Effective Dates: 01/31/2023 - Present Previous | Next

TN 16 (01-23)

HI 00930.110 Health Insurance Critical Case Procedure

A. Introduction

When all other Health Insurance (HI) correction efforts have failed and SSA’s Master Beneficiary Record (MBR) HI data fields are correct, CMS has responsibility for correcting the Health Insurance Master .

Regardless of the source of the problem (carrier, intermediary or beneficiary), field offices (FOs) are responsible for identifying, developing and referring problem cases to the CMS regional offices.

B. Policy

FOs may use the critical case procedures provided:

  • •

    Beneficiary’s claim for Hospital Insurance (HI or Part A) and/or Supplementary Medical Insurance (SMI or Part B) is pending.

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    Health Insurance Master has error(s).

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    Error prevents carrier or intermediary from receiving approved query response.

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    Problem still exists after all applicable correction procedures exhausted (including CMS 2178 -HI/SMI Problem Referral).

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    At least 90 days have elapsed since initial correction action.

    In the event the beneficiary’s Medicare claim(s) is being denied/ rejected by the carrier/intermediary and the MBR/Health Insurance Master records are both correct the CMS 2178 is not used. These cases should be referred directly to the CMS RO for resolution.

C. Procedure - Field Offices

This chart outlines the steps required by the FOs for forwarding critical cases to the CMS RO.

STEP ACTION
1 Preface memorandum (email message)outlining nature of problem.
2 Describe action taken.
3 Submit copies all available evidence of entitlement including Abbreviated Accounts Query (AACT’s) and Entitlement Status Query (ESQ’s). Include screen-shots as attachments to your email, as appropriate
4 Provide copy of the CMS 2178 (if used).
5 Send envelope email to CMS RO marked CMS “CRITICAL CASE.”See list for the email address of the CMS ROs.
  • •

    OPLE IFM BOS@cms.hhs.gov

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    OPLE IFM NY@cms.hhs.gov

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    OPOLE IFM PHI@cms.hhs.gov

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    OPOLE IFM ATL@cms.hhs.gov

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    OPOLE IFM CHIKCGP@cms.hhs.gov

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    OPOLE IFM DALDENGP@cms.hhs.gov

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    OPOLE IFM CHIKCGP@cms.hhs.gov

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    OPOLE IFM DALDENGP@cms.hhs.gov

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    OPOLE IFM SF@cms.hhs.gov

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    OPOLE IFM SEA@cms.hhs.gov

6 If problem is resolved after referral, cancel request to CMS RO via email.

D. Procedure - Regional Offices

This chart explains the procedures to be followed by the CMS ROs after receipt of the case from the FO.

STEP ACTION
1 Establish and maintain control of referral and followups.
2 Insure correction of Medicare records.
3 Notify FO when case resolved.
4 Supply status report to FO if corrective action not completed within 30 days of receipt of referral.
To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600930110
HI 00930.110 - Health Insurance Critical Case Procedure - 01/31/2023
Batch run: 01/31/2023
Rev:01/31/2023