HI 00825.005 Determining Enrollment Status

Examine the folder to ascertain whether documentation of the SMI decision and /or the SMI enrollment form will substantiate the beneficiary's allegation or the data recorded on the MBR. Documentation of the SMI election may be reflected in item 6 of the SSA-101-U3 award form, on an CMS-40 (the corresponding folder documentation for elections resulting from the initial mass enrollment period), and an SSA-1596-C1, a 5 ×8 informational form, or other document.

There may be instances where no Form SSA-1596C1 is in the folder and enrollment data is not shown on the award form. When this occurs, and the claimant is age 64 and 9 months or older, look for a Form CMS-40, CMS-40B, RRB Form G-44 (Application for Enrollment Filed with RRB), or other application forms or correspondence in the folder that will indicate the enrollment option of the individual.

In some instances, there will be more than one enrollment form, in which case, accept the form bearing the latest date that falls within the prescribed enrollment period as the individual's final decision with regard to SMI coverage.

Review the MBR and the screens available from the HIQR query to verify periods of SMI coverage (see SM 00710.004 How Online Queries Work).