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 item
-
-
•
FO Code (to be completed in all cases no matter where the form originated)
-
-
-
-
-
-
Section 3.
Complete all items:
-
-
•
Beneficiary’s Telephone 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 appropriate 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.
Section 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.