If both the EDB and MBR reflect apparently incorrect HI/SMI entitlement factors or no HI and/or SMI entitlement factors at all and the FO has information, which disputes the data (or lack of data) in both records, a Form CMS-2178 with copies of the MBR and HIM are sent to the PSC via the Paperless process. This routing is necessary because the DO has no knowledge of any final determination handled in the PSC on the HI/ SMI entitlement.
In communicating an apparent MBR/EDB data problem to the PSC via a Form CMS-2178-U2, the FO will attempt to break the problem down into the specific error(s). For more information on form CMS-2178-U2, please see the PDF document below:
Priority should be taken with Forms CMS-2178-U2 since a problem can prelude the beneficiary from receiving health insurance reimbursement until you correct the MBR and EDB.
In the subsequent sections, the description of the problems being relayed by the FO relays will be used to differentiate the kinds of handling required by the Benefit Authorizer (BA) in the module. Although these Form CMS-2178-U2 procedures may not be all inclusive, FO can handle the majority of inquiries with the guidelines prescribed below. In all FO inquiry situations related to HI/SMI, a final or interim reply is sent to the inquiring FO within 20 days of receipt of the CMS-2178-U2 in the PSC. The PSC procedure for replying to the FO is below.
The BA in the module receives the Form CMS-2178-U2 via the paperless process. A copy of the form is to be retained for folder documentation once the appropriate action to be taken on the issue is determined by the PSC.
Forward the form to FO so they may determine the action taken on the issue previously presented.
If a final determination on the issue reflected on the form CMS-2178-U2 cannot be made within the 20 days referred to above, an interim reply must be sent to the appropriate FO (otherwise, the FO will send a 30-day follow-up status request). If the situation warrants an especially quick interim reply, prepare an email to the FO, referring e to the Form CMS-2178-U2 dated (MM/YYYY), and explaining why you are not sending a final reply . The email should reflect the claim number and the name of the enrollee as shown on the Form CMS-2178-U2.
Use Form SSA-3339-U2, “Interim Reply to HIB/SMIB Problem Referrals.” To send the interim reply (See HI 00825.908.). Once the interim reply is forwarded, the final reply must be made within 30 days after mailing of the interim.
If the problem is not corrected within 90 days (of the initial DO referral), the DO will refer the problem to the CMS Regional Office who in turn will contact central office. Subsequently, central office will contact the PSC. To limit the necessity for such contact, maximum control over the form CMS-2178-U2 must be maintained with the objective of correcting the MBR immediately upon the receipt of the FO referral.
The final reply to the FO should must be sent immediately after you make a determination on the issue presented on the form CMS-2178-U2. The MBR corrective action begins after the above notification been sent to the FO.
HI 00825.100 defines the procedures to be used in resolving the issues presented by the DO. HI
00825.110 explains the interpretation of the combined EDB/MBR query accompanying the form CMS-2178-U2.
In all cases, check the issue cited on the CMS-2178-U2 against the MBR response to the EDB/MBR query to verify that the allegation is in conflict with the MBR data. If the MBR and allegation agree with each other, the FO should not have referred the issue to the PSC return the entire CMS-2178-U2 package should be returned to the DO explaining the reason for return. If a conflict exists between the MBR and the allegation, handle the matter as described in the appropriate section below.