC/BSS will retain the yellow copy and send a response back to the district office on the blue original.

  3. When followup referrals to the PC or BSS are necessary (HI 00930.070), send the pink DO Followup Copy with the proper followup blocks checked.

  4. When referral to the CMS Associate Regional Administrator for Program Operations is necessary (HI 00930.070 D), send a photocopy of the white DO Control Copy of the form to document actions previously taken.

D. Chart of Basic Problem Situations Requiring HI Entitlement Corrections (For Critical Case Procedure, see HI 00930.110.) (For RR Involvement, see HI 00901.165.)

 

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

1. ENTITLEMENT PROBLEM

a. MBR (only) or Both MBR and HI Record Incorrect

Initial ActionFollowup ProcedureFinal Followup
Send blue original and yellow copy of CMS- 2178 to the servicing PC. The Exceptions and Inquiries Examiner will take action to correct the MBR and will advise the DO of action taken by completing the "Reviewing Office Reply" section of the CMS-2178. MBR and HI queries should be requested to verify that the MBR is corrected and has updated the HI system.No reply from PC within 30 working days of the CMS-2178 referral; or MBR is still incorrect 30 working days after PC took corrective action Send pink DO Followup Copy to PC. Check “30 Day Followup” block. In “Correction Needed” section indicate either “No reply received to original CMS-2178 dated         .”or: “Verify correction indicated in your reply dated        . MBR still incorrect.”No reply within 30 working days of a followup; or problem is not corrected within 90 calendar days of initial CMS-2178 referral: Send problem to CMS RO (HI 00930.070D). Include photocopy of white DO Control Copy of CMS-2178 to document actions taken.

b. HI Record (Only) Incorrect

Initial ActionFollowup ProcedureFinal Followup
Send blue original and yellow copy of CMS-2178 to CMS, BSS. BSS will notify the DO whenaction has been taken to correct the HImaster. Verify the correction by requesting an ESQ.No replay from BSS within 30 working days of the CMS-2178 referral; or: HI record is still incorrect after BSS took corrective action: Send pink DO Followup Copy to BSS. Check 30 Day Followup block. In “Correction Needed” section indicate either “No reply received to original CMS-2178 dated        .” or: “Verify action indicated in your reply dated      . HI record still incorrect.”No reply within 30 working days of a followup; or: problem is not corrected within 90 calendar days of initial CMS-2178 referral: Send problem to CMS RO (HI 00930.070D). Include photocopy of white DO Control Copy of CMS-2178 to document action taken.

2. NAME/SEX CODE PROBLEM

a. Both MBR and HI Record Incorrect

Initial ActionFollowup ActionFinal Followup
Use direct input. Submit form SSA-3709 (See Desk Guide - SM 00706.265, Ehibit W).Beneficiary has not received a correct HI card after 30 working days: Request an HMQ. If HI record is correct, use HIC query procedures to generate a replacement HI card (See SM 00706.035). If both records are still incorrect, send blue original and yellow copy of CMS-2178 to the servicing PC. Indicate in “Correction Needed” block that SSA-3709 was transmitted but failed to correct records. The PC will advise the DO of action taken by completing the “Reviewing Office Reply” section of the CMS-2178. MBR and HI queries should be requested to verify that the MBR is corrected and has updated the HI system.Corrected HI card not received within 30 working days of a followup. Refer problem to CMS RO (HI 00930.070D). Include photocopy of white DO Control Copy of CMS-2178 to document actions taken.

b. HI Record (Only) Incorrect

Initial ActionFollowup ActionFinal Followup
Send blue original and yellow copy of CMS-2178 to BSS. BSS will notify the DO when action has been taken to correct the HI master.
Verify the correction by requesting an ESQ.
No reply from BSS within 30 working days of the CMS-2178 referral; or: HI record is still incorrect after BSS took corrective action: Send pink “DI Followup Copy” to BSS. Check “30 Day Followup” block. In “Correction Needed” Section indicate either: “No reply received to original CMS-2178 dated       .” or: “Verify action indicated in your reply dated       . HI record is still incorrect.”Corrected HI card is not received within 30 working days of followup: Refer problem to CMS Regional Office. Include photocopy of white DO Control Copy actions taken.

c. MBR (Only) Incorrect

Initial ActionFollowup ActionFinal Followup
Use direct input. Submit form SSA-3709 (See Desk Guide - SM 00706.265, ExhibitW).MBR not corrected after 30 working days: Send blue original and yellow copy of form CMS-2178 to the servicing PC.No reply within 30 working days or MBR still incorrect 30 working days after PC took corrective action: Refer to CMS Regional Office. Include photocopy of white DO Control Copy of CMS-2178 to document actions taken.

3. DATE/FACT OF DEATH DISCREPANCY (SEE SM 00706.075 ff.)

a. Both MBR and HI Record Incorrect

  1. Only Day of Death Wrong

Initial ActionFollowup ProcedureFinal Followup
Use direct input. Submit form SSA-3709. (SM 00706.080).Request HMQ replies on the 10th working day following the SSA-3709 input. If day of death correction has not processed, verify original input. If error, resubmit with correct data. If no error in transmission found, send blue original and yellow copy of CMS-2178 to the PC. Include HMQ replies and documentary evidence.Request HMQ replies on the 20th working day following release of CMS-2178 to the PC. If day of death still wrong, refer problem to the CMS Regional Office. Include photocopy of white DO Control Copy of CMS-2178 to document actions taken.
  1. Month and/or Year Wrong or Date of Death Should Be Removed

Initial ActionFollowup ProcedureFinal Followup
Send blue original and yellow copy of CMS-2178 to servicing PC. Include HMQ replies and documentary evidence.Request HMQ replies on the 20th working day following release of CMS-2178. If still wrong, send pink DO Followup Copy to PC.Request HMQ replies on the 20th working day following date of followup to PC. If records still wrong, refer problem to the CMS Regional Office. Include photocopy of white DO Control Copy of CMS-2178 to document actions taken.

b. HI Record (Only) Incorrect (To Change or Remove)

  1. Date of Death Not Proven

Initial ActionFollowup ProcedureFinal Followup
Use direct input. Submit form HCFA-3274. (SM 00706.095). If direct input fails, follow 2 below.  
  1. Date of Death Proven

Initial ActionFollowup ProcedureFinal Followup
Send blue original and yellow copy of CMS-2178 to BSS. Include HMQ replies and documentary evidence.No reply from BSS within 30 working days of the CMS-2178 referral; or HI record is still incorrect after BSS took corrective action; then send pink DO Followup Copy to BSS. Check “30 Day Followup” block. In “Correction Needed” section indicate either: “No reply received to original CMS-2178 dated     .” or: “Verify action indicated in your reply dated     . HI record is still incorrect.”No reply within 30 working days of a followup; send problem to CMS Regional Office. Include photocopy of white DO Control Copy of CMS-2178 to document actions taken.

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HI 00930.080 - Completion and Use of the CMS-2178-U2 (HIB/SMIB Entitlement Problem -- Priority) - 05/21/2013
Batch run: 05/21/2013
Rev:05/21/2013