TN 2 (09-09)

A. Completing MQGE denial notices

The various form and model letters and paragraphs to be used are shown in the denial charts below. The notices are intended to supplement, but not replace, any requirements for personalized notices.

1. Notice Chart 1 - Disabled Insurance Beneficiary (DIB)

¹ Add the following after the first sentence on the SSA-L443, “Your claim for Medicare as a disabled individual is based on your employment with the Federal, State, or local government.”

² In any situation where the SSA-L443 contains insufficient space for the fill-in paragraphs, combine the preprinted paragraphs from the SSA-L443 with the assigned paragraphs to form the notice.

³ The Reconsideration Letter Number is L928. On the SSA-L928, include “Medicare Coverage-Only” as a type of claim.

In concurrent recon affirmations of denials, use one SSA-L928 with each type of claim checked off. Place a copy of the letter in each folder and show the multiple claim numbers at the top of the letter.

⁴ Include Paragraph No. 267 as an attachment to initial notices.

⁵ See DI 90070.900 – Exhibit 5.

2. Notice Chart 2 - Disabled Insurance Beneficiary (DIB) Death Claim

¹ Add the following after the first sentence on the SSA-L443, “Your claim for Medicare on behalf of (NH's Name) as a disabled individual is based on (NH's Name) employment with the Federal, State, or local government.”

² In any situation where the SSA-L443 contains insufficient space for the fill-in paragraphs, combine the preprinted paragraphs from the SSA-L443 with the assigned paragraphs to form the notice.

³ If the W/E died within 5 months of AOD, refer to DI 23510.000 for processing. Make no entry in item 29.

⁴ The Reconsideration Letter Number is L928. On the SSA-L928, include “Medicare Coverage-Only” as a type of claim.

In concurrent recon affirmations of denials, use one SSA-L928 with each type of claim checked off. Place a copy of the letter in each folder and show the multiple claim numbers at the top of the letter.

⁵ Include Paragraph No. 267 as an attachment to initial notices.

3. Notice Chart 3 - Disabled Widow(er) Beneficiary (DWB)

¹ In Federal Medicare cases only, add the following after the first sentence on the SSA-L443, “Your claim for Medicare as a disabled individual is based on (NH's Name) employment with the Federal, State, or local government.”

² In any situation where the SSA-L443 contains insufficient space for the fill-in paragraphs, combine the preprinted paragraphs from the SSA-L443 with the assigned paragraphs to form the notice.

³ Paragraph 864 should not be included in this notice when the widow is receiving mother's benefits and the ending date of the PP is in the future.

⁴ The Reconsideration Letter Number is L928. On the SSA-L928 include “Medicare Coverage-Only” as a type of claim.

In concurrent recon affirmations of denials, use one SSA-L928 with each type of claim checked off. Place a copy of the letter in each folder and show the multiple claim numbers at the top of the letter.

⁵ Include Paragraph No. 266 as an attachment to initial notices.

⁶ See DI 90070.900 – Exhibit 5

4. Notice Chart 4 – Childhood Disability Beneficiary (CDB)

¹ Add the following after the sentence on the SSA-L443, “Your claim for Medicare as a disabled individual is based on (NH's Name) employment with the Federal, State, or local government.” If another person filed on behalf of claimant, add “on behalf of John Jones” after “Medicare.” Write the personalized notice in the third person when an individual is filing on behalf of the child.

² In any situation where the SSA-L443 contains insufficient space for the fill-in paragraphs, combine the preprinted paragraphs from the SSA-L443 with the assigned paragraphs to form the notice.

³ Delete “and the earnings requirement” from paragraph 920.

⁴ The Reconsideration Letter Number is SSA-L928. On the SSA-L928, include “Medicare Coverage-Only” as a type of claim.

In concurrent recon affirmations of denials, use one SSA-L928 with each type of claim checked off. Place a copy of the letter in each folder and show the multiple claim numbers at the top of the letter.

⁵ Include Paragraph No. 267 as an attachment to initial notices.

⁶ See DI 90070.900 – Exhibit 5

See Also:

DI 26535.026 – Denial Notices for Initial Disabled Widow(er) Medicare Coverage-Only, Medicare Qualified Government Employee (MQGE), CDB and Medicare-Only DWB Claims

B. Routing Medicare Qualified Government Employment (MQGE) cases

The routing procedures for MQGE cases are the same as those for Title II non-MQGE cases.

See Also:

DI 32005.000 Routing - Initial/Reconsideration/Reopening Cases