Identification Number:
HI 00930 TN 5
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Resolving Entitlement Problems
Type:POMS Transmittals
Program:Medicare,Medicaid
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part HI – Health Insurance
Chapter 009 – Evidence of Entitlement
Subchapter 30 – Resolving Entitlement Problems
Transmittal No. 5, 06/23/2021

Audience

OCO-OEIO: CAQCR, CR, CR TII, DRT, EIE, FR, OA, OS, PETL, RR, SR, TA, TE, TSC-SR;
OCO-ODO: BTE, CST, 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 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

 

HI 00930.005 Revised Form CMS-2178 U2 (HI/SMI Entitlement Problem Referral)

A. Background

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 not 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 00208.073.

B. Completion of Form CMS-2178 U2, HI/SMI Entitlement Problem Referral

Section 1.

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.

Section 2.

Complete the appropriate items:

  • TSC Code

  • FO Code (to be completed in all cases no matter where the form originated)

  • PSC (Circle One) and MOD

  • Contact Name

  • Unit

  • Telephone Number

  • Ext

  • FO Address

Section 3.

Complete all items:

  • Beneficiary’s Name

  • Beneficiary’s Telephone Number

  • Claim Number

  • Cross Reference Number

Section 4.

Check whether this is an Original or Follow-up request.

Section 5.

Determine whether the referral is to be made to SSA, the CMS RO or CMS CO:

Section 5A:

  • 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 RO.

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.

Section 5B:

  • 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.)

  • Check the block(s) which best explains the problem.

  • 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.

Section 5C:

  • 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.

Section 6:

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.

Section 8:

  • 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 SSA FO.

C. CMS RO and CO Addresses

NOTE: CMS ROs service the same States as SSA ROs.

  1. a. 

    CMS CO:2178 Mailbox@cms.hhs.gov

 

 

REGION I.

CMS

Beneficiary Services/Contractor Operations Branch

RM 2375 JFK Federal Building

Boston, MA 02203

REGION II.

CMS

Beneficiary Services and Providers Branch

26 Federal Plaza Room 3800

New York, NY 10278

REGION III.

CMS/DBHPP

801 Market Street

Suite 9400

Philadelphia PA 19107-3134

REGION IV.

CMS DBS BSB

61 Forsyth St. SW Suite 4T20

Atlanta, GA. 30303-8909

REGION V.

CMS

Beneficiary Services Branch

233 N. Michigan Ave. Suite 600

Chicago, IL 60601

REGION VI.

DHHS, CMS

Beneficiary Services Branch

1301 Young St. Room 833

Dallas, TX 75202

REGION VII.

CMS/Division of Beneficiary Services

601 E. 12th St. Room 242

Kansas City, MO 64106

REGION VIII.

CMS/Customer Relations Branch

Colorado State Bank Building

1600 Broadway Suite 700

Denver, CO 80202-4367

REGION IX.

Health Plan & Provider Operations

90 7th Street

Suite 5-300 (5W)

San Francisco, CA 94103

REGION X.

CMS/Customer Relations Branch

Suite 1600/M/S RX 300

701 Fifth Avenue

Seattle, WA 98104

Central Office

CMS

Attn: CBC, MEAG, DEEP

C2-12-16

7500 Security Blvd

Baltimore, MD 21244-1850

 

HI 00930.010 District Office Procedure

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:

A. MBR Reply NIF

Email the problem and copies of the replies to the appropriate reviewing office. See HI 00930.050 for the email addresses.

B. Impediment Indicator on HI Master Tape

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.

C. HI Reply NIF (code 52)

Refer the problem to CMS(see HI 00930.080 (C) for the email address).

D. No Impediment Indicator on HI and MBR and/or HI Require Correction

Follow HI 00930.050.

HI 00930.040 No Impediment Indicator, and MBR and/or HI Require Correction

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:

A. MBR and Allegation Agree

Refer the problem to BSS/ CMS. This is the proper action regardless of what the health insurance master shows.

B. MBR and Allegation Disagree

Obtain the necessary facts and refer them, together with the problem to the appropriate processing center (see HI 00930.050).

C. MBR-NIF

Obtain the necessary facts and refer to the appropriate processing center (see HI 00930.050).

HI 00930.060 Problem Correction Process

A. If Both the MBR and Health Insurance Master are Incorrect

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).

B. If Health Insurance Master Only Is Incorrect

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.

EXCEPTION:

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.

HI 00930.070 Problem Case Followup Procedures

A. Do Referral to Processing Center (PC)

  •  

    SITUATIONS:

    (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.

    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.

B. DO Referral to CMS

  •  

    SITUATIONS:

    (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.

    ACTION:

    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.

C. Misrouted CMS-2178"s

  •  

    SITUATION:

    Interim reply indicates case was misrouted and has been referred to proper component (PC or CMS).

    ACTION:

    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.

D. Followup with CMS, Associate Regional Administrator for Program Operations

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:

  1. I.  
    ROBOSORA @cms.hhs.gov
    John F. Kennedy Federal Bldg.
    Room 1301
    Boston, MA 02203
  2. II.  
    RONYCORA@cms.hhs.gov
    26 Federal Plaza
    Room 38-130
    New York, NY 10007
  3. III.  
    ROPHIORA@cms.hhs.gov
    Public Ledger Building, Suite 216
    150 South Independence Mall West
    Philadelphia, PA 19106
  4. IV.  
    ROATLORA@cms.hhs.gov
    101 Marietta Street
    Suite 702
    Atlanta, GA. 30323
  5. V.  
    ROCHIORA@cms.hhs.gov
    233 North Michigan Avenue
    Suite 600
     Chicago, IL 60601
  6. VI.  
    RODALORA@cms.hhs.gov
    CMS
    Beneficiary Services Branch
    1301 Young St. Room 833
    Dallas, TX 75202

  7. VII.  
    ROCKCMORA@cms.hhs.gov
    New Federal Office Bldg.
    601 East 12th Street
    Room 225
    Kansas City, MO 64106
  8. VIII.  
    ROREAORA@cms.hhs.gov
    Social Security Administration
    Denver Regional Office
    1001 17th Street
    Denver, CO 80202
  9. IX.  
    ROSFOORA@cms.hhs.gov
    CM 100 Van Ness Avenue
    20th Floor
    San Francisco, CA 94102
  10. X.  
    ROSEA_ORA2@cms.hhs.gov
    2901 Third Avenue
    Mail Stop 407
    Seattle, WA. 98121

HI 00930.110 Health Insurance Critical Case Procedure

A. Introduction

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.

B. Policy

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.

C. Procedure - Field Offices

This chart outlines the steps required by the FOs for forwarding critical cases to the CMS RO.

STEP ACTION
1 Preface memorandum (email message)outlining nature of problem.
2 Describe action taken.
3 Submit copies all available evidence of entitlement including Abbreviated Accounts Query (AACT’s) and Entitlement Status Query (ESQ’s). Include screenshots as attachments to your email, as appropriate
4 Provide copy of the CMS 2178 (if used).
5 Send envelope email to CMS RO marked CMS “CRITICAL CASE.”See here for the email address of the CMS ROs.
6 If problem is resolved after referral, cancel request to CMS RO via email.

D. Procedure - Regional Offices

This chart gives an explanation of the procedures to be followed by the CMS ROs after receipt of the case from the FO.

STEP ACTION
1 Establish and maintain control of referral and followups.
2 Insure correction of Medicare records.
3 Notify FO when case resolved.
4 Supply status report to FO if corrective action not completed within 30 days of receipt of referral.

HI 00930 TN 5 - Resolving Entitlement Problems - 6/23/2021