TN 1 (07-04)

A. CAPS

Complete the following forms:

1. SSA-450 Earnings Record Request

2. SSA-892-U3 (see HI 00801.308)

3. SSA-3687-U2 (Determination of Benefit Rights Coding Sheet)

   1. Review and correct all items as required.

   2. If the ESRD patient is entitled to SSI or is a Medicaid recipient, see HI 00815.030 regarding possible coverage under a State buy-in agreement. If buy-in applies, special coding is required (FAC code PW).

   3. Verify the appropriate coding in the MH field. Coding in this field must be correct as the system derives the date of entitlement (DOE) from this entry.

   4. Do not enter a Spanish notice request indicator in the CH field.

   5. If applicable, it will be necessary to request the following paragraphs: (1) RM-30 with appropriate fill-in, when copy of notice is to be sent to a third party, (2) Paragraph listed in DI 45001.355 A. when waiver of qualifying period based on self-care dialysis is denied.

   Request the paragraphs on Form SSA-5002. Also check block 3.a. of Form SSA-3293 and indicate in remarks: “See SSA-5002 in file for additional notice language.”

4. SSA-5015-U2 (when needed in successful transplant and cessation of dialysis cases).

B. Non-CAPS

Complete the following forms:

1. SSA-450 Earnings Record Request

2. SSA-892-U3 (HI 00801.308)

3. SSA-3687-U2 to delete CAPS orbit. Use DLO6 on SSN of parent or spouse; use DLO7 on SSN of claimant. If MQGE provision is involved, see DI 45001.326.

4. SSA-101-U3 (required to process a non-CAPS award) If not entitled to a monthly benefit, the claimant will be entitled to R-HI/R-SMI on his/her own SSN, even if insured status is met on another SSN. (See exception for MQGE's, DI 45001.326).

   Follow MS MCS 014.000 for preparation instructions.

   Entries on the SSA-101-U3 - Reminder Items

   1. FAC “RD” is used only on monthly benefit awards (not T or TA awards).

   2. If the applicant is entitled to SSI or is a Medicaid recipient, see HI 00815.030 regarding possible coverage of SMI premiums under a State buy-in agreement. If buy-in applies, special coding is required (FAC code PW).

   3. FAC code PW should be no earlier than the SMI entitlement date.

   4. Equitable relief coding: If the SMI entitlement date is later than the HI entitlement date because the claimant requests SMI to begin as of the date claim filed or current operating month (HI 00801.251B), code item 7 as follows: BIC = T; FAC = SI; EARN = 00BCU; code SMI entitlement date in YR and month blocks.

   5. If SMI is refused, enter SEC of R in item 6 and show “T SMIB - none” in item 11 (Remarks).

5. Notice to Claimant: In item 12 of SSA-101 enter an “I” under the BIC to show incomplete notice. Prepare a Form SSA-5002 listing the necessary paragraphs (See a. through g. below); check item 4.f. on the SSA-3601 and enter “See SSA-5002 in file.” in “Remarks” section.

   Indicate the following paragraphs on Form SSA-5002 when needed:

   1. MH16: The paragraph with appropriate fill-ins should be shown if the date of entitlement is based on transplant.

   2. MH17: This paragraph should be shown if the date of entitlement is based on dialysis.

   3. RM30 (or its equivalent) with appropriate fill-in, when copy of notice is to be sent to a third party;

   4. Premium Arrearage of 6 Months or More—Claimant Elects SMI as of month of filing or current operating month - Language in DI 45001.355C.

   5. Waiver of qualifying period based on previous R-HI—Language in DI 45001.355B.

   6. Waiver based on self-care dialysis is denied—Language in DI 45001.355A.

   7. Equitable Relief Paragraph, if applicable.

6. SSA-5015-U2 for diaries (when needed)

7. SSA-1418 to clear claim to ODO

8. In addition to any annotations required by 1 through 7 above, check item 2.1 (other) in Column 1 of SSA-3601 and indicate in Remarks:

   1. “Route to BPRC for EAM Processing” (if no record on MBR) or

   2. “Route to Benefit Authorizer for Processing” (if claimant has prior Medicare which has ceased on own SSN.)