TN 31 (02-97)

NL 00703.012 Usage Chart for HI/SMI Exhibit Letters

 

TypeSituation/Exhibit Manual
Section
Document
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 NL 00703.625E3625
MISCELLANEOUSNew Health Insurance Card - As a Result of Requested Changes NL 00703.609E3609
 Address Change - Returning HI Card NL 00703.610E3610
 DIB to RIB Conversion - Full retirement age PAC Reduction NL 00703.624E3624
 Notice When Claimant Protests Amount of Premium NL 00703.626E3626
 Notice When Claimant's Correspondence Contains an Incorrect Claim Number NL 00703.627E3627
 Notice When Claimant Protests Termination NL 00703.628E3628
 General “Check Box” Notice NL 00703.629E3629
 Government Medicare - Coverage Based on Disability - Coverage Begins More Than 2 Months After COM NL 00703.630E3630

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900703012
NL 00703.012 - Usage Chart for HI/SMI Exhibit Letters - 01/28/2015
Batch run: 01/28/2015
Rev:01/28/2015