PROGRAM OPERATIONS MANUAL SYSTEMPart HI – Health InsuranceChapter 009 – Evidence of EntitlementSubchapter 30 – Resolving Entitlement ProblemsTransmittal No. 5, 06/23/2021
This is a Quick Action Transmittal and no change to policy or procedure.
Summary of Changes
HI 00930.005 Revised Form CMS-2178 U2 (HI/SMI Entitlement Problem Referral)
HI 00930.010 District Office Procedure
HI 00930.040 No Impediment Indicator, and MBR and/or HI Require Correction
HI 00930.060 Problem Correction Process
HI 00930.070 Problem Case Followup Procedures
HI 00930.110 Health Insurance Critical Case Procedure
In December 1998, CMS changed the way Medicare problem cases are processed. Many cases are now handled by the CMS Regional Office (RO) staff instead of staff in CMS Central Office (CO).
CMS has redesigned the Form CMS-2178 U2 to correspond to the processing changes. The new forms are available to SSA field offices (FOs), teleservice centers (TSCs) and processing centers (PCs) using regular distribution lists. All the old CMS-2178 U2 forms dated prior to 09/06 should be destroyed and new ones requested.
We redesigned the Form CMS-2178-U2 to aid the user in identifying the problem and determining the appropriate referral action.
In the Spring of 2021, CMS updated the CMS-2178 U2 to be an electronically fillable PDF. Both initial referrals and all follow-ups are made using this form.
The Form CMS-2178 U2 is
to be used
for the following:
State Buy-in problems. (Use Form CMS-1957) .
Medicare Premium problems. (Use Form SSA-5002 Overlay) See HI 01001.375.
Medicare +Advantage problems (e.g., Managed Care enrollments and disenrollments). See HI
Check the block indicating where to send the CMS-2178 U2 and circle the correct program service center (PSC), Office of Disability Operations (ODO), Office of International Operations (OIO), CMS Regional Office (RO) or CMS Central Office (CO).
Complete the date.
Complete the appropriate items:
FO Code (to be completed in all cases no matter where the form originated)
PSC (Circle One) and MOD
Complete all items:
Beneficiary’s Telephone Number
Cross Reference Number
Check whether this is an Original or Follow-up request.
Determine whether the referral is to be made to SSA, the CMS RO or CMS CO:
If both the Master Beneficiary Record (MBR) and the Enrollment Data Base (EDB) are incorrect, the CMS-2178 U2 referral is to the PSC, ODO or OIO. When both records are incorrect, the correction must be made to the MBR. The EDB will not be corrected independently of the MBR and all CMS-2178 U2s referred to CMS when the MBR is incorrect will be sent to a PSC, ODO or OIO as appropriate. The MBR correction will automatically update the EDB so no separate action (or CMS-2178 U2) is necessary to correct the EDB.
Check the block(s) which best explains the problem.
If the original referral was to a PSC, ODO or OIO, all follow-ups should be made to that office. Check the appropriate follow-up time frame.
The final follow-up is to be made to the appro priate SSA RO, not CMS
Since the referral is being made within SSA, a Modernized Development Worksheet (MDW) should be used instead of a CMS-2178 U2 to refer the problem. Remember that the MDW cannot be used if this form has to go to CMS.
If the MBR has been corrected but the EDB still contains incorrect data, prepare a new CMS-2178 U2 and send to CMS CO. Check the “other” block and explain the problem in Section 6.
If only the EDB is incorrect and the problem is not one of the three specified in Section 5C, the CMS-2178 U2 should be referred to the appropriate CMS RO. (The CMS ROs and their service areas are listed at the end of this message.)
If the original referral was to the CMS RO, the first follow-up is to the CMS RO. For the second follow-up, see the following bullet.
If there has been no response to the first follow-up, the second follow-up is to CMS CO. Check the block indicating a 45-day follow-up and send the CMS-2178 U2 to the address shown for CMS CO in Section 1.
If the EDB problem is one of the three specific situations listed in Section 5C, the CMS-2178 U2 must be sent to CMS CO.
If the original referral was to CMS CO, the follow-up is to CMS CO.
If the check block in Section 5 does not fully explain the situation, use the space in Section 6 for a detailed explanation of the problem(s) and/or correction(s) needed.
Sect ion 7:
Check whether or not a reply to the FO is requested.
This is for the PSC or CMS to complete if the FO requested an explanation.
NOTE: CMS will not respond to the beneficiary directly.
Note: Some CMS ROs will reply with an electronic Administrative Message to the
NOTE: CMS ROs service the same States as SSA ROs.
CMS CO:2178 Mailbox@cms.hhs.gov
CMS RO: CMS Regional
Beneficiary Services/Contractor Operations Branch
RM 2375 JFK Federal Building
Boston, MA 02203
Beneficiary Services and Providers Branch
26 Federal Plaza Room 3800
New York, NY 10278
801 Market Street
Philadelphia PA 19107-3134
CMS DBS BSB
61 Forsyth St. SW Suite 4T20
Atlanta, GA. 30303-8909
Beneficiary Services Branch
233 N. Michigan Ave. Suite 600
Chicago, IL 60601
1301 Young St. Room 833
Dallas, TX 75202
CMS/Division of Beneficiary Services
601 E. 12th St. Room 242
Kansas City, MO 64106
CMS/Customer Relations Branch
Colorado State Bank Building
1600 Broadway Suite 700
Denver, CO 80202-4367
Health Plan & Provider Operations
90 7th Street
Suite 5-300 (5W)
San Francisco, CA 94103
Suite 1600/M/S RX 300
701 Fifth Avenue
Seattle, WA 98104
Attn: CBC, MEAG, DEEP
7500 Security Blvd
Baltimore, MD 21244-1850
Check any availabel queries for a T LAF code. If a T LAF code does appear, see HI 00930.030 (A)-(E).
If there is no a T LAF code does not appear, send an HMQ (see SM 00706.005), and when the replies are received, examine them for the following:
Email the problem and copies of the replies to the appropriate reviewing office. See HI
00930.050 for the email addresses.
An impediment is indicated when the preclusion field shows YES, i.e., PCL YES on line 2 of the query reply; on SMI terminated field (PBT) Field, e.g., PATXXXX.
Refer the problem to CMS(see HI 00930.080 (C) for the email address).
Follow HI 00930.050.
Compare the following items on the health insurance master and MBR replies and with the allegation: Date(s) of entitlement to HI and SMI and any termination information. Take the following action:
Refer the problem to BSS/ CMS. This is the proper action regardless of what the health insurance master shows.
Obtain the necessary facts and refer them, together with the problem to the appropriate processing center (see HI 00930.050).
Obtain the necessary facts and refer to the appropriate processing center (see HI 00930.050).
Refer the form CMS-2178 (HIB/SMIB Entitlement Problem - Priority) to the appropriate Processing Center (PC). If the documentation agrees with the DO request, the Exceptions and Inquiries Examiner will take action to correct the MBR and will advise the DO of the action taken by completing the “Reviewing Office Reply” portion of the CMS-2178.
The PC will no longer send the CMS-2178 to CMS for correction of the health insurance record. The MBR correction should update the health insurance master and both records should be corrected within 30 days of the date of the PC action to correct. The DO must query the MBR and HI record to determine if the corrections have processed. If the MBR is still wrong 30 working days after the date of the PC action, see the procedures for followup action in HI 00930.070. If the HI record only is still incorrect, follow the procedures in section B below.
In situations where the beneficiary"s name is spelled incorrectly or the sex code is incorrect on both the MBR and the Health Insurance master, use direct input (see SM 00706.265, Exhibit W).
The DO referral is to CMSCMS notifies the DO when they corrected the health insurance master by completing the “CMS/ Reply” section of the CMS-2178. The DO must verify the correction by requesting an ESQ.
Health Insurance record problems dealing with Health Maintenance Organization (HMO) indicators or United Mine Workers of America (UMWA) jurisdiction coding should be directed to the appropriate CMS Regional Office at the address given in HI 00930.070D. Do not use the CMS-2178 for these coding problems.
(1) No final or interim reply received within 30 working days; or (2) MBR is still incorrect 30 working days after date PC took corrective action.
Send Followup copy back to the PC. If the PC had advised that corrective action was taken but the MBR is still incorrect, indicate in "Correction Needed" block that PC reply was received but MBR is still wrong. Include current query reply. Allow an additional 30 working days for the Followup to be processed.
(1) No final or interim reply is received within 30 working days; or (2) HI record is still incorrect after date CMS notifies it has been corrected.
Send Followup copy back to CMS. If CMS previously advised that corrective action was taken and the HI record is still incorrect, indicate in "Correction Needed" block that BSS reply was received but HI record is still wrong. Include current query reply. Allow an additional 30 working days for the followup to be processed.
Interim reply indicates case was misrouted and has been referred to proper component (PC or CMS).
Allow 30 working days from the date of the interim reply for the proper component to take action on the CMS-2178. If no reply from the component to which the form was referred is received within this timeframe, send Followup Copy. Allow an additional 30 working days for the followup to be processed.
If an interim or final reply is not received within 30 working days of a followup made in accordance with (A), (B) or (C) above, or if the problem is not corrected within 90 calendar days of the initial DO referral, refer the problem by memorandum to CMS, Associate Regional Administrator for Program Operations.
In the memorandum, outline the nature of the problem and DO action taken to correct it. Attach copies of all pertinent material, i.e., SSA-250, CMS-2178, processing center or BSS/CMS replies, as well as a current combined query reply.
NOTE: A current HI/MBR Status Query (HMQ) is one received in the DO no earlier than 10 working days prior to the date of referral to the CMS Regional Office.
The addresses for the CMS, Associate Regional Administrator for Program Operations in each region are:
When all other Health Insurance (HI) correction efforts have failed and SSA’s Master Beneficiary Record (MBR) HI data fields are correct, CMS has responsibility for correcting the Health Insurance Master (HIM).
Regardless of the source of the problem (carrier, intermediary or beneficiary), field offices (FOs) are responsible for identifying, developing and referring problem cases to the CMS regional offices.
FOs may use the critical case procedures provided:
Beneficiary’s claim for Hospital Insurance (HI or Part A) and/or Supplementary Medical Insurance (SMI or Part B) is pending.
HIM has error(s).
Error prevents carrier or intermediary from receiving approved query response.
Problem still exists after all applicable correction procedures exhausted (including CMS 2178 -HI/SMI Problem Referral).
At least 90 days have elapsed since initial correction action.
In the event the beneficiary’s Medicare claim(s) is being denied/ rejected by the carrier/intermediary and the MBR/HIM records are both correct the CMS 2178 is not used. These cases should be referred directly to the CMS RO for resolution.
This chart outlines the steps required by the FOs for forwarding critical cases to the CMS RO.
This chart gives an explanation of the procedures to be followed by the CMS ROs after receipt of the case from the FO.