Identification Number:
HI 00930 TN 7
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. 7, 07/09/2021

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 and procedure.

Summary of Changes

HI 00930.080 Completion and Use of the CMS-2178-U2 (HIB/SMIB Entitlement Problem — Priority)

Updated sections with email addresses.

HI 00930.070 Problem Case Followup Procedures

Updated sections with email addresses

HI 00930.110 Health Insurance Critical Case Procedure

Updated sections with email addresses

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

Updated sections with email addresses

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

  2. b. 

    CMS RO:See email address below.

 

 

REGION I.

 

OPOLE IFM BOS@cms.hhs.gov

CMS

Beneficiary Services/Contractor Operations Branch

RM 2375 JFK Federal Building

Boston, MA 02203

REGION II.

 

OPOLE IFM NY@cms.hhs.gov

CMS

Beneficiary Services and Providers Branch

26 Federal Plaza Room 3800

New York, NY 10278

REGION III.

 

OPOLE IFM PHI@cms.hhs.gov

CMS/DBHPP

801 Market Street

Suite 9400

Philadelphia PA 19107-3134

REGION IV.

 

OPOLE IFM ATL@cms.hhs.gov

CMS DBS BSB

61 Forsyth St. SW Suite 4T20

Atlanta, GA. 30303-8909

REGION V.

 

OPOLE IFM CHIKCGP@cms.hhs.gov

CMS

Beneficiary Services Branch

233 N. Michigan Ave. Suite 600

Chicago, IL 60601

REGION VI.

 

OPOLE IFM DALDENGP@cms.hhs.gov

DHHS, CMS

Beneficiary Services Branch

1301 Young St. Room 833

Dallas, TX 75202

REGION VII.

 

OPOLE IFM CHIKCGP@cms.hhs.gov

CMS/Division of Beneficiary Services

601 E. 12th St. Room 242

Kansas City, MO 64106

REGION VIII.

 

OPOLE IFM DALDENGP@cms.hhs.gov

CMS/Customer Relations Branch

Colorado State Bank Building

1600 Broadway Suite 700

Denver, CO 80202-4367

REGION IX.

 

OPOLE IFM SF@cms.hhs.gov

Health Plan & Provider Operations

90 7th Street

Suite 5-300 (5W)

San Francisco, CA 94103

REGION X.

 

OPOLE IFM SF@cms.hhs.gov

CMS/Customer Relationshions Branch

Suite 1600/M/S RX 300

701 Fifth Avenue

Seattle, WA 98104

Central Office

 

2178 Mailbox@cms.hhs.gov

Attn: CBC, MEAG, DEEP

C2-12-16

7500 Security Blvd

Baltimore, MD 21244-1850

 

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.  

    OPOLE IFM BOS@cms.hhs.gov

    John F. Kennedy Federal Bldg.
    Room 1301
    Boston, MA 02203
  2. II.  

    OPOLE IFM NY@cms.hhs.gov

    26 Federal Plaza
    Room 38-130
    New York, NY 10007
  3. III.  
    .

    OPOLE IFM PHI@cms.hhs.gov

    Public Ledger Building, Suite 216
    150 South Independence Mall West
    Philadelphia, PA 19106
  4. IV.  

    OPOLE IFM ATL Inq@cms.hhs.gov

    101 Marietta Street
    Suite 702
    Atlanta, GA. 30323
  5. V.  

    OPOLEIFMCHIKCGP@cms.hhs.gov

    233 North Michigan Avenue
    Suite 600
     Chicago, IL 60601
  6. VI.  

    OPOLEIFMDALDENGP@cms.hhs.gov

    CMS
    Beneficiary Services Branch
    1301 Young St. Room 833
    Dallas, TX 75202

  7. VII.  
    .

    OPOLE IFM CHIKCGP@cms.hhs.gov

    New Federal Office Bldg.
    601 East 12th Street
    Room 225
    Kansas City, MO 64106
  8. VIII.  
    .

    OPOLE IFM DALDENP@cms.hhs.gov

    Social Security Administration
    Denver Regional Office
    1001 17th Street
    Denver, CO 80202
  9. IX.  
    .

    OPOLEIFMSF@cms.hhs.gov

    CM 100 Van Ness Avenue
    20th Floor
    San Francisco, CA 94102
  10. X.  
    .

    OPOLE IFM SEA@cms.hhs.gov

    2901 Third Avenue
    Mail Stop 407
    Seattle, WA. 98121

HI 00930.080 Completion and Use of the CMS-2178-U2 (HIB/SMIB Entitlement Problem — Priority)

A. Use of the CMS-2178-U2

The CMS-2178-U2 (see Exhibit HI 00930.090) is a one page, fillable form that the FO or TSC can use to notify the PC and/or CMS, of needed corrections to both the MBR and the health insurance record. It is also used to effect all changes on the Health Insurance card (CMS-1966). These include misspelled given names or surnames and incorrect sex, if direct input cannot be used (see HI 00901.245). You can use the CMS-2178-U2 for entitlement issues, which cannot be correct by direct input, but not for routine premium issues.

Before using the form CMS-2178-U2 process, you should consider the use of direct input facilities such as the Post Entitlement Online System (POS).

  • If the sex codes or name on both the MBR and HI Master are incorrect, it can be corrected by updating the information via the POS. This action will subsequently update the Enrollment Data Base (EDB).

  • Date of Death – If the MBR and HI Master are incorrect, it can be corrected by updating the information via the Death Information Processing System (DIPS

Also, if a state buy-in problem exists do not use Form CMS-2178-U2. Instead, use Form CMS-1957, (See HI 00815.088.)

B. Completing the CMS-2178-U2

A fillable form CMS-2178 U2 is available by clicking on the PDF document below:

  1. 1. 

    If both MBR and HI records are incorrect, attempt to correct the address via POS or send a CMS-2178-U2 to the PC of jurisdiction via paperless. If HI record only is incorrect, send a CMS-2178-U2 to CMS via email to 2178Mailbox@cms.hhs.gov

  2. 2. 

    “From” block: Enter the complete FO mailing address, including the ZIP code. Enter the FO code in space provided. Indicate name and phone number (include area code) of person in FO to be contacted if additional information is needed. Also, annotate the office email address and phone number.

  3. 3. 

    In the appropriate space in the upper left hand corner, enter the date you email the form to CMS.

  4. 4. 

    Enter the beneficiary’s claim number, and, if applicable, any related RRB or SSA claim number.

  5. 5. 

    Enter the beneficiary’s name, address, and telephone number in the spaces provided.

  6. 6. 

    Check whether the CMS-2178-U2 is an “Original Request” or “Followup.”

  7. 7. 

    Reason for Referral:

    • Attach any documentation, e.g., SSA-250, establishing the fact and date of filing of the CMS-40B

    • Be sure to consider the direct input capabilities which exist for name, sex code, and death corrections (HI 00930.080A). Failure to use direct input when possible will delay the correction process unnecessarily.

    • Attach screen shots of pertinent MBR and HI printouts for all numbers involved.

    • Use the space provided to explain the problem situation as precisely as possible.

8. Correction Needed:

State clearly what the final result of the correction should be, i.e., how the MBR and HI record should look if accurate entitlement information is entered. Attach the documentation available to support any change.

C. Routing of the CMS-2178-U2

Use the form CMS-2178-U2 to refer all Medicare entitlement problems to the PC or CMS. It should be used to report date of death problems when direct input cannot be used. Do not use the SSA-5002 to report needed death corrections.

  1. 1. 

    When initially referring the form, check the appropriate block in the “Routing of Referral” section and the address section. . Email the form to the PC or CMS, as appropriate. Maintain a copy in NDRED. For referrals to CMS Central Office uses 2178Mailbox@cms.hhs.gov. For referrals to CMS Regional Offices, use the appropriate email from the list below:

  2. 2. 

    The PC or CMS will send a response back to the email address(es) you annotated on the form.

  3. 3. 

    When follow-up referrals to the PC or CMS are necessary (HI 00930.070), send a second email with the proper follow-up blocks checked.

  4. 4. 

    When referral to the CMS Associate Regional Administrator for Program Operations is necessary (HI 00930.070 D), email a copy of the form to document actions previously taken. For appropriate CMS RO email addresses, please reference the list above..

D. Chart of Basic Problem Situations Requiring HI Entitlement Corrections (For Critical Case Procedure, see HI 00930.110.) (For RR Involvement, see HI 00901.165.)

 

INCLUDE CURRENT MBR AND HI QUERY REPLIES WITH ALL REFERRALS (INITIAL AND FOLLOWUP).

1. ENTITLEMENT PROBLEM

a. MBR (only) or Both MBR and HI Record Incorrect

 

 

 

Initial Action Follow-up Procedure Final Follow-up
If the corrective actions cannot be resolved via POS. Send the CMS-2178-U2 via Paperless to the servicing PC. The PC technician will take action to correct the MBR and will advise the FO of action taken by completing the " Reviewing Office Reply section of the CMS-2178-U2. MBR and HI queries should be requested to verify that the MBR is corrected and has updated the HI system. No reply from PC within 30 working days of the CMS-2178-U2 referral; or MBR is still incorrect 30 working days after PC took corrective action. Send a follow-up to PC via an Modernized Development Worksheet (MDW). No reply within 30 working days of a follow-up; or problem is not corrected within 90 calendar days of initial CMS-2178-U2 referral: Send an email to the appropriate from the list above. CMS RO. Please Include a copy of the CMS- 2178-U2 to document actions taken. for email addresses.

b. HI Record (Only) Incorrect

 

 

 

Initial Action Follow-up Procedure Final Follow-up
Send an email to CMS with the CMS 2178-U2 attached. CMS will notify the FO when they take an action to correct the HI master. Verify the correction by requesting an ESQ. No reply from CMS within 30 working days of the CMS-2178 U2 referral; or HI record is still incorrect after CMS took corrective action: You should send an email to CMS indicating follow up with a copy of the CMS-2178 U2 to CMS. Check 30 Day follow up block. In "Correction Needed" section indicate either "No reply received to original CMS 2178 dated". Verify action indicated in your reply dated. HI record still incorrect". No reply within 30 working days of a follow-up; or: problem is not corrected within 90 calendar days of initial CMS-2178-U2 referral: Send an email to the appropriate CMS RO from the list above. Include a copy of CMS-2178 to document the action taken.

2. NAME/SEX CODE PROBLEM

a. Both MBR and HI Record Incorrect

 

 

 

Initial Action Follow-up Action Final Follow-up
.Use direct input. If the sex codes or name on both the MBR and HI Master are incorrect, it can be corrected by updating the information via the Post Entitlement Online System (POS) Beneficiary has not received a correct HI card after 30 working days: Request an HMQ. If HI record is correct, use HIC query procedures to generate a replacement HI card (See SM 00706.035). If both records are still incorrect, send a CMS-2178 to the servicing PC via paperless. Corrected HI card not received within 30 working days of a follow-up. Send an email to the appropriate CMS RO from the list above. .. Please include a copy of the CMS-2178-U2 to document actions taken.

b. HI Record (Only) Incorrect

 

 

 

Initial Action Follow-up Action Final Follow-up
.Send an email to CMS with the CMS-2178-U2 attached. CMS will notify the FO when they take an action to correct the HI master. Verify the correction by requesting an ESQ. No reply from CMS within 30 working days of th-U2 referral; or: HI record is still incorrect after CMS took corrective action: You should send an email to CMS. Check “30 Day Follow-up” block. In “Correction Needed” Section indicate either: “No reply received to original CMS-2178 dated .” or: “Verify action indicated in your reply dated . HI record is still incorrect." Corrected HI card is not received within 30 working days of follow-up: Refer problem to the appropriate CMS Regional Office from the list above. Include a copy of the CMS-2178-U2 to document actions taken. for email addresses.

c. MBR (Only) Incorrect

 

 

 

Initial Action Follow-up Action Final Follow-up
If the sex codes or name on both the MBR and HI Master are incorrect, it can be corrected by updating the information via the Post Entitlement Online System (POS) MBR not corrected after 30 working days: Send a CMS-2178-U2 to the servicing PC via paperless. No reply within 30 working days or MBR still incorrect 30 working days after PC took corrective action: Send an email to the appropriate CMS Regional Office from the list above. Include a copy of the CMS-2178 to document actions taken.

3. DATE/FACT OF DEATH DISCREPANCY (SEE SM 00706.075 ff.)

a. Both MBR and HI Record Incorrect

  1. 1. 

    Only Day of Death Wrong

 

 

 

Initial Action Follow-up Procedure Final Follow-up

If the MBR and HI Master are incorrect, it can be corrected by updating the information via the Death Information Processing System ( DIPS).

If day of death correction has not processed, verify original input. If error, resubmit with correct data. If no error in transmission found, fax the CMS-2178 via Paperless to the servicing PC. Include the HMQ replies and documentary Request HMQ replies on the 20th working day following email release of CMS-2178-U2 to the PC. If the day of death is still wrong, email the problem to the appropriate CMS Regional Office from the list above. Include a copy of the CMS-2178 to document actions taken.
  1. 2. 

    Month and/or Year Wrong or Date of Death Should Be Removed

 

 

 

Initial Action Follow-up Procedure Final Follow-up
If the MBR and HI Master are incorrect, it can be corrected by updating the information via the Death Information Processing System (DIPS). Request HMQ replies on the 20th working day following release of CMS-2178-U2. If still wrong, send a CMS-2178-U2 with the “follow-up” box checked to the PC via Paperless. .Request HMQ replies on the 20th working day following date of follow-up to PC. If records still wrong, email the CMS-2178-U2 to the appropriate CMS Regional Office from the list above.

b. HI Record (Only) Incorrect (To Change or Remove)

  1. 1. 

    Date of Death Not Proven

 

 

 

Initial Action Follow-up Procedure Final Follow-up
Use direct input where possible. If direct input fails, follow 2 below.
  1. 2. 

    Date of Death Proven

 

 

 

Initial Action Follow-up Procedure Final Follow-up
Send an email to CMS with a copy of the CMS-2178 U2. Include screen-shots of HMQ replies and documentary evidence. No reply form CMS within 30 working days of the CMS-2178-U2 referral; or HI record is still incorrect after CMS took Corrective action; then send an email marked "Follow-up Copy to CMS." Check “30 Day Follow-up” block. In “Correction Needed” section indicate either: “No reply received to original CMS-2178 dated .” or: “Verify action indicated in your reply dated . HI record is still incorrect.” No reply within 30 working days of a follow-up. Send an email to the appropriate CMS Regional Office from the list above.

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 screen-shots 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 7 - Resolving Entitlement Problems - 7/09/2021