HI 009: Evidence of Entitlement
Compare the information on the health insurance master tape and MBR replies with the information furnished by the requester to determine if the information is consistent and refers to the same beneficiary. Look for the following:
A. An Indication that Another Individual is Involved
Determine the correct name, claim number, and address of each involved individual. Send a HI/MBR Status Query (see SM 00706.005) for the second claim number obtained and when the replies are received, forward both sets of replies as in HI 00930.060 with a request that the records be unscrambled. If the MBR or the MBR and the health insurance master tape are scrambled, send the request to the processing center attention: Health Insurance Inquiries Examiner. If only the health insurance master tape is scrambled, send the request to CMS, BSS, OHPS, TPB.
B. The Individual Has More Than One Claim Number
If there is more than one claim number involved, and the cross-reference claim number is shown, determine whether the health insurance master tape is properly cross-referred. If it is not, forward copies of the health insurance master tape and MBR replies to CMS, BSS, OHPS, TPB (see HI 00930.060) for the cross-reference to be made.
If the beneficiary appears under both an RRB and an SSA claim number, see HI 00901.165.
C. Neither of the Above Exists
If neither A. or B. above is applicable, compare the information on the request with the information on the health insurance master tape and MBR replies and proceed as follows:
| Health Insurance Claim Number and Name | MBR Claim Number and Name | DO Action |
|---|---|---|
| Exactly matches* | Exactly matches* | Advise carrier/intermediary to requery |
| Substantially matches* | Substantially matches* | Advise carrier/ intermediary to requery using data from the health insurance master tape |
| Substantially matches* | Exactly matches* | Advise carrier/ intermediary to requery using data on the health insurance master tape. Notify CMS, BSS, OHPS, TPB to correct the Health Insurance master tape. |
| Different from* | Different from* | Locate another claim number (see HI 00910.040 E.2. above. If located transmit a new HI/MBR Status Query |
| 52 (No record) | NIF (No record) | Same as above. If requirements are not met, refer replies to the Health Insurance Inquiries Examiner (HI 00930.060). |
| Different from* | Exactly matches* | Refer to CMS, BSS, OHPS, TPB for correction. See |
* Information supplied on the Code 52
D. CMS Processing
Whether the problem is referred to CMS directly by the DO, or by the DO through the processing center attention: Health Insurance and Inquiries Examiner, CMS has the capability of notifying any intermediary or carrier of selective changes in the health insurance master tape. A carrier"s or intermediary"s processing of a Medicare claim under a different name of claim number may result in a reject. If a claim is referred to the DO, process in accordance with HI 00910.030 ff.
E. Other Considerations
The replies from the health insurance master tape and MBR should be reviewed, not only for a possible identification problem, (see A. above), but also for any impediments, (see HI 00930.040) or discrepancies in entitlement to HI and /or SMI (see HI 00930.001). It is possible that in rare instances more than one problem will be incountered. Each should be resolved before the development and copies of the replies received to the HMQ are forwarded to CMS, BSS, OHPS, TPB or Health Insurance and Inquiries Examiner as appropriate.