Identification Number:
HI 00825 TN 11
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Inquiries and Referrals for HI/SMI
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 25 – Inquiries and Referrals for HI/SMI
Transmittal No. 11, 07/16/2021

Audience

PSC: BA, CS, ICDS, IES, ILPDS, IPDS, PETE, SCPS, TSA, TST;
OCO-OEIO: BET, BIES, EIE, ERE, FCR, PETL;
OCO-ODO: BET, BTE, CCE, CTE TE, DEC, EHI, LCC, PAS, PETE, PETL, RECONR;

Originating Component

CMS

Effective Date

Upon Receipt

Background

 

Summary of Changes

HI 00825.095 Form CMS-2178, HIB/SMIB Entitlement Problem — Priority

 

HI 00825.100 Entitlement Issue

 

HI 00825.095 FormCMS-2178-U2, HIB/SMIB Entitlement Problem — Priority

The Form CMS-2178-U2, HIB/SMIB Entitlement Problem - Priority (see HI 00930.005 ) is designed to provide a coordinated and efficient method of effectuating appropriate entitlement corrections. You use CMS 2178 to (correct HI and/or SMI coverage or non-coverage, whether prior or current, etc.,) to both the Enrollment Data Base (EDB) and/or MBR by means of referral from the FO to the PSC and/or CMS, OMB.

For more information on form CMS-2178-U2, please see the PDF document below:

To preclude an incorrect referral, all FOs have a query facility into both the EDB and MBR records. Therefore, whenever a FO receives a complaint relating to HI and/or SMI entitlement issues (including health insurance card issues), the FO, the EDB and MBR systems are queried. Based on the data available in both master records, the FO takes the following steps to have the issue resolved:

A. HIM Incorrect

If the HI/SMI information on the MBR is correct based on the allegation but the EDB data is incorrect, it is apparent that any action produced from the EDB would reflect the alleged incorrect data. Since the EDB issues health insurance cards , and is the process we use to pay HI/SMI benefits, that record must be corrected. CMS, OMB has the means of accomplishing corrective actions to the EDB, which are consistent with data contained on the MBR. Therefore, the FO and CMS, OMB takes the appropriate action to correct the EDB record without contacting the PC.

B. MBR and EDB Incorrect

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.

HI 00825.100 Entitlement Issue

Resolve entitlement issues following the instructions pertaining to the various situations indicated in this section.

A. Entitlement to a current period of HI or SMI coverage is not shown

The field office (FO) receives an allegation of Health Insurance (HI) or Supplemental Medical Insurance (SMI) entitlement but no record of such entitlement is on the master beneficiary record (MBR) or the enrollment database (EDB).

The FO explains the facts of the case in the “Reason for Referral” portion of the form CMS-2178-U2, HI/SMI Entitlement Problem Referral. The FO faxes the CMS-2178-U2 to:

  • program service center (PSC) of jurisdiction via the dedicated paperless fax number based on the MBR, or for

  • Medicare eligibility issues for End-Stage Renal Disease (ESRD) fax into paperless to PSC 7 regardless of MBR PSC, or for

  • Medicare eligibility issues for the Disabled Working Individual (DWI) – Section 6012 – fax to PSC 7 regardless of MBR PSC.

For more information on form CMS-2178-U2, please see the document below:

The PSC will scan and convert the faxed document to an image for electronic (paperless) processing and direct to a Benefit Authorizer (BA). The BA should check for:

  • An image in paperless,

  • A Processing Center Action Control System (PCACS) or Paperless Read Only Query System (PPL ROQS) item,

  • T2 exception on the Transaction History Query (THIS),

  • A Daily Update Master Accounting System (DUMAS) exception,

  • A Manual Adjustment Credit and Award Process/ Manual Adjustment Credit and Award Data Entry System (MADCAP/MACADE) exception, etc., (in case the enrollment action processed after the FO sent the CMS-2178-U2).

If necessary, the BA requests the Information Retrieval Group (IRG), via PCACS for a review of the claims folder. If the folder review reveals

  • an unprocessed general enrollment application in file; or

  • The claimant is entitled to HI or SMI as alleged but the award form A-101 (or the electronic form 101, EF-101) has not been processed.

The reviewer should fax the documented proof to the requesting technician for processing. After processing, the technician should send an interim reply to the FO using District Office Telephone Procedures (DOTEL), PCACS, or the Modernized Development Worksheet (MDW).

If the folder review reveals a processed manual action or computer output reflecting HI or SMI entitlement as alleged, compare the processing dates of the folder document with the MBR update month reflected on the MBR query reply, included with the form CMS-2178-U2 (scanned documents). When the MBR update month on the query reply is earlier than the intended MBR update of the folder document, obtain a current MBR .to verify that the action on the folder document actually updated the MBR. If the MBR is updated with the current information, notify the FO via DOTEL, PCACS, or the MDW.

If the MBR does not reflect the entitlement factor in the later MBR update month, an exception or some other problem has occurred and the BA should reprocess the final action and notify the FO via DOTEL, PCACS, or the MDW.

If the folder review reveals no record of HI or SMI, as alleged on the CMS-2178-U2, determine if any inconsistencies may have occurred which would prevent an update to the MBR. If so, send an interim reply to the FO as noted in HI 00825.095. If a record of enrollment was located, use MACADE/ MADCAP to process the enrollment. Notify the FO of the final findings as noted in HI 00825.095.

If the entitlement factors do not coincide with one of the prior enrollment periods, notify the FO regarding the findings via DOTEL, PCACS, or the MDW.

NOTE: Attainment of age 65 or 25 months of entitlement to disability benefits by an insured beneficiary automatically entitles that claimant to free HI coverage.

If the folder contains correspondence, which could be an implied request for HI/SMI entitlement, the Claims Technical Examiner (CTE), makes a determination.

  • If the claimant is not entitled to HI or SMI, notify the FO of the findings via DOTEL, PCACS, or the MDW.

  • If the claimant is entitled to HI or SMI, notify the FO as noted in HI 00825.095. Take action to have the entitlement recorded on the MBR.

See Reference:

  • HI 00825.095, Form CMS-2178-U2, HIB/SMIB Entitlement Problem — Priority

B. Entitlement to a prior period of HI or SMI coverage is not shown

The FO receives an allegation of HI/SMI entitlement, which is prior to a current period of HI/SMI coverage, but no record of a prior period of coverage is on the MBR or EDB (CMS database). The FO explains the facts of the case in the “Reason for Referral” portion of the referral form. Upon receipt of the CMS-2178-U2, review the claims folder and take the following actions if

  1. 1. 

    Prior period of coverage exists. If a prior period of HI/SMI coverage exists, annotate the prior period of entitlement to the MBR via MACADE. Notify the FO of the pertinent HI/SMI entitlement data via DOTEL, PCACS, or the MDW.

    NOTE: The MBR contains up to 20 occurrences for SMI and 10 occurrences for HI. If the beneficiary becomes entitled to a new period of coverage and this exceeds the maximum number of occurrences, the earliest occurrence drops and the new occurrence is added to the MBR.

  2. 2. 

    Prior period of coverage does not exist. If no prior period of HI/SMI coverage exists, document the file and notify the FO via DOTEL, PCACS, or the MDW.

For more information on form CMS-2178-U2, please see the document below:

C. HI or SMI entitlement dates appear to be incorrect

The FO receives an allegation that the HI/SMI entitlement dates on the MBR or EDB are incorrect. The FO explains the facts of the case in the “Reason for Referral” portion of the referral form and includes any available proofs. Upon receipt of the CMS-2178-U2, review the claims folder as shown in section A. Take the following actions if the folder examination reveals:

  1. 1. 

    EDB and MBR are incorrect. If the entitlement date(s) reflected on the MBR and EDB are incorrect, take corrective action, and advise the FO accordingly, (i.e., date of entitlement to SMI and date of entitlement to HI).

  2. 2. 

    MBR is suspect. If the data on the MBR is questionable have the CTE, determine the correct entitlement dates and prepare an interim reply to the FO. If the CTE verifies that the MBR date(s) is incorrect, take appropriate action from item 1. If the CTE determines that the MBR and EDB dates are correct as posted, take appropriate action in item 3.

  3. 3. 

    EDB and MBR are correct. If the data on the MBR and EDB are correct and the allegation on the CMS-2178-U2 is incorrect, inform the FO and request proofs to support the original allegation if the enrollee still disagrees with the MBR data.

D. SMI termination or withdrawal data appears incorrect

The FO receives an allegation that the SMI termination or withdrawal data on the MBR and EDB is incorrect. The FO explains the facts of the case in the “Reason for Referral” portion of the form and includes any available proofs.

Upon receipt of the CMS-2178-U2, review the claims folder as shown in section A.

Take the following actions if the folder examination reveals:

  • a protest to a SMI termination action for nonpayment of premiums is questioned, the FO should not to use the Form CMS-2178-U2 to transmit their determination on the protest. If the FO makes an error of this type, return all copies of the CMS-2178-U2 and request the FO to follow HI 01001.375 in handling this type of situation.

  • a potentially erroneous date of termination, withdrawal, or protest of a withdrawal action, handle the case as follows:

    1. 1. 

      MBR is incorrect. When the SMI termination or withdrawal date on the MBR is incorrect and the allegation on the CMS-2178-U2 is correct, take corrective action.

    2. 2. 

      MBR is correct. When the termination or withdrawal date on the MBR is correct and the allegation on the CMS-2178-U2 is incorrect, explain the findings to the FO.

    3. 3. 

      MBR is suspect. When the data on the MBR is suspect, the CTE makes the final determination and takes the following action

      • If the MBR data is correct, follow the instructions in item 2 , or

      • If the MBR data is incorrect, follow the instructions in item 1.

See Reference


HI 00825 TN 11 - Inquiries and Referrals for HI/SMI - 7/16/2021