Complete (C)

Notice is complete and requires no further action.

Systems Bad (S)

001

T2R cannot complete a notice in a fully automated fashion and manual intervention is required. Asterisks appear for fill-in values that cannot be determined or T2R did not generate an introductory UTI.

Instructions:

The technician needs to

• •

  complete the fill-in values, and

• •

  include an appropriate introductory paragraph.

Review (R)

Notice is complete but needs additional information.

002

The Post-MBR shows a change in payee, the Person Information database or Pre-MBR does not contain a valid address for the beneficiary, and the Representative Payee Data (REPD) line shows:

• •

  Type of Payee (TOP) is not equal to A (Self-SEL),

• •

  Custody Code (CC) is not equal to V (in payee’s custody),

• •

  Competency Code (CMC) = Y, and

• •

  The beneficiary is age 18 or older.

Instructions:

• •

  The technician reviews and sends the notice to the beneficiary to inform him or her of the new payee.

• •

  The technician can obtain the beneficiary’s address from the Representative Payee System (RPS) or Supplemental Security Income Record (SSR).

020

There is a new hospital insurance (HI) occurrence with HI-TYPE = P (PREMIUM), a new Supplementary Medical Insurance (SMI) occurrence and no Hospital Insurance Premium (HIPR), or Supplementary Medical Insurance Premium (SMPR).

Instructions:

The technician reviews the action as well as the notice. If HI/SMI is open, there should be an HIPR or SMPR occurrence on the Post-MBR.

Incomplete (I)

The notice needs additional language added. The code is generated if the following conditions are met:

003

A HI/SMI occurrence based on Disability Insurance Benefits (DIB) is established. The T2R enrollment process establishes the DIB HI (free) and SMI granting equitable relief based on the time limitation for CMS payment of Part B (SMI) bills for medical claim services.

Instructions:

The technician needs to add the AURORA (manual notice system) paragraph “Supplementary Medical Insurance based on Disability” (SMID) to the notice.

004

A beneficiary requests waiver of equitable relief for SMI (meaning the beneficiary wants the earlier SMI coverage).

Instructions:

The technician needs to add the AURORA (manual notice system) paragraph “Supplementary Medical Insurance based on Disability” (SMID) to the notice.

007

This is used for three scenarios:

The Post-MBR History Reason for Suspension or Termination (HRFST) = OTHTRM.

The HRFST = CHDTRM and there is a changed Child in Care (CIC) occurrence with the CIC-ENDRSN = Other Child Termination Reason (O).

The HRFST = Disability Insurance Benefits Cessation (DIBCES) and there is a changed CIC occurrence with the CIC-ENDRSN = Other Child Termination Reason (O).

Instructions:

The technician needs to determine the specific termination reason and add dictated language to the notice.

008

The Post-MBR History Reason for Suspension or Termination (HRFST) = CHDTRM and there is a change in more than one occurrence of Child in Care (CIC) Data. All the occurrences of changed CIC Data show the same CIC-END date with the CIC-ENDRSN = Death (D) and there is more than one deceased beneficiary.

Instructions:

The technician needs to add a paragraph using the names of all deceased beneficiaries (PIC C’s). This paragraph explains to the BIC B or BIC E that SSA terminated benefits because named C’s were the last children in their care.

009

The Post-MBR History Reason for Suspension or Termination (HRFST) = Miscellaneous (MISCEL) for any effective date that the pre-MBR does not show with the HRFST = MISCEL.

Instructions:

The technician needs to review the case to determine the reason SSA suspended the beneficiary and add dictated language to the notice.

011

On the Post-MBR, if a Prior Month Accrual Amount (PAMT) is present and is > $0.00, the PAMT-PAID date equals the Run Date and no UTIs generate under Caption INFC17. If ADJ048 or HIB111 generates, process as a complete notice.

Instructions:

The technician needs to determine why we are paying the Prior Monthly Accrual (PMA) and add language to the notice.

012

A new overpayment was established and The Historical Date of Entitlement Termination (BCLM-DOETERM) on the Post-MBR is earlier than the BCLM-DOETERM date on the Pre-MBR for the same occurrence of Beneficiary Claim Data (BCLM). We cannot use the language in UTI OPT122 when the termination changes to an earlier date.

Instructions:

The technician needs to review the case and include information about the termination date changing to an earlier date.

013

The Payee Name and Address Legend (PNAL) data does not contain the word “FOR”, "GDN OF" or "CONS OF". T2R uses the RPY073 to tell the beneficiary the name of the new payee. The RPY073 UTI value for Fill-in 1 is the new payee’s name.

Instructions:

The technician needs to fill-in the new payee’s name.

014

The Payee Name and Address Legend (PNAL) data does not contain the word “FOR”, "GDN OF" or "CONS OF". T2R uses PAY084 when the beneficiary has a new payee and a Current Amount (CAMT) check is paid. The PAY084 UTI value for Fill-in 2 is the new payee’s name.

Instructions:

The technician needs to fill in the new payee’s name.

015

The Payee Name and Address Legend (PNAL) data does not contain the word “FOR”, "GDN OF" or "CONS OF". T2R uses the PAY085 UTI when a beneficiary has a new payee and a Prior Month Accrual Amount (PAMT) and a Current Amount (CAMT) check are paid. The PAY085 value for Fill-in 2 is the new payee’s name.

Instructions:

The technician needs to fill in the new payee’s name.

016

The Payee Name and Address Legend (PNAL) data does not contain the word “FOR”, "GDN OF" or "CONS OF". T2R generates PAY126 when a beneficiary has a new payee, we paid a Current Amount (CAMT) check, and benefits are terminating Current Operating Month (COM) + 1. The PAY126 value for Fill-in 2 is the New Payee’s Name.

Instructions:

The technician needs to fill in the new payee’s name.

018

T2R terminated benefits for History Reason for Suspension or Termination (HRFST) = CHDTRM and the CIC-END date is not equal to Historical Date of Entitlement Termination (BCLM-DOETERM). The T2Redesign Enrollment and Eligibility process will use the HRFST = CHDTRM. In certain situations, the BCLM-DOETERM date does not equal the CIC-END date.

Instructions:

The technician needs to explain why the termination date does not equal the CIC-END date.

EXAMPLE: In Current Operating Month (COM) 05/04, HA dies 04/04.

Pre-MBR shows HC1 terminated HRFST = CMARRY.

Pre-MBR shows HB2 suspended HRFST = CERTEL (B2 is age 62) with CIC-END date.

Post-MBR shows HB2 terminated 04/04 HRFST = CHDTRM with CIC-END date.

019

Benefits are suspended with History Reason for Suspension or Termination (HRFST) = LEGIS2. The HRFST is used for interim processing until full automation is implemented.

Instructions:

The technician needs to review the notice to include appropriate Legislative language.

021

More than one beneficiary dies and the Beneficiary Dates of Death (BDOD) are not equal; or there are more than three dead beneficiaries and their BDODs are equal. T2R suppresses the UTI OPT133 under Caption INFC17.

Instructions:

The technician needs to fill-in the deceased beneficiaries names and dates of death when either of these situations occur.

022

Reverse Jurisdiction Start is present and the Monthly Benefit Amount (MBA) is still reduced; however, no Amount of Offset Stop Date (AMOF-STOP) is on the post-MBR.

Instructions:

The technician needs to explain why the MBA is still in offset.

025

There are more than 20 Medicare Advantage Reduction Data (MARD) occurrences from the first point of change on.

Instructions:

The technician must determine the correct MARD occurrences. Add UTIs MHP013, MHP014, MHP008 and MHP018 to the notice to explain the reduction of Part B premium due to Medicare Advantage.

NOTE: When the T2R notice process generates a complete automated notice with MHP013, MHP014 and MHP008, if there are MARD occurrences on the pre-MBR that are now wiped out, the T2R notice attempts to include the wiped out occurrences in MHP008. For a wipe out, MHP008 shows the reduction amount as $0.00 and the Supplementary Medical Insurance (SMI) amount after reduction reflects the beneficiary’s full SMI rate.

026

The History Reason for Suspension or Termination (HRFST) = TWPFRD for an ongoing or embedded period of suspension.

Instructions:

The Fraudulent Unit in the Processing Centers needs to add special language to the T2R notice.

028

The Master Beneficiary Record (MBR) is updated with a new open Hospital Insurance (HI) occurrence with the HI-TYPE = P, a new open Supplementary Medical Insurance (SMI), a new open SMI Third-Party (SMTP) occurrence, and the SMI Start date is earlier than the SMTP Start date.

Instructions:

The technician needs to determine if the beneficiary owes SMI premiums in addition to the HI premiums for months prior to the third-party start date.

029

The Income-Related Monthly Adjustment Amount (IRMAA) affects the Supplementary Medical Insurance (SMI) premium amount and there are more than three SMI premium rates and effective dates. UTI HIB005 currently only allows for three rates and dates.

Instructions:

The technician needs to provide all SMI rates and corresponding effective dates.

030

The T2R notice process determines that Income-Related Monthly Adjustment Amount (IRMAA) affects the Supplementary Medical Insurance (SMI) premium amount but after comparing the IRMAA amounts there is no change and Deductions and Additions History (DAH) data shows DAH-ITEM 175 or 180 (Part B refund).

Instructions:

The technician needs to determine if the Medicare Part B refund indicated in DAH data is due to IRMAA since there is no change in the Part B premium amount.

031

Premium Relief data is present on the Post-MBR and the Relief Establish date equals the Post-Entitlement (PE) run date. The Relief Reason is not equal to Income-Related Monthly Adjustment Amount (IRMAA) or IRMAA D.

Instructions:

The technician needs to explain the reason(s) we are offering relief for the Supplementary Medical Insurance (SMI) premiums due.

032

Going from a Variable Supplementary Medical Insurance (VSMI) rate to a non-VSMI rate and T2R does not generate the UTI HIB005. In addition, VSMI data is deleted or a VSMI-TERM date updates to the post-MBR.

Instructions:

The technician needs to review the notice to include information about the change in rate.

033

There is more than one occurrence with the History Reason for Suspension or Termination (HRFST) = WINFAL.

Instructions:

The technician needs to explain the Start and Stop dates of each WINFAL occurrence.

034

There are more than four Annual Earnings Limit amounts.

Instructions:

The technician needs to provide all the Annual Earnings amounts and date changes.

036

More than four Annual Earnings (AORE) amounts that change to zero ($0.00) exist.

Instructions:

The technician needs to provide all the years that change to zero ($0.00).

Appointed Representative (L)

We issue a copy of the beneficiary’s notice to an appointed representative. This code is generated when:

• •

  Supplemental Security Income (SSI) Windfall is processed and,

• •

  An appointed representative is present and,

• •

  The Registration, Appointment and Services for Representatives (RASR) system does not show the representative as the active principal representative who is approved for direct payment.

NOTE: T2R produced and released a complete notice to the beneficiary. A copy of that notice is in AURORA.

Instructions:

The technician should review the notice and process through Aurora. A cover letter addressed to the appointed representative on the notice should be the only change to the notice.

If the beneficiary has more than one representative, the technician sends only one copy to the principal representative per GN 03910.040C.1.Note.

NOTE: Due to the Print Mail Cost-Savings project, implemented in May 2013, do not generate ENC003 (enclosures) on the attorney copies of notices.

Manual (M)

You must prepare a manual notice because the T2R notice program cannot explain the processing situation. In most situations, you need to use dictated language to explain the T2R action. We list the conditions that require preparation of a manual notice below.

101

Limited group payer

When a group payer pays for a limited period of Medicare, prepare a manual notice. The notice needs to explain the group payer buy-in and buy-out period and the effect this period has on the beneficiary’s HI/SMI coverage.

102

Third-party wipe out processed

When a third-party wipe out action is processed, the technician needs to prepare a manual notice. Prepare a notice to explain that the third-party data is being deleted because it was erroneously established (refer to wipeout processing in SM 03040.245B.3).

103

Medicare application withdrawal processed

When the pre-MBR has an open HI/SMI occurrence and the post-MBR is updated with an HI-NONCOVRSN = X and the HI-BASIS is not End-Stage Renal-Disease (E); or an SMI-NONCOVRSN = X and the SMI-BASIS is not E. Prepare a manual notice when the HI/SMI BASIS is not E. The notice needs to explain that a withdrawal of a Medicare application was processed.

104

Monthly Benefit Amount is less than the Supplementary Medical Insurance premium amount (LESSDO) and the beneficiary is in LAF S9 with past premiums due

When the beneficiary goes from current pay status (LAF C) to suspended (LAF S9) with History Reason for Suspension or Termination (HRFST) of LESSDO (Monthly Benefit Amount is less than the Supplementary Medical Insurance premium amount), and owes past SMI premiums. Prepare a manual notice to explain the S9 suspension and the amount of any premiums due. T2R can only address the S9 suspension when it is effective with the current operation month. For instruction on processing LESSDO cases refer to SM 00850.475.

NOTE: If BENH01 is included on the manual notice, review to determine if BEN125 should be added to the notice.

105

Multiple third-party closed periods posted

If multiple third-party actions are processed and the updated MBR shows two or more closed third-party periods either being established or changed for the same coverage type, prepare a manual notice to explain the closed periods of coverage. In addition, provide the beneficiary with information regarding medical expenses for the closed periods.

106

Special Payment Amount Overpayment Disposition Amount (OPA) posted to Beneficiary Over/Underpayment Data (BOUD) – Termination status to termination status

When the pre-MBR has a Special Payment Amount (SPA) overpayment and the beneficiary is in terminated status (LAF = T (any except T1)) with post-MBR Beneficiary Over/Underpayment Data (BOUD) where the Due Process Overpayment (DPO) is equal to the pre-MBR DPO plus SPA and there is no change in the Historical Date of Entitlement Termination (BCLM-DOETERM) on the pre- and post-MBR, prepare a manual notice to advise the beneficiary of the overpayment posted to BOUD. In these situations, the SPA overpayment was incorrect and the technician should have posted the overpayment to BOUD. The T2R Summary Business Function recognizes this and is now posting the overpayment to BOUD. The T2R notice process has to assume that we never advised the beneficiary of the SPA overpayment.

107

Suspension for withdrawal claim

If benefits are suspended with History Reason for Suspension or Termination (HRFST) = WITHDR and the Beneficiary’s Date of Death (BDOD) = zeroes on the post-MBR, prepare a manual notice to send Exhibit 3700 to the beneficiary.

109

Multiple fugitive felon occurrences changed

If there is more than one changed fugitive felon (FFEL) occurrence when comparing pre-MBRs and post-MBRs, the technician needs to determine the changed occurrences and prepare a manual notice that addresses the particular warrant date(s). The T2R notice process only has language for one changed occurrence.

110

Warrant issuing agency name is blank

If the warrant-issuing agency name is blank or not available to the T2R notice process, the technician needs to determine the agency’s name and prepare a manual notice.

111

Master Beneficiary Record Originating Agency Identifier (ORI) and warrant data do not match on Fugitive Felon SSA Control File (FFSCF)

If the Fugitive Felon (FFEL) data and the Fugitive Felon SSA Control File (FFSCF) data do not match, the technician in the Program Service Center needs to determine the FFSCF data that corresponds to the FFEL occurrence. Prepare a manual notice based on the FFEL update.

112

Workers’ Compensation/Public Disability Benefits stop and no Amount of Offset (AMOF) data present

If the T2R notice process has determined that we are no longer reducing or withholding the Monthly Benefit Amount (MBA) because of WC/PDB and the post-MBR does not contain Amount of Offset (AMOF) data (the AMOF data should be present on the MBR when WC/PDB stops), the technician needs to review the MBR and prepare a manual notice that contains dictated language to explain the action.

113

Fugitive Felon (FFEL) suspension – no change in FFEL occurrences

If The T2R system suspends benefits based on the History Reason for Suspension or Termination (HRFST) of Fugitive Felon (FUGFEL), and the FFEL data was previously updated to the MBR when the beneficiary was placed in suspense for PRISON then the T2R notice process cannot determine what FFEL occurrence the suspension corresponds to because there is no change in pre-FFEL and post-FFEL data. The technician needs to determine the appropriate FFEL occurrence that corresponds to the fugitive felon suspension and prepare a manual notice.

114

Title II Interactive Computation Facility (ICF) input – Workers’ Compensation data deleted on post-MBR

If Injury or Illness (INIL) Data is present on the Pre-MBR and all INIL occurrences are deleted on the Post-MBR, the technician needs to review the case to determine why Workers’ Compensation (WC) data was deleted. Prepare a manual notice to advise the beneficiary of the findings. If payments have not changed, do not send a manual notice, see DI 52165.015B.6.