DI 45001.020 Processing ESRD Claims of Railroad Retirement Beneficiaries

The FO’s should process most of the initial ESRD Medicare claims involving the Railroad Retirement Board (see DI 45001.324). ERE’s should only become involved when initial ESRD Medicare allowances result from reconsideration or higher appeals decisions, referrals from quality review components or an inquiry from CMS, OD, RO, etc.

The basic issue concerning railroad retirement beneficiaries entitled to Medicare based on ESRD is whether SSA or the RRB is responsible for billing for SMI premiums. For the purpose of the ERE"s responsibility for resolving this issue in the adjudication of initial ESRD Medicare allowances, the ERE needs only to determine if: (a) the claimant is already entitled to Medicare based on age 65 or disability and (b) RRB has jurisdiction of the claim. If so, the RRB is responsible for billing for SMI premiums; otherwise, SSA is responsible for billing for SMI premiums.

The ERE will determine if the claimant is already entitled to Medicare based on age 65 or disability and if RRB has jurisdiction of the claim by reviewing the MBR or ESQ.

If the MBR shows a HOC or SOC of “P” and the LAF code indicates an allowance, complete Form SSA-892-U3, delete the CAPS orbit if one exists, prepare an SSA-559 to have BA correct MBR to show HENC/SENC of “K” and ESRD dates of entitlement, if earlier than the dates on record, and complete an SSA-573 with appropriate notice information.

If the MBR or ESQ indicates the claimant is already entitled to Medicare and the RRB has jurisdiction but the MBR does not show a HOC or SOC of “P”, take the actions shown immediately above and send the claim post-adjudicatively to OD, SPB; 3-M-25 Operations Building. Show in remarks “Claimant entitled to Medicare, RRB jurisdiction. MBR shows HOC/SOC other than P”. OD will take necessary actions with SSA Systems and CMS to determine why the MBR is not properly annotated. OD will also inform ODO as to any additional adjudicative action required to insure correct billing. If the MBR shows “no record” for the claimant, but the ESQ shows the claimant has Medicare under a RRN, prepare an SSA-101-U3 using a BIC of “T” and SEC of “K” , show HOC and SOC of “P” in item 11, prepare an SSA-573 for notice information and prepare an SSA-892-U3 and any other forms necessary for adjudication.

In all cases, notify RRB of ESRD award action by completing and forwarding Form SSA-3103 (SSA Certification of Title II Monthly Benefits to RRB for Payment or Adjustment) as follows:

1. A. 

   Enter the beneficiary’s name and SSN in the appropriate blocks and the RRN, if known.

2. B. 

   Enter the HI and SMI effective dates and the SMI premium rate in the blocks provided. In the “remarks” section enter the phrase “ESRD Medicare Award.”

3. C. 

   If SSA has collected SMI premiums, enter in “Remarks” section: “SSA collected premiums for coverage months from   (month/year)   through   (month/year)   .”

4. D. 

   Forward the completed SSA-3103 to:

   Railroad Retirement Board
   Attention: Medicare Program Section
   844 North Rush Street
   Chicago, Illinois 60611–2092
   MARK ENVELOPE: “DO NOT OPEN IN MAILROOM.”

Do not prepare Form HCFA-8063 or send a temporary notice of eligibility.

Send a manual award notice (see DI 45001.102 for suggested language.) It is important that the beneficiary be advised that Medicare continues under the Railroad Retirement number.