TN 3 (04-92)

HI 00930.110 Health Insurance Critical Case Procedure

A. Introduction

When all other Health Insurance (HI) correction efforts have failed and SSA’s Master Beneficiary Record (MBR) HI data fields are correct, CMS has responsibility for correcting the Health Insurance Master (HIM).

Regardless of the source of the problem (carrier, intermediary or beneficiary), field offices (FOs) are responsible for identifying, developing and referring problem cases to the CMS regional offices.

B. Policy

FOs may use the critical case procedures provided:

  • Beneficiary’s claim for Hospital Insurance (HI or Part A) and/or Supplementary Medical Insurance (SMI or Part B) is pending.

  • HIM has error(s).

  • Error prevents carrier or intermediary from receiving approved query response.

  • Problem still exists after all applicable correction procedures exhausted (including CMS 2178 -HI/SMI Problem Referral).

  • At least 90 days have elapsed since initial correction action.

    In the event the beneficiary’s Medicare claim(s) is being denied/ rejected by the carrier/intermediary and the MBR/HIM records are both correct the CMS 2178 is not used. These cases should be referred directly to the CMS RO for resolution.

C. Procedure - Field Offices

This chart outlines the steps required by the FOs for forwarding critical cases to the CMS RO.

1 Preface memorandum outlining nature of problem.
2 Describe action taken.
3 Submit all available evidence of entitlement including Abbreviated Accounts Query (AACT’s) and Entitlement Status Query (ESQ’s).
4 Provide copies of the CMS 2178 (if used).
5 Send envelope to CMS RO marked CMS “CRITICAL CASE.”
6 If problem is resolved after referral, cancel request to CMS RO via memorandum.

D. Procedure - Regional Offices

This chart gives an explanation of the procedures to be followed by the CMS ROs after receipt of the case from the FO.

1 Establish and maintain control of referral and followups.
2 Insure correction of Medicare records.
3 Notify FO when case resolved.
4 Supply status report to FO if corrective action not completed within 30 days of receipt of referral.

To Link to this section - Use this URL:
HI 00930.110 - Health Insurance Critical Case Procedure - 05/08/2008
Batch run: 05/08/2008