Effective Dates: 03/15/1999 - Present Previous | Next

HI 00825.906 Sample MBR Reply to Combined MBR/HIM Query

Identification —111-01-1111 M JONES, 12 PCI
Address —1256 SOUTH ST, 40726
Beneficiary —M U 0601P 1273 M 0174 MARY J. SMITH
Current HIB —0773 Y 33.00 1273 S33 0773 1273
Current SMIB —0766 Y 7.20 1273 330 0766 1273
Cross-Reference —M 316-91-2454 PC 4
—W 33 632324789151

LINE 1

Identification 111-01-1111 M JONES,   P   PSC1
​      1   2    3     4    5
  1. (1) 

    SSN (from the SSA-2467)

  2. (2) 

    BIC

  3. (3) 

    Name (from the SSA-2467)

  4. (4) 

    Unit Identifier (from the SSA-2467)

  5. (5) 

    PSC number

LINE 2

Address 1256 SOUTH ST. 40726 (No city or state shown)
​      1           2
  1. (1) 

    First line of address on MBR

  2. (2) 

    ZIP Code

LINE 3

Beneficiary M U 0601 P 1273 M 0174 Mary J. Smith
​ 1 2  3 4  5 6  7     8
  1. (1) 

    BIC

  2. (2) 

    LAF

  3. (3) 

    DOB

  4. (4) 

    Proof of DOB

  5. (5) 

    DOD

  6. (6) 

    LAP Code

  7. (7) 

    LAP Date

  8. (8) 

    Name of MBR

  9. (9) 

    Sex Code

 

LINE 4

Current HIB 0773 Y 33.00 1273 S33 0773 1273
​  1 2  3   4   5   6   7
 
  1. (1) 

    Part A Entitlement Date

  2. (2) 

    Current Part A Option Code

  3. (3) 

    Premium Amount Collectable Part A

  4. (4) 

    Date of Termination Part A

  5. (5) 

    Third Party Code Part A

  6. (6) 

    Third Party Entitlement Date Part A

  7. (7) 

    Third Party Termination Date Part A

LINE 5

Current SMIB 0766 Y 7.20 1273 330 766 1273
​  1  2   3   4   5   6   7
 
  1. (1) 

    Part B Entitlement Data

  2. (2) 

    Current Part B Option Date

  3. (3) 

    Premium Amount Collectable Part B

  4. (4) 

    Date of Termination Part B

  5. (5) 

    Third Party Code Part B

  6. (6) 

    Third Party Entitlement Date Part B

  7. (7) 

    Third Party Termination Date Part B

LINE 6

Cross-Reference M 316-01-2454 PSC 4
​ 1     2         3
 
  1. (1) 

    Type of cross-reference

  2. (2) 

    Cross-reference SSN (up to nine SSN's)

  3. (3) 

    PSC number

​ W 33 632324789151
​ 1 2         3
 
  1. (1) 

    Welfare indicator

  2. (2) 

    State code (first two digits of State code)

  3. (3) 

    Welfare number (up to twelve digits)

LINE 7

Security Income Data A 0174 C 12345 0175 A
​ 1  2  3    4   5 6
  1. (1) 

    Security income file type (SIFT)

  2. (2) 

    Security income entitlement/termination date (SIED)

  3. (3) 

    Security income status code (SISC)

  4. (4) 

    State and county code of residence (SCCR)

  5. (5) 

    Security income effective date of residence change (EDRC)

  6. (6) 

    Security income living arrangement code (SILAC)

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600825906
HI 00825.906 - Sample MBR Reply to Combined MBR/HIM Query - 03/15/1999
Batch run: 03/29/2017
Rev:03/15/1999