TN 31 (02-97)

NL 00703.012 Usage Chart for HI/SMI Exhibit Letters

 

Type Situation/Exhibit   Manual
Section
Document
Identifier For Word Processor
DECLINATION SMI - Processed Declination of Coverage -Beneficiary in Current Pay Status - Refund Due NL 00703.616 E3616
SMI - Processed Declination of Coverage - Beneficiary in Suspense Status - Discard Any Bill For Premiums NL 00703.617 E3617
Beneficiary's Refusal of SMI Coverage Not Acceptable - State is Paying Premiums NL 00703.618 E3618
ENROLLMENT SMI - Reenrollment During the GEP After Prior Enrollment Terminated NL 00703.602 E3602
Enrollment Beyond the Initial Enrollment Period NL 00703.603 E3603
Applied Prior to Beginning of Initial Enrollment Period NL 00703.604 E3604
SMI Denial - Not in GEP or SEP NL 00703.605 E3605
ENTITLEMENT HI/SMI - Reduced HI Premium NL 00703.600 E3600
SMI Only - Eligible for Reduced Premium NL 00703.601 NONE
HI/SMI - Entitled to Mother's or Widow's Benefits - Coverage Based on Disability - Coverage Begins Within 2 Months After COM NL 00703.619 E3619
HI/SMI - Entitled to Mother's or Widow's Benefit - Coverage Based On Disability - Coverage Begins More Than 2 Months After COM NL 00703.620 E3620
HI/SMI - Based on Chronic Renal Provisions NL 00703.621 E3621
INELIGIBLE Ineligible For HI/SMI Coverage Due to DIB Termination NL 00703.622 E3622
Ineligible For HI/SMI Coverage Because DIB Ceased NL 00703.623 E3623
WITHDRAWAL SMI Reversal Request Treated as GEP Enrollment NL 00703.606 E3606
Withdrawal From SMI - Entitlement to CHAMPUS or CHAMPVA NL 00703.625 E3625
MISCELLANEOUS New Health Insurance Card - As a Result of Requested Changes NL 00703.609 E3609
Address Change - Returning HI Card NL 00703.610 E3610
DIB to RIB Conversion - Full retirement age PAC Reduction NL 00703.624 E3624
Notice When Claimant Protests Amount of Premium NL 00703.626 E3626
Notice When Claimant's Correspondence Contains an Incorrect Claim Number NL 00703.627 E3627
Notice When Claimant Protests Termination NL 00703.628 E3628
General “Check Box” Notice NL 00703.629 E3629
Government Medicare - Coverage Based on Disability - Coverage Begins More Than 2 Months After COM NL 00703.630 E3630

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