TN 31 (02-97)

NL 00703.012 Usage Chart for HI/SMI Exhibit Letters


TypeSituation/Exhibit Manual
Identifier For Word Processor
DECLINATIONSMI - Processed Declination of Coverage -Beneficiary in Current Pay Status - Refund Due NL 00703.616E3616
 SMI - Processed Declination of Coverage - Beneficiary in Suspense Status - Discard Any Bill For Premiums NL 00703.617E3617
 Beneficiary's Refusal of SMI Coverage Not Acceptable - State is Paying Premiums NL 00703.618E3618
ENROLLMENTSMI - Reenrollment During the GEP After Prior Enrollment Terminated NL 00703.602E3602
 Enrollment Beyond the Initial Enrollment Period NL 00703.603E3603
 Applied Prior to Beginning of Initial Enrollment Period NL 00703.604E3604
 SMI Denial - Not in GEP or SEP NL 00703.605E3605
ENTITLEMENTHI/SMI - Reduced HI Premium NL 00703.600E3600
 SMI Only - Eligible for Reduced Premium NL 00703.601NONE
 HI/SMI - Entitled to Mother's or Widow's Benefits - Coverage Based on Disability - Coverage Begins Within 2 Months After COM NL 00703.619E3619
 HI/SMI - Entitled to Mother's or Widow's Benefit - Coverage Based On Disability - Coverage Begins More Than 2 Months After COM NL 00703.620E3620
 HI/SMI - Based on Chronic Renal Provisions NL 00703.621E3621
INELIGIBLEIneligible For HI/SMI Coverage Due to DIB Termination NL 00703.622E3622
 Ineligible For HI/SMI Coverage Because DIB Ceased NL 00703.623E3623
WITHDRAWALSMI Reversal Request Treated as GEP Enrollment NL 00703.606E3606
 Withdrawal From SMI - Entitlement to CHAMPUS or CHAMPVA