Form CMS-2384, (see HI 01005.810), Third Party Premium Billing Request is used in establishing a third party premium payer for an uninsured enrollee who must pay medical insurance premiums by direct remittance.The term “third party” in this instance means someone other than the claimant but not a State or formal group payer (see HI 01001.225). A premium payer is not the same as a representative payee, and therefore representative payee procedures are not to be used in these instances.

The CMS-2384 has three distinct parts: the first part contains the claimant's authorization for his or her premium billing notices to be mailed to the third party; the 2nd part contains the request of the third party that billing notices be mailed to him or her; and the 3rd part reflects the action taken by the DO. All three parts of the form should be completed before the DO forwards the form to the PSC.

Forms CMS-2384 for T and M claimants will be received by the Exceptions and Inquiries Examiner without the claims folders. Those for J and K claimants should be received attached to the appropriate claims folders. If a form for a J or K claimant is received without the corresponding claims folder, forward it to the Records Analysis Clerk with a request that it be associated with the claims folder and returned to the Exceptions and Inquiries Examiner.

The forms will be examined for completeness and legibility and handled as described below.

A. T and M Claims

If the CMS-2384 has been properly completed and approved by the DO and a complete address is shown in Part II for the third party payer, update the Master Beneficiary Record (MBR) by processing a Post-Entitlement Online System (POS) change of address and fax the form CMS-2384 to the Program Service Center (PSC) using the appropriate Paperless Barcode.

B. J and K Claims

Examine the claims folder to ascertain if the claimant is actually in a billable status; i.e., is in conditional payment status and no impediment to direct billing exists.

If the claimant is in a billable status and the Form CMS-2384 has been properly completed and approved by the DO, process a POS change of address and fax as described above for T and M Claims. Annotate the action taken on the Form CMS-2384 and file it on the right side of the claims folder. Also prepare a Form SSA-1208, Flag - Keep on Top, indicating that the claims folder should be referred to the Claims Authorizer for a determination as to the payee name and address that should be used when and if benefit payments are resumed. The Form SSA-1208 should be filed on the left side of the claims folder which can then be returned to the Records Analysis Clerk.

NOTE: SSA-1208 is a paper form only — No PDF is available.