TN 4 (05-09)

A. Policy – EXR denials effect on Medicare

1. When to deny an EXR request

We may deny an expedited reinstatement (EXR) request for:

1. Not meeting the technical requirements (see DI 13050.001 for EXR requirements);

2. A “not same as or related” determination (shown on the SSA-832/833 as a code of 28 for Title II cases and a code of 61 for Title XVI - see DI 28057.015C for medical criteria and DI 28057.020 for coding information); or

3. Not meeting the medical improvement review standard (MIRS) due to medical improvement (shown on the SSA-832/833 as a MIRS denial code - see DI 28084.015 for MIRS denial codes).

2. Determining if Medicare ends when denying an EXR request

When we deny the EXR request, Medicare entitlement may or may not terminate depending on the basis of Medicare entitlement (see HI 00801.165).

1. If the only basis for Medicare entitlement is the provisional benefit period, Medicare will terminate the earlier of:

   • the last day of the 6^th month of the provisional benefit period, or

   • the last day of the month following the month the unfavorable decision notice is mailed.

2. Medicare based on end-stage renal disease (ESRD) or age will not terminate when the provisional period ends, or when we deny an EXR request.

3. Extended Medicare will continue, unless the DDS determines that the individual has medically improved (MIRS denial). If the individual has medically improved, coverage will end the last day of the month following the month the notice of the unfavorable decision is mailed.

NOTE: If the individual is working, and has not medically improved, he or she may be eligible for Premium HI under the Disabled Working Individual (DWI) provision, see (SM 00850.525 and HI 00801.170). If the individual chooses to elect Premium HI, the field office (FO) will send a high priority message (HP2560) using the modernized development worksheet (MDW) to OCO to establish Premium HI entitlement. If you need assistance on how to complete an MDW, follow instructions found in the National Toolkit: MDW Instructions .

3. Procedure when Medicare ends due to EXR denial

The FO will identify the reason for the EXR denial, and determine the Medicare termination month. If Medicare terminates, the FO will send a HP2560 using the MDW to OCO/PC with instructions to input the correct termination month and prepare the termination notice.

4. Medicare termination notice used in EXR denials

OCO/PC prepares and releases the appropriate Medicare termination notice. If Medicare was based solely on the provisional benefit period, the beneficiary will not have appeal rights with this termination (see HI 00801.165).

B. Procedure - Medicare language in denial notices

When the FO prepares the denial notice, they will include the appropriate Medicare language, based on the type of denial and type of Medicare coverage. The chart below shows the appropriate notice language (known as a UTI in DPS) to use when constructing the denial notice. In some situations, there won’t be Medicare language inserted. Examples of these notices are contained in DI 13050.105, Exhibits 6, 7 and 8.

C. References

HI 00801.164 - Medicare Entitlement during the Provisional Benefit Period – Expedited Reinstatement of Disability Benefits

HI 00801.165 - Medicare Termination When the Provisional Benefit Period Ends

HI 00801.166 - Favorable Medical Decisions