TN 22 (11-01)

HI 01001.375 Premium Problems

A. Policy

Premium problems are those in which there is a question about one or more of the following:

  • Incorrect premium deduction (dual Social Security, civil service, or railroad retirement premium deductions are not incorrect premium deductions). This type of problem cannot be resolved by reviewing the Health Insurance Query Response (HIQR). Use an overprint SSA-5002-HB and refer the problem to the appropriate program service center (PSC);

  • Incorrect premium billing or incorrect check amount applied to enrollee’s record;

  • Hospital Insurance-Supplementary Medical Insurance terminated for nonpayment of premiums;

  • Premium refund due;

  • Private third party group payer; or

  • Civil service deductions of premiums from an annuity.

It is very important to correctly identify the nature of the enrollee’s problem since this dictates the action to be taken.

Example: Mr. James comes into the field office (FO) and alleges nonreceipt of either a HI card or any premium bills. The Master Beneficiary Record (MBR) and the HIQR show no information on file or "NIF" even though the enrollee has alleged an apparent premium problem. This is actually an "entitlement problem" and the procedure in HI 00930.001 applies. This situation cannot be a premium problem since no entitlement exists.

Premium problems are divided into three categories: individual payer, group payer, and civil service. Individual payer problems include problems that do not involve a private third party group or civil service.

B. Process -- Problems Correction

Once it is determined that a premium problem exists, and proper documentation has been provided, proceed as follows:

  1. For individual payer problems, obtain an HIQR (see MSOM QUERIES 008.001). (There will not be a direct billing record if the beneficiary has always been in current pay status.) Make every effort to resolve the problem using the HIQR.

    For group payer and civil service problems, obtain a Master Beneficiary Record and a copy of the HIQR (Third Party).

  2. If it is necessary to refer the problem for resolution, submit your problem via the Modernized Development Worksheet (MDW) or on an overprint SSA-5002-HB to the servicing PSC. Outline the situation. If using an overprint 5002-HB, also attach documentation. The specifically designed form is shown in HI 01001.380. This form should be reproduced locally and used to document and refer premium problem cases.

    Use the SSA-5002-HB overprint form only for premium problems. Do not submit a premium problem on a HCFA -2178. The use of this form may delay resolution of the problem. The PSCs have been advised to return all HCFA-2178s that are improperly used for premium problems to the originating office.

    If the inquiry relates to a premium payment that is not shown on the direct billing record, complete the SSA-5002-HB overprint form. Attach a copy of the canceled check (back and front) and forward to:

    Centers for Medicare &Medicaid Services (CMS)
    Office of External Affair, Medicare Ombudsman Group
    Division of Ombudsman Casework & Trends Management
    7500 Security Boulevard, S1-20-2
    Baltimore, MD 21244-1850.

    For group payer and Civil Service Commission (CSC) problems, review the HIQR query to determine if the information is correct. If the inquiry cannot be resolved by reviewing the on-line HIQR, attach documentation to the SSA-5002-HB and send it to:

    The Centers for Medicare & Medicaid Services (CMS)
    Office of Information Services
    Division of Exceptions Processing
    7500 Security Boulevard, N2-05-06
    Baltimore, MD 21244-1850.

C. Procedure--Premium Problem Follow-Up

1. Individual Payer Problem Case Follow-Up Procedures

FO follow-up efforts on premium problems should be made only in accordance with the following:

a. FO Referral to PSC

If the initial problem remains unresolved 10 days after the referral, send a follow-up to the appropriate PSC and annotate in red that this is a duplicate of the original premium problem.

b. FO Referral to the Centers for Medicare & Medicaid Services (CMS)

If the initial problem remains unresolved 30 days after the referral, send a follow-up to CMS. Annotate in red, "Second Request." This follow-up should be a duplicate of the original problem referral. If the corrective action has not been taken within 45 days from the second request or if the problem is not corrected within 60 days from the original request, send a third request to CMS at the above address. Annotate "third request" on the form in red and foll