Training Guide for Lesson C: Releasing Some Claim Information

Releasing Some Beneficiary-Specific Information

Release some beneficiary- And… Additional steps Notes specific information when the caller is… A legal representative as The representative’s name There is documentation A beneficiary must provide a defined by the state matches the representative’s stating that the caller written request for a legal name on file. represents the beneficiary for representative in order to verify the limited services. relationship. The representative also provides the beneficiary’s name, date of Legal representatives can be To answer any questions via the birth, and Medicare number, and given information pertaining telephone, you must have proof of one additional piece of to the matter for which they the arrangement for services on file information such as SSN, have been appointed as the or the representative’s name must address, phone number, effective beneficiary’s representative. appear on the system (e.g., Master date(s), or whether the A beneficiary may have more Beneficiary Record (MBR), beneficiary has Part A or Part B than one legal representative. Supplemental Security Income coverage. Record (SSR), Health Insurance Master Record (HIMR), or Inquiry Response Numident Identification Screen (QRID)).

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Release some beneficiary- And… Additional steps Notes specific information when the caller is… Other health insurer (MSP  The beneficiary has signed Answer any questions Refer the caller to Coordination of involved) an agreement with the health pertaining to the beneficiary’s Benefits contractor for all Medicare insurer granting that file that are necessary to Secondary Payer (MSP) inquiries company the right to coordinate benefits. (except claims-related questions) coordinate benefits with including: Medicare.  The reporting of potential MSP situations  Changes in a beneficiary’s insurance coverage  Changes in employment  All other general MSP questions.

COB contractor number 1-800-999-1118

TTY/TDD 1-800-318-8782

CSRs are available 8 am to 8 pm (Eastern Time).

Release some beneficiary- And… Additional steps Notes specific information when the caller is… A beneficiary’s spouse, The caller provides the Release some claim Written consent/authorization relative, friend, or advocacy beneficiary’s full name, date of information if the written includes either of the following: group (excluding State Health birth, Medicare number, and one consent/authorization limits  Indication on the desktop that Insurance Assistance Program additional piece of information the caller’s access to written consent/authorization is (SHIP) employees and such as SSN, address, phone information. on file volunteers) number, effective date(s), or  A signed disclosure form or whether the beneficiary has Part other written A or Part B coverage. consent/authorization on file including the following: Current written  Beneficiary signature and date consent/authorization is on file  Name of individual, for the caller. organization, or class of individuals  Types of information that may be disclosed  Indication of whether the consent/authorization is a one- time, a limited-time, or ongoing release.

The SHIP employees and volunteers are not addressed in this chart. Disclosure instructions for the SHIP employees and volunteers will be addressed as a separate issue. Continue your current practice until such instructions are published.

Release some beneficiary- And… Additional steps Notes specific information when the caller is… A beneficiary’s spouse, The beneficiary is not available Only release information on Suggest that the caller have the relative, friend, or advocacy for verbal consent/authorization whether or not the claim has beneficiary forward written group (excluding State Health and there is no current verbal or been received or processed consent/authorization to the call Insurance Assistance Program written consent/authorization on and the date the beneficiary center if he/she anticipates any need (SHIP) employees and file. However, the caller has the can expect to receive the for future telephone contacts. volunteers) beneficiary’s: MSN/EOMB.  Full name, date of birth, Medicare number  Information on a specific claim (service date, physician name, procedure).

The caller does not have an MSN or EOMB. A beneficiary’s spouse, The beneficiary is not available Only release information for Suggest that the caller have the relative, friend, or advocacy for verbal consent/authorization the service(s) that appear on beneficiary forward written group (excluding State Health and there is no current verbal or the MSN or EOMB. consent/authorization to the call Insurance Assistance Program written consent/authorization on center if he/she anticipates any need (SHIP) employees and file. However, the caller has the for future telephone contacts. volunteers) beneficiary’s:  Full name, date of birth, Medicare number  A copy of an MSN or EOMB  Information on a specific claim (service date, physician name, procedure).

Release some beneficiary- And… Additional steps Notes specific information when the caller is… An Employee of another The employee of the other There are three ways that a If the CSR is reasonably certain that Federal Agency (e.g., SSA, agency provides the following CSR may verify that he/she is he/she is speaking to the other RRB, VA, DoD) who needs information in order to identify speaking with an employee of agency’s employee, the CSR may the information to perform the beneficiary in question: another agency. release any claim information and their duties  Full name; 1. Both parties on the call answer any questions related to the  Date of birth; look at the MBR record administration of that agency’s  HIC number; and (or other beneficiary program.  One additional piece of record to which they both information such as SSN, have access). The CSR address, phone number, can name a field on the effective date(s), whether MBR and ask that the he/she has Part A and/or Part other agency’s employee B coverage. identify what is in that particular field. Ensure that the reason for the OR inquiry is related to the 2. The CSR may ask for the administration of that agency’s employee’s phone number program. and call him/her back, making sure that the area code and exchange matches a listed phone number for that agency. NOTE: Caller ID or similar service may be used to verify the area code and exchange in lieu of a callback.

Release some beneficiary- And… Additional steps Notes specific information when the caller is… OR The CSR may take the name An Employee of another and number of the agency Federal Agency (e.g., SSA, employee, the name and RRB, VA, DoD) who needs number of his/her supervisor, the information to perform the date and reason for the their duties (continued) inquiry, and post this information to the “NOTES” screen. Complementary Health The beneficiary has signed an Verify the complementary Answer any question pertaining to Insurer (Medigap, agreement with the health insurer is identified on the beneficiary’s claims that should complementary crossover, complementary health insurer the beneficiary’s file. have crossed over to the supplemental) granting that company the complementary insurer. authorization to receive Verify the identity of the Medicare claim information. beneficiary in question by asking for his/her:  Full name;  Date of birth;  HIC number; and One additional piece of information such as SSN, address, phone number, effective date(s), whether he/she has Part A and/or Part B coverage.

Release some beneficiary- And… Additional steps Notes specific information when the caller is… Medicare Contractor (Fiscal The Medicare Contractor being There are three ways that a If the CSR is reasonably certain that Intermediary/Carrier/ contacted processed the claim in CSR may verify that he/she is he/she is speaking to the other DMERC/RHHI) question. speaking with an employee of contractor’s employee, the CSR another agency. may release any claim information Verify the identity of the 1. Both parties on the call and answer any questions beneficiary in question by asking look at the MBR record pertaining to the beneficiary’s for his/her: (or other beneficiary claims that were processed by the  Full name; record to which they both Medicare Contractor being  Date of birth; have access). The CSR contacted.  HIC number; and can name a field on MBR One additional piece of and ask that the other information such as SSN, agency’s employee address, phone number, effective identify what is in that date(s), whether he/she has Part particular field. A and/or Part B coverage. OR 2. The CSR may ask for the employee’s phone number and call him/her back, making sure that the area code and exchange matches a listed phone number for that agency. NOTE: Caller ID or similar service may be used to verify the area code and exchange in lieu of a callback.

Release some beneficiary- And… Additional steps Notes specific information when the caller is… Medicare Contractor (Fiscal OR Intermediary/Carrier/ The CSR may take the name DMERC/RHHI) (continued) and number of the agency employee, the name and number of his/her supervisor, the date and reason for the inquiry, and post this information to the “NOTES” screen. An Institutional Provider, Refer the provider to the Physician, Supplier, or Other provider inquiry line. Provider (received on the beneficiary inquiry line) Blended call centers (those that answer both beneficiary and provider calls at the same place) may choose to answer provider calls on the beneficiary line if they have the ability to track the calls appropriately. Otherwise, they should refer the contact to the appropriate provider inquiry number.

You may speak with that provider only about his/her own claims. You may not

Release some beneficiary- And… Additional steps Notes specific information when the caller is… An Institutional Provider, discuss other provider’s Physician, Supplier, or Other claims. Provider (received on the beneficiary inquiry line) When there is a systems (continued) problem that causes a claim to be rejected or denied, it is your responsibility to accept the information from the provider in order to make corrections that will allow the claim to be processed. It is at the discretion of the contractor as to whether certain types of calls may be referred to the provider representatives or whether to utilize the beneficiary representative to resolve the issue in the most cost effective and efficient manner.

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