Identification Number:
NL 00703 TN 92
Intended Audience:See Transmittal Sheet
Originating Office:ORDP OISP
Title:Exhibit and Dictated Letters
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part NL – Notices, Letters and Paragraphs
Chapter 007 – Letters and Paragraphs for Title II, Title XVI, and Title XVIII
Subchapter 03 – Exhibit and Dictated Letters
Transmittal No. 92, 11/10/2022

Audience

PSC: BA, CA, CCRE, CS, DS, ICDS, IES, ILPDS, IPDS, ISRA, NPR, PETE, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, BIES, BTE, CC, CDT, CR, CTE, EIE, ERE, FDE, PETL, RECONR, RECOVR;
OCO-ODO: BET, BTE, CCE, CR, CST, CT, CTE, CTE TE, DE, DEC, DS, DSE, PAS, PETE, PETL, RCOVTA, RECONE, RECOVR;
FO/TSC: CS, CS TII, CS TXVI, CSR, DRT, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

OISP

Effective Date

Upon Receipt

Background

Creating a new POMS section as part of the request submitted for notice changes under Consolidated Appropriations Act, 2021. Creating a Medicare Development Notice for development for incomplete Medicare enrollment forms when the request cannot be confirmed by phone.

Summary of Changes

NL 00703.640 Medicare Development Notice

Added new Exhibit E4064 Medicare Development Notice containing UTIs HIB319, HIB320, caption REFC01, and REF196.

NL 00703.640 Medicare Development Notice

Document Identifier for Word Processor: E4064

A. Requesting instructions

This letter is used when developing an incomplete Medicare enrollment or disenrollment request.

B. Exhibit Letter

Universal Text Identifier (UTI) or Caption

Language

HIB319

We are writing to let you know we received (1) (2).

HIB320

We reviewed (1) form and the request (2). Please call Social Security to confirm your request. We cannot process your request until you contact us or submit a new request.

REFC01

Suspect Social Security Fraud?

Please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

REF196

Need More Help?

1. Visit www.ssa.gov for fast, simple, and secure online

service.

2. Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm.

If you are deaf or hard of hearing, call TTY 1-800-325-0778.

Please mention this letter when you call.

3. You may also call your local office at (1).

 

(2)

(3)

(4)

(5)

(6)

(7)

 

How are we doing? Go to www.ssa.gov/feedback to tell us.

C. Exhibit Fill-ins

Universal Text Identifier (UTI) or Caption

Fill-ins

HIB319

  1. 1. 

    your, or Beneficiary's name (possessive)

  2. 2. 
    • CMS-40B Application for Enrollment in Medicare Part B (Medical Insurance) form

    • CMS-L564 Request for Employment Information form (or other evidence of GHP or LGHP coverage based on current employment status)

    • CMS-10797 Application for Medicare Part A and Part B – Special Enrollment Period (Exceptional Circumstances)

    • CMS-10798 Application for Enrollment in Part B Immunosuppressive Drug Coverage form

    • CMS-4040 Request for Enrollment in Supplementary Medical Insurance form

    • request for enrollment

    • CMS-1763 Request for Termination of Premium Hospital and/or Supplementary Medical Insurance form

    • returned Medicare card

    • request for disenrollment

    • (blank for dictated fill-in)

HIB320

  1. 1. 

    your, or Beneficiary's name (possessive)

  2. 2. 
    • was incomplete

    • was not signed

    • was missing accompanying Form CMS-L564 Request for Employment Information (or other evidence of GHP or LGHP coverage based on current employment status)

    • was missing accompanying Form CMS-40B Application for Enrollment in Medicare Part B (Medical Insurance)

    • was missing supporting documentation of eligibility for the SEP (Exceptional Circumstances)

    • did not have the attestation completed

    • did not have the refusal box checked

    • was submitted a significant amount of months ago

    • (blank for dictated fill-in)

REF196

  1. 1. 

    Phone number

  2. 2. 

    Address Line 1

  3. 3. 

    Address Line 2

  4. 4. 

    Address Line 3, or null

  5. 5. 

    Address Line 4, or null

  6. 6. 

    Address Line 5, or null

  7. 7. 

    Address Line 6, or null


NL 00703 TN 92 - Exhibit and Dictated Letters - 11/10/2022