TN 1 (03-07)

HI 01194.065 IRMAA Reconsideration Dismissal (Notice Type 580)

A. Purpose/Use

We will dismiss requests for reconsiderations when the request is based on a beneficiary belief that IRS sent data that are not correct. We will advise the beneficiary to contact the IRS to obtain proof of the IRS error, and if provided we will use the corrected information to make a new initial determination. We will also send a dismissal notice when the request for reconsideration was made outside of acceptable timeframes. No appeal rights are included in dismissal notices.

B. Sample – IRMAA Reconsideration Dismissal, Title II Beneficiary, Reconsideration Dismissed Because it is Based on Incorrect IRS Information, and Must be Processed as A New Initial Determination

Social Security Administration

Medicare Part B Premium

Important Information

Return Address

Date

Claim Number: xxx-xx-xxxxA

Beneficiary Name

Beneficiary Address

We have dismissed your request for a reconsideration of our decision about your Medicare Part B income-related monthly adjustment amount. You told us that the information we used from the Internal Revenue Service (IRS) is incorrect. In order for us to change that information, you must get the correct tax information from IRS for 2005 and provide it to us. We may be able to use your correct information to make a new decision. If you have already requested your tax return information from IRS, and have not yet received it, contact us. You should also read the information below about other information that we may be able to use to make a new decision.

If You Have Any Questions

If you have questions about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4273, TTY 1-877-486-2048).

If you have questions about your Medicare Part B premium, please visit www.medicare.gov on the Internet. For general information, you can visit our website at www.socialsecurity.gov. You also can call us at 1-800-772-1213 and speak to a representative from 7 a.m. to 7 p.m. on business days. If you have a touch-tone phone, recorded information and services are available 24 hours a day. We can answer most questions over the phone. If you are deaf or hard of hearing, you can call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

Address of field office

If you call or visit an office, please have this letter with you. It will help us to answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

(Signature)

Regional Commissioner

C. Sample – IRMAA Reconsideration Dismissal, Title II Beneficiary, Reconsideration Dismissed Because It was Made Outside of the 60 Day Time Frame for Appeal and Good Cause Not Established

Social Security Administration

Medicare Part B Premium

Important Information

Return Address

Date

Claim Number: xxx-xx-xxxxA

Beneficiary Name

Beneficiary Address

We are writing to you about your request for a reconsideration of our determination about your Medicare Part B income-related monthly adjustment amount. Because you waited more than 60 days after you received our letter explaining that determination, and you did not have a good reason for the delay, we must dismiss your request.

You Asked for a Review Too Late

We sent you our letter on May 18, 2007 explaining our determination about your Medicare Part B income-related adjustment amount. The letter explained that you could request a reconsideration within 60 days following receipt of the letter. The 60 days started the day after you received the letter. You asked for a review on September 5, 2007. This is after the 60-day time limit.

If You Have Any Questions

If you have questions about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4273, TTY 1-877-486-2048).

If you have questions about your Medicare Part B premium, please visit www.medicare.gov on the Internet. For general information, you can visit our website at www.socialsecurity.gov. You also can call us at 1-800-772-1213 and speak to a representative from 7 a.m. to 7 p.m. on business days. If you have a touch-tone phone, recorded information and services are available 24 hours a day. We can answer most questions over the phone. If you are deaf or hard of hearing, you can call our TTY numb