TN 15 (11-22)
HI 00930.030 Health Insurance LAF Codes and Health Insurance Impediments
The LAF code on the health insurance master tape can preclude HI and SMI entitlement
and can prevent the issuance of health insurance cards.
If there is a PCL YES (HI card preclusion) on line 2 or there are impediment indicators
“XXXX” following HI and/or SMI termination fields, e.g., PAT XXXX on the health insurance
reply, the proper course of action can depend on the LAF code shown in line 2.
The LAF codes and what they can preclude are listed below. If only the health insurance
master tape contains one of these LAF codes refer the problem to BSS/CMS for correction.
However, if both the MBR and health insurance master tapes contain one of these LAF
codes, it will first be necessary to undertake development to determine if the LAF
code is correct. If the LAF code is not correct then refer the problem to the appropriate
processing center, see HI 00930.050.
Generally, LAF codes which appear in the MBR will appear in the HI system. However,
the following LAF Codes are peculiar only to the HI system:
-
EW-Part B termination because of elected withdrawal.
NP-Part B termination because of non payment of SMIB premiums.
RN-Part B has been reinstated.
PC-A Temporary record has been established in the HI system.
ZZ-Entitlement was previously established in error on this claim number. Impediment
indicators (XXXX) will follow F trailers and T trailers.
NOTE:
There may be a number of instances in which the LAF code on the MBR and health insurance
master do not agree. However, if the LAF code on the health insurance master is not
one of those listed below, do not refer the case to either BSS/CMS or the processing
center for correction. Any LAF codes other than the ones identified do not preclude
HI and SMI entitlement and do not prevent the issuance of a health insurance card.
A. LAF Codes Preventing HI Card Issuance:
-
SJ-Suspended under alien provision. Develop according to current procedures.
SK-Suspended because of deportation. Refer the problem to DIO.
TO-(XO)-Benefits paid by another agency (e.g., RRB), Refer the problem to RRB, see
HI 00901.165.
TI (XI)-Death of beneficiary. Determine whether the beneficiary is alive, see HI 00930.050.
B. LAF Code Precluding HI Entitlement:
T3-Divorce, marriage, remarriage, (e.g., B to T case).
C. LAF Code Precluding HI Entitlement and Preventing the Issuance of a Health Insurance
Card:
-
T4-Last entitled child attains 18 (22)
T5-Entitled to equal or greater benefits on another account.
T6-Last entitled child"s marriage or death.
T7-Last entitled child adopted prior to 10/72.
D. LAF Codes Precluding HI and SMI Entitlement and Preventing the Issuance of a Health
Insurance Card:
-
SL-Living in barred payment country. Determine the date of the beneficiary"s return
to the United States and notify the appropriate reviewing office.
T&-Withdrawal of claim.
TA-Termination prior to entitlement.
X&-Withdrawal of SMI in SMI only case.
The following do not necessarily cause impediments in the health insurance master
but do present problems requiring resolution.
Miscellaneous termination. Check the microfiche (see HI 00900.020) for a possible other claim number. If a claim number is located, prepare a HI/MBR
Status Query (HMQ) and when the replies are received follow HI 00930.001. If no other claim number is located, refer the problem to the Health Insurance Inquirers
Examiner of the appropriate reviewing office, see HI 00930.050. For Age 115 Termination, see SM 03020.380.
F. Dual Entitlement Code on MBR
Send a HMQ on the cross-reference claim number, and when the replies are received,
forward the replies to BSS/CMS (see HI 00930.050). If the query had been submitted under the inactive number, supply the carrier or
intermediary with the active claim number.
G. HI and SMI of P Option on MBR
Examine the microfiche (see HI 00901.020) for an RRB claim number for the beneficiary.
If the problem is a HI claim, advise the intermediary to requery under the RRB claim
number.
If the complaint involves a SMI claim, advise the carrier or the beneficiary to submit
the claim to Travelers using the RRB claim number, see HI 00920.045.
3. HEALTH INSURANCE CARD ISSUANCE
If the problem concerns the issuance of the health insurance card, refer the inquiry
to RRB.
If the microfiche does not show an RRB claim number for the beneficiary, and the beneficiary
alleges no new entitlement, refer the problem to the reviewing office to initiate
correction action. The processing center will remove the erroneous P option and establish
entitlement for the beneficiary under the SSA claim number.
Forward the problem and the query replies to the appropriate reviewing office, see
HI 00930.050.