NL: Notices, Letters and Paragraphs
TN 2 (09-11)
A. Description of MADCAP Notice System
The MADCAP notice system produces a notice based on the action input through the operating system. Some notices can be totally automated without any requested paragraphs, but most require input of paragraph numbers and fill-in information.
The MADCAP system is programmed to generate all notice language and captions in a pre-established order, regardless of the order in which technicians input requested paragraphs.
B. Kinds of MADCAP Notices
There are three groups of MADCAP notices.
1. Group I
Group I notices are adjustment notices that cannot have requested paragraphs:
SSA-L226 (Notice to Former Payee), and
Payment Cycle Change notice.
2. Group II
Group II notices are adjustment notices that may have requested paragraphs:
Category A, Adjustment Notices A20, A21, A22,
Category B, Reinstatement Notice,
Category C, Termination Notice,
Category D, Suspension Notice, and
Category O, Overpayment Notices E31, E32, and E34.
3. Group III
Group III notices are award notices, including change of payee awards, and the category E and M adjustment notices that may have requested paragraphs:
Award Notice, including Change of Payee and Dual Entitlement (Primary after Auxiliary/Survivor),
Dual Entitlement Award (Auxiliary/Survivor after Primary),
HIMEX Award (Medicare only),
Category M, Lump-Sum Death Payment, and
Category E, (A18) One-Check-Only Notice.
C. Description of Group I Notices
Group I notices are completely automated notices, which the system generates based on the result of a technician's action. The technician does not determine what notice will generate, and cannot add any paragraphs.
D. Description of Group II Notices
1. How Group ll notices are produced
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Group II notices will generate:
automatically by the system; i.e., the technician does not have to indicate the notice code, or
requested by the technician; i.e., A21, and all Category O notices must be indicated;
The technician must request at least one paragraph to explain the action taken in order to make the system produce a complete notice; and
If the action is solely a Medicare action, the technician does not have to request a paragraph to get a complete notice.
2. Automatically generated paragraphs
Most paragraphs that are automatically generated should not be keyed on the ENB. There are some that are both generated and requested.
Requesting a paragraph on the ENB will override their automatic generation criteria. Fill-ins may be required on the ENB for these certain paragraphs.
E. Description of categories under Group II
The following are categories under Group II:
1. Category A-A20
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Category A-A20 explains:
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Generation criteria are as follows:
The new LAF status is C or D and
The prior LAF status is C or D.
The A20 is not longer allowed on the ENB. The technician must provide the paragraphs they want to appear in the A20 notice. Failure to provide the necessary Paragraphs and Fill-ins causes the system to produce the A-20 notice with a completion code of 'S'. A manual action by the technician to complete the notice will be required.
Example: C*ADJ027 ,A,08/2011,C.
2. Category A-A21
Category A-A21 explains the withholding of an overpayment after the initial notification of the overpayment has been sent. Generation criteria are as follows:
The special A21 notice code is indicated; and
The new LAF status is C or D;
The prior LAF status is C or D.
The technician must provide the overpayment amount to be recovered with the A21 notice code, to use as a Fill-in in paragraph OPT159 . Failure to provide the overpayment amount will result in the A21 notice being produced with a completion of 'S' for manual completion by the technician.
Example: C*A21,600.00.
3. Category A-A22
Category A-A22 explains actions taken on:
work notices,
readjustment rate cases, and
all other miscellaneous adjustment actions not covered in the A20 or A21 notices.
Generation criteria are as follows:
The new LAF status is C or D, and
The prior LAF status is C or D.
NOTE: Do not enter the special A22 notice code on the ENB. The system automatically generates the A22 notice, if the above generation criteria are met and no other notice code is indicated on the ENB,. the system automatically generates the A22 notice.
Example: C*.
4. Category B
Category B is used when reinstating benefits. Generation criteria are as follows:
The new LAF is C or D, and
The old LAF is S or T or U or X.
The reinstatement/resumption date must be provided as the first entry on the ENB, for use as a Fill-in in paragraph RNS031 . Failure to provide the reinstatement/resumption date will result in the reinstatement/resumption notice being produced with a completion of 'S' for manual completion by the technician.
Example: C*08/1992.
5. Category C
Category C notifies beneficiaries that benefits have been terminated. Generation criteria are as follows:
The new LAF is T (excluding T1) or U or X (excluding X1), and
The old LAF is C or D or S or T or U or X.
6. Category D
Category D is used when benefits are suspended. Generation criteria are as follows:
The new LAF is S, and
The old LAF is C or D or S or T or U or X.
7. Category 0-E31
Category 0-E31 is used when an initial overpayment is being established and recovery is proposed via benefit withholding. Generation criteria are as follows:
Notice code E31 is indicated.
The new LAF status is C or D, and
OVERPAYMENT is initially being established, and
No previous overpayment is present on the MBR in the O/U PAY or PAR REC fields.
NOTE: The technician must provide a complete explanation of the overpayment. i.e. AAA031 , OPT122 , OPT132 , OPT181 , PAY184 or TBL019 . For more instructions on notifying overpaid beneficiaries, see GN 02201.009.
8. Category 0-E32
Category 0-E32 is used when an initial overpayment is established for a person in LAF S or LAF T and a refund is requested. Generation criteria are as follows:
Notice code E32 is indicated,
The LAF is S or T (excluding T1) or U or X (excluding X1), and
OVERPAYMENT is initially being established, and
No previous overpayment is present on the MBR in the O/U PAY or PAR REC fields.
NOTE: The technician must provide a complete explanation of the overpayment. i.e. AAA031 , OPT122 , OPT132 , OPT181 , PAY184 or TBL019 . For more instructions on notifying overpaid beneficiaries, see GN 02201.009.
9. Category 0-E34
Category 0-E34 is sent to a beneficiary on the same record as the overpaid beneficiary when the overpayment cannot be recovered from the benefits of the overpaid person. Generation criteria are as follows:
Notice Code E34 is indicated,
The LAF is C or D, and
OVERPAYMENT is initially being established, and
No previous overpayment is present on the MBR in the O/U PAY or PAR REC fields.
NOTE: The technician must provide a complete explanation of the overpayment. i.e. AAA031 , OPT122 , OPT132 , OPT181 , PAY184 or TBL019 .
For more instructions on notifying overpaid beneficiaries, see GN 02201.009
Also, the name of the overpaid beneficiary and the amount of the overpayment must be provided with the E34 notice code, for use as Fill-ins in paragraph OPT163 . Failure to provide the necessary Fill-ins will result in an ‘invalid entry’ edit on the MACADE screen, which requires Fill-ins in order to proceed to the next screen.
Example: C*E34,JOHN DOE,150.00.
F. Description of Group III Notices
Under Group III:
Award notices and Category M, Lump-Sum Death Payment notices are automatically generated, and
Category E notices must be requested.
An award notice can have a combination of computer generated paragraphs and paragraphs requested by the CR, CA or BA.
G. Description of categories under Group III
The following are categories under Group III:
1. Award notices including change of payee or dual entitlement (primary after auxiliary or survivor)
A Notice of Award is automatically generated when:
MADCAP processes an initial, conditional, or deferred award;
The Special Indicator (SIC) is EC which represents entitlement conversion; or
The Letter Identification (LID) entry is completed indicating a change of payee. (The third line heading is Important Information).
Generation criteria are as follows:
The ABT is 1 or 5 or 6; or
The LID is Y.
2. Dual entitlement (auxiliary or survivor after primary)
Dual entitlement (auxiliary/survivor after primary) is used when a beneficiary is in pay status and entitlement to auxiliary benefits on another account is initially being established via the beneficiary's primary record. Generation criteria are as follows:
The LAF is C, S, D or E,
D30 is coded as the first entry on the ENB,.
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When D30 is coded, paragraph BEN089 is required as the introductory paragraph and must be provided on the ENB along with the necessary fill-ins.
EXAMPLE: C*D30*BEN089,A,999-99-9999,05/2011.
NOTE: Paragraph AWD017 is not systems derived on the D30. If required, the technician must request it on the input record.
3. Category M, Lump-Sum Death Payment (LSDP)
Category M, Lump-Sum Death Payment, is used when processing a lump-sum death payment only. This notice is automatically generated when the Payment Identification Code (PIC) column in RID 5 contains the claims symbol of G (any subscript).
4. Category E (A18) One-Check-Only Notice
Category E (A18) is a Group III notice and is used for ‘One Check only’ notices. This means use this UTI when a payment is in addition to regular payments. This notice is automatically generated when the A18 notice code is keyed as the first entry on the ENB. Please refer to the description of Category III notices before keying.
If A18 is used on an adjustment notice it will produce an “S” notice.
The Fill-ins for UTI's listed below are mutually exclusive paragraphs that must be provided with the A18 notice code. Failure to provide the necessary Fill-ins will result in the A18 notice being produced with a completion code of 'S' for manual completion by the technician.
Example: C*A18,B,JOHN DOE.
ADJ058 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'A' or ' D' or 'E' or 'H' or 'I' or 'L'.
ADJ059 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'C'.
ADJ060 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'F'.
ADJ061 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'G'.
ADJ062 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'M'.
ADJ063 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'J'.
ADJ064 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'K'.
ADJ048 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'B'. In this situation, a second Fill-in (fill-2) representing a person's name must be provided with A18.
ADJ049 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'N'.
NOTE: The second Fill-in only needs to be provided when the first Fill-in is 'B'. The system will automatically generate the proper UTI based on the value of Fill-in 1
Exclusions
A18 cannot be used on BOND Notices
A18 cannot be used on Adjustment notices (Group II Notices)