+-----------------+-----------------------------+---------------------+
| **1-800         |                             |                     |
| MEDICARE CSRs   |                             |                     |
| Can Perform the |                             |                     |
| Activities      |                             |                     |
| Shown Below**   |                             |                     |
|                 |                             |                     |
| The appropriate |                             |                     |
| CSR level for   |                             |                     |
| each topic is   |                             |                     |
| also listed     |                             |                     |
| below.          |                             |                     |
| H               |                             |                     |
| igher/different |                             |                     |
| levels of CSRs  |                             |                     |
| do              |                             |                     |
| [n              |                             |                     |
| ot]{.underline} |                             |                     |
| have access to  |                             |                     |
| different (or   |                             |                     |
| more)           |                             |                     |
| information     |                             |                     |
| than the CSR    |                             |                     |
| tier shown      |                             |                     |
| below.          |                             |                     |
+-----------------+-----------------------------+---------------------+
| Subject         | Comment                     | CSR Level           |
+-----------------+-----------------------------+---------------------+
| Prospective     | GM Tier I CSR determines if | Disenrollment CSR   |
| Disenrollment   | a disenrollment is          |                     |
|                 | applicable. If so, the CSR  | (Note: If the       |
|                 | will transfer to a          | caller wants to     |
|                 | Disenrollment CSR.          | enroll in a new     |
|                 |                             | plan, the GM Tier I |
|                 |                             | CSR can handle the  |
|                 |                             | enrollment.         |
|                 |                             | Enrollment in a     |
|                 |                             | plan will           |
|                 |                             | automatically       |
|                 |                             | disenroll the       |
|                 |                             | beneficiary from    |
|                 |                             | their current       |
|                 |                             | plan.)              |
+-----------------+-----------------------------+---------------------+
| Compare Drug    | Plan Compare is available   | GM Tier I CSR       |
| Plans Tool      | on the web to SHIPs and     |                     |
|                 | beneficiaries               |                     |
+-----------------+-----------------------------+---------------------+
| File PDP        | Contact a GM Tier I CSR     | GM Tier I CSR       |
| Complaints      | only after you or the       |                     |
|                 | beneficiary has contacted   |                     |
|                 | the plan and the issue has  |                     |
|                 | not been resolved.          |                     |
+-----------------+-----------------------------+---------------------+
| Provide         | Enrollment status is        | GM Tier I CSR       |
| Enrollment      | available on the web and in |                     |
| Status          | the IVR to SHIPs and        |                     |
|                 | beneficiaries               |                     |
+-----------------+-----------------------------+---------------------+
| Provide LIS     | LIS status is available on  | GM Tier I CSR       |
| eligibility     | the web and in the IVR to   |                     |
| Information     | SHIPs and beneficiaries     |                     |
+-----------------+-----------------------------+---------------------+
| Send out a LIS  | LIS applications are        | GM Tier I CSR       |
| application     | available on SSA's website  |                     |
+-----------------+-----------------------------+---------------------+
| Medicare        | A simple termination is     | Claims Tier I Part  |
| Secondary Payer | performed by adding an      | A, Part B, or DME   |
|                 | "end" date to an existing   | CSRs                |
| (Simple         | Working Aged MSP record     |                     |
| Termination --  | using Next                  | Note: in some       |
| when a person   |                             | instances, only     |
| retires or      | Generation Desktop (NGD).   | COBC can perform    |
| terminates      |                             | the simple          |
| insurance that  |                             | termination. In     |
| pays before     |                             | that case, the      |
| Medicare.)      |                             | caller will be      |
|                 |                             | referred to COBC.   |
+-----------------+-----------------------------+---------------------+
| Premium         | The CSR can verify if the   | GM Tier I CSR       |
| Withhold        | beneficiary is in premium   |                     |
|                 | withhold status. The CSRs   |                     |
|                 | cannot see the actual       |                     |
|                 | amount withheld/refunded    |                     |
|                 | for the check. The CSR can  |                     |
|                 | file a complaint if the     |                     |
|                 | beneficiary is experiencing |                     |
|                 | a premium withhold problem. |                     |
+-----------------+-----------------------------+---------------------+
| Crossover       | GM Tier I CSR can determine | GM Tier I CSR       |
|                 | if crossover is set up and  |                     |
|                 | if a claim was selected to  |                     |
|                 | be crossed over. If         |                     |
|                 | crossover is not set up, or |                     |
|                 | if the secondary insurer is |                     |
|                 | stating that the claim was  |                     |
|                 | not crossed over, the       |                     |
|                 | beneficiary must call the   |                     |
|                 | insurer.                    |                     |
+-----------------+-----------------------------+---------------------+
| Simple Claims   | GM Tier I CSRs can handle   | GM Tier I CSR       |
| inquiries       | simple claims inquiries --  |                     |
|                 | e.g., order duplicate MSN;  |                     |
|                 | indicate whether a claim    |                     |
|                 | was approved or denied;     |                     |
|                 | provide information on the  |                     |
|                 | amount paid to the          |                     |
|                 | provider, the amount owed   |                     |
|                 | by the beneficiary, the     |                     |
|                 | date the claim processed.   |                     |
+-----------------+-----------------------------+---------------------+
| Claims Denials  | The beneficiary or SHIP     | Claims Tier I CSRs  |
|                 | should check the MSN prior  |                     |
|                 | to contacting 1-800         | Note: Claims CSRs   |
|                 | MEDICARE and to determine   | are specific to the |
|                 | whether the claim is a Part | line of business -- |
|                 | A, B or DME service. Claims | Part A, Part B, or  |
|                 | Tier I CSRs can provide     | DME.                |
|                 | information on the reasons  |                     |
|                 | for the claim denial,       |                     |
|                 | details on suspended claims |                     |
|                 | (i.e. claims that have not  |                     |
|                 | yet been paid or denied);   |                     |
|                 | and status of appeals.      |                     |
+-----------------+-----------------------------+---------------------+
| Complex         | Certain complex inquiries   | Claims Tier I CSRs  |
| Inquiries       | will need to be referred to |                     |
|                 | the claims processing       | Note: These CSR     |
|                 | contractor (FI, Carrier, or | will refer complex  |
|                 | DMAC) for further research  | inquiries to FFS    |
|                 | action. Examples would      | claims processing   |
|                 | include reissuing checks,   | contractors through |
|                 | investigation of claims     | the CSR desktop.    |
|                 | suspended for long periods  | This is not a live  |
|                 | of time, reprocessing of    | transfer. The FFS   |
|                 | claims.                     | contractor does the |
|                 |                             | research and takes  |
|                 |                             | appropriate actions |
|                 |                             | offline.            |
+-----------------+-----------------------------+---------------------+
| SPAPs (State    | Ships can find information  | GM Tier 1 CSR       |
| Prescription    | on SPAPs and PAPs via       |                     |
| Assistance      | [www.medicare.gov]          |                     |
| Programs) and   | (http://www.medicare.gov/). |                     |
| PAPs (Plan      | From the home page, select  |                     |
| Administered    | "*Lower Your Costs During   |                     |
| Pharmaceutical  | the Coverage Gap*." This    |                     |
| Assistance      | will take you to a page     |                     |
| Programs)       | with links to information   |                     |
| questions       | on SPAPS (by state) and     |                     |
|                 | PAPs (by drug). If the SHIP |                     |
|                 | or beneficiary does not     |                     |
|                 | have access to the web, a   |                     |
|                 | GM Tier CSR can look up     |                     |
|                 | this information.           |                     |
+-----------------+-----------------------------+---------------------+
| Drug Coverage   | If the beneficiary received | GM Tier 1 CSR.      |
| Fraud Marketing | misleading or false         |                     |
| Sales           | information from an agent   |                     |
|                 | broker and/or marketing     |                     |
|                 | representative and          |                     |
|                 |                             |                     |
|                 | Related to Prescription     |                     |
|                 | Drug = Refer to Medicare    |                     |
|                 | Drug Integrity Contractor   |                     |
|                 |                             |                     |
|                 | 877-7SAFERX (877) 772-3379  |                     |
|                 | or                          |                     |
|                 |                             |                     |
|                 | Not related to Prescription |                     |
|                 | Drugs = Refer to OIG Fraud  |                     |
|                 | Hotline at 1-800 HHS-TIPS   |                     |
|                 | 8:30 a.m. -- 5:00 p.m. M -- |                     |
|                 | F                           |                     |
+-----------------+-----------------------------+---------------------+

+-----------------+----------------------------------------------------+
| **1-800         |                                                    |
| MEDICARE CSRs   |                                                    |
| Cannot**        |                                                    |
+-----------------+----------------------------------------------------+
| Subject         | Comment                                            |
+-----------------+----------------------------------------------------+
| Provide Status  | CSRs do not have access to CTM. 1-800 MEDICARE     |
| of a complaint  | sends a feed to CTM. 1-800 does not currently      |
|                 | receive a feed file from CTM so the CSR is unable  |
|                 | to provide a status of the complaint. The plan     |
|                 | would be in the best position to provide an update |
|                 | on resolution of the complaint. 1-800 MEDICARE     |
|                 | CSRs will have the ability to obtain status for    |
|                 | future CTM complaint entries effective Nov 12.     |
+-----------------+----------------------------------------------------+
| Perform a       | CMS policy allows the GM CSR to perform a          |
| R               | prospective enrollment. If the caller requires a   |
| etro-enrollment | retro-enrollment, the CSR will transfer the call   |
|                 | to a Help Queue CSR to file a complaint. For 2007  |
| Recon           | retrospective enrollments, you can also contact    |
| Enrollment      | the plan directly.                                 |
+-----------------+----------------------------------------------------+
| Help            | SSA must assist a beneficiary                      |
| beneficiaries   |                                                    |
| complete LIS    | 1-800-772-1213                                     |
| application     |                                                    |
+-----------------+----------------------------------------------------+
| Make a LIS      | SSA must make a determination and can provide      |
| determination   | status                                             |
|                 |                                                    |
|                 | 1-800-772-1213                                     |
+-----------------+----------------------------------------------------+
| Perform         | 1-800 MEDICARE CSRs submit as a complaint to CTM.  |
| Retroactive     | For 2007 retroactive disenrollments, you can also  |
| Disenrollment   | contact the plan directly. \* CMS is currently     |
|                 | exploring the feasibility of 1-800 MEDICARE CSRs   |
|                 | performing Retroactive Disenrollments.             |
+-----------------+----------------------------------------------------+
| Medicare        | CSRs perform simple terminations for Working Aged  |
| Secondary Payer | MSP records only. All other MSP issues are         |
| Issues          | referred to COBC, MSPRC, etc. for resolution       |
|                 | depending on the type of insurance.                |
| ex:             |                                                    |
| WC/Liability,   |                                                    |
| Disability      |                                                    |
+-----------------+----------------------------------------------------+
| Medicare        | Submitted in writing. Appeal rights and where to   |
| R               | send the reconsideration request or appeal are on  |
| econsiderations | the back of the MSN.                               |
| & Appeals       |                                                    |
+-----------------+----------------------------------------------------+
| Resolving LIS   | Plans can review evidence of LIS/dual status and   |
| discrepancies   | work with the CMS regional office to get a         |
|                 | beneficiary's LIS/dual status updated. These cases |
|                 | should be referred to the plans. Following the     |
|                 | policy on Best Available Evidence, plans can       |
|                 | resolve LIS discrepancies and transmit requests to |
|                 | change LIS levels monthly via an excel spreadsheet |
|                 | to the ROs (for 2007....in 2008, it will be        |
|                 | IntegriGuard). 1-800 CSRs can file a complaint on  |
|                 | behalf of callers if the beneficiary believes they |
|                 | have provided adequate proof of LIS eligibility (a |
|                 | new CTM subcategory was just added this past       |
|                 | week).                                             |
+-----------------+----------------------------------------------------+
| Enrollment      | Working directly with the plan will result in the  |
| Issues (e.g.,   | most expeditious resolution. CSRs can file a       |
| beneficiary's   | complaint on behalf of callers. If the enrollment  |
| enrollment is   | was submitted via the medicare.gov online          |
| not in the CMS  | enrollment center, 1-800 CSRs can check to see     |
| system)         | plan contract number and date of enrollment using  |
|                 | the administrative console. SHIP will have access  |
|                 | to this information effective Nov 05. The URL      |
|                 | along with further instructions and how to use the |
|                 | site will be forthcoming.                          |
+-----------------+----------------------------------------------------+
| Retiree Drug    | Working directly with the plan will result in the  |
| Subsidy (RDS)   | most expeditious resolution. CSRs can file a       |
|                 | complaint on behalf of callers. The enrollment     |
|                 | process is as follows: (1) plan submits enrollment |
|                 | to CMS; (2) CMS rejects the enrollment due to RDS; |
|                 | (3) plan is to contact beneficiary to explain that |
|                 | the beneficiary may lose retiree insurance if join |
|                 | plan; and (4) if beneficiary still wants Part D    |
|                 | enrollment, plan re-submits the enrollment to CMS  |
|                 | with a RDS override.                               |
+-----------------+----------------------------------------------------+