In December 1998, CMS changed the way Medicare problem cases are processed. Many cases are now handled by the CMS Regional Office (RO) staff instead of staff in CMS Central Office (CO).

CMS has redesigned the Form CMS-2178 U2 to correspond to the processing changes. The new forms are available to SSA field offices (FOs), teleservice centers (TSCs) and processing centers (PCs) using regular distribution lists. All the old CMS-2178 U2 forms dated prior to 09/06 should be destroyed and new ones requested.

We redesigned the Form CMS-2178-U2 to aid the user in identifying the problem and determining the appropriate referral action.

In the Spring of 2021, CMS updated the CMS-2178 U2 to be an electronically fillable PDF. Both initial referrals and all follow-ups are made using this form.

For more information on form CMS-2178 U2, please click on the PDF document:

The Form CMS-2178 U2 is not to be used for the following:

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  State Buy-in problems. (Use Form CMS-1957) .

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  Medicare Premium problems. (Use Form SSA-5002 Overlay) See HI 01001.375.

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  Medicare +Advantage problems (e.g., Managed Care enrollments and disenrollments). See HI 00208.073.

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

 

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  TSC Code

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  FO Code (to be completed in all cases no matter where the form originated)

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  PSC (Circle One) and MOD

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  Contact Name

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  Unit

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  Telephone Number

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  Ext

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  FO Address

Section 3.

Complete all items:

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  Beneficiary’s Name

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  Beneficiary’s Telephone Number

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  Claim Number

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  Cross Reference 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:

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  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.

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  Check the block(s) which best explains the problem.

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  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.

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  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:

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  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.)

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  Check the block(s) which best explains the problem.

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  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.

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  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:

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  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.

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  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:

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  This is for the PSC or CMS to complete if the FO requested an explanation.

  NOTE: CMS will not respond to the beneficiary directly.

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  NOTE: Some CMS ROs will reply with an electronic Administrative Message to the SSA FO.

NOTE: CMS ROs service the same States as SSA ROs.

1. a. 

   CMS CO:2178 Mailbox@cms.hhs.gov

2. b. 

   CMS RO:See email address below.