TN 33 (02-06)

A. Policy

All evidence establishing an individual’s right to HI and/or SMI must be received before a temporary notice may be issued. For an insured individual, this would include proof of age and evidence of insured status. For an auxiliary or survivor, it would also include evidence of relationship, dependency, etc., as appropriate.

There is no exception to, or relaxation of, the normal evidentiary requirements because an individual has an immediate compelling need for a temporary notice of eligibility.

A temporary notice of eligibility is valid for 60 days from the month of issuance and is not renewable.

B. Procedure

When all requirements in HI 00801.500 are met, issue a Temporary Notice of HI-SMI Eligibility patterned closely after the sample in HI 00801.904. Do not issue a temporary notice any earlier than 20 days prior to the first month of entitlement. If a claimant requests a temporary notice earlier than 20 days before the first month of entitlement, advise him/her that the notice will be sent shortly before eligibility begins.

Prepare the notice in duplicate. Give the original to the claimant (or the claimant’s representative) and place the copy in the claims folder.

On the same day the notice is prepared, FOs should prepare a Report of Contact (SSA-5002) with the following information:

• DO Code

• DO Name

• Contact Name and Phone Number

• SUBJECT: Temporary Notice of Medicare Eligibility

• TEXT: Text should include the following information about the beneficiary for whom the record will be established:

  1. Claim Number

  2. Name (First, Middle Initial, Last)

  3. Date of Birth (MMDDYYYY)

  4. HI Entitlement Date (MMYY) - if no entitlement, enter (0000) four zeros)

     NOTE: Temporary records will only be established effective with the current month.

  5. SMI Entitlement Date (MMYY) - if no entitlement, enter (0000) four zeros

     NOTE: Temporary records will only be established effective with the current month.

  6. State of beneficiary residence

  7. Sex (male = M; female = F)

  8. Date notice issued (six-digit figure)

  9. Program Service Center numerical designation (e.g., Northeast PSC is “1,” etc.)

Fax the SSA -5002 to:

CMS
MEAG, DEEP
ATTN: N Rappaport
Fax# 410-786-9963

When forwarding the claims file to the PSC, attach a “Special” tag (HEW-94) to the claims routing sheet and note “TEMP” in large letters on the tag.