Identification Number:
HI 00805 TN 42
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Supplementary Medical Insurance Entitlement
Type:POMS Transmittals
Program:Medicare,Medicaid
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part HI – Health Insurance
Chapter 008 – Requirement for Entitlement and Termination
Subchapter 05 – Supplementary Medical Insurance Entitlement
Transmittal No. 42, 05/06/2021

Audience

PSC: BET, BTE, CR, CST, CTE, DEC, EHI, LCC, PAS, PCS, PETL, RECONR;
OCO-OEIO: BET, BIES, CCRE, CR, CTE, EIE, ERE, FCR, PETL, RECONE, RECONR;
OCO-ODO: BET, BTE, CR, CST, CTE, CTE TE, DEC, PAS, PETE, PETL;
FO/TSC: CS, CS TII, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

CMS

Effective Date

Upon Receipt

Background

This is a Quick Action Transmittal and no change to policy or procedure.

Summary of Changes

HI 00805.175 Evidence of Government Error or Delay

Updated the information with new language:

In cases involving alleged misinformation from WSU, WSU management should assess the likelihood that misinformation was given

 

HI 00805.175 Evidence of Government Error or Delay

A. Introduction

In most cases, the file shows that an error occurred, e.g., delay in awarding entitlement, erroneous termination, failure to bill for or deduct premiums, disallowance reversed on appeal. In other cases, an allegation by the beneficiary may be the first indication that an error occurred.

B. Policy - Substantiation of alleged errors

The individual may allege that his/her rights were prejudiced due to misinformation received. Such allegations must be substantiated.

The Government employee or agent identified as having given the misinformation should report his/her recollection of the event. If the employee cannot recall the interview or discussion, he/she should nevertheless report on the probability that he/she gave the misinformation or misadvice that the individual claims receiving.

If the Government employee or agent cannot be identified for any reason, a statement should be made by the supervisor or other person in authority as to the likelihood of such an error. NOTE: This statement may be based on the supervisor's observations of the type of errors known to have been committed in the FO, the fact that there was a preponderance of trainees who could have interviewed the beneficiary when the alleged error occurred, etc.

In cases involving alleged misinformation from a TSC, FO management should assess the likelihood that misinformation was given.

In cases involving alleged misinformation from WSU, WSU management should assess the likelihood that misinformation was given

C. Policy - Required documentation

Equitable relief may not be granted unless the file contains documentary evidence. The evidence can be in the form of statements from employees, agents, or persons in authority that the alleged misinformation, misadvice, misrepresentation, inaction, or erroneous action actually occurred.

In the absence of such personal knowledge, the evidence can consist of a statement that there is a strong likelihood based on personal knowledge or prior experience that an error occurred.


HI 00805 TN 42 - Supplementary Medical Insurance Entitlement - 5/06/2021