Department of Health and Human Services (HHS)

Administration for Community Living (ACL)

Senior Medicare Patrol Program (SMP)

Delivery:

November 26th, 2019

SMP Information and Reporting System (SIRS) Final 

Form Fields
SIRS Final Form Fields

1

Contents

Team Member Form ....................................................................................................................................2

Team Member Activity Form .......................................................................................................................4

Interaction Form ..........................................................................................................................................5

Individual Interaction Form..........................................................................................................................6

Subject Form ..............................................................................................................................................12

Group Outreach & Education Form ...........................................................................................................12

Media Outreach & Education Form ...........................................................................................................14
SIRS Final Form Fields

2

Team Member Form

Object Name Required Object Type Input Options/Functions

First Name R Text Field N/A

Middle Initial N Text Field N/A

Last Name R Text Field N/A

Nickname N Text Field N/A

Primary Phone Number R Numbers Field N/A

Primary Phone Number Extension N Numbers Field N/A

Secondary Phone Number N Numbers Field N/A

Secondary Phone Number 

Extension N Numbers Field N/A

Email Address N Text Field N/A

Address N Text Field N/A

City N Text Field N/A

Zip Code N Numbers Field N/A

State/Territory

R Drop Down Options:

· 54 States and Territories

County N Drop Down Auto-populated based on “Zip 

Code”

Start Date R Date Picker N/A

End Date N Date Picker N/A

Status N Drop Down

Options:

· Active

· Retired

Partner Organization Affiliation R Drop Down

Options:

· Organizations

Paid Status N Drop Down

Options:

· In-Kind-Paid

· SMP-Paid

· Volunteer

Race R Multi-select Field

Options: 

· American Indian or Alaskan

Native

· Asian

· Black or African American

· Hispanic or Latino
SIRS Final Form Fields

3

· Native Hawaiian or Other

Pacific Islander

· White

· Not collected

Gender R Drop Down

Options:

· Male

· Female

· Other

· Not Collected

Date of Birth R Date Picker N/A

Primary Language N Drop Down

Options:

· English

· Chinese

· Korean

· Russian

· Spanish

· Vietnamese

· Other

Secondary Language N Drop Down

Options:

· English

· Chinese

· Korean

· Russian

· Spanish

· Vietnamese

· Other

English as a Second Language N Radio Button

Options:

· Yes

· No

Role R Drop Down

Options:

· Enterprise Manager

· ACL Staff

· OIG

· SMP Resource Center

· SMP Director

· State Level Staff

· Site Manager

· Site Staff

· Team Member

· SIRS Submitter

Username R Read Only Populated After Saving
SIRS Final Form Fields

4

eFile ID R Read Only Populated After Saving

Send Login Credentials N Radio Button

Options:

· Yes

· No

Revoke Login N Radio Button

Options:

· Yes

· No

Send eFile ID N Radio Button

Options:

· Yes

· No

Revoke eFile ID N Radio Button

Options:

· Yes

· No

Create 1-800 Medicare Unique ID 

Number R Radio Button

Options:

· Yes

· No

Send 1-800 Medicare Unique ID 

Number N Radio Button

Options:

· Yes

· No

Status of 1-800 Medicare Unique ID 

Number R Drop Down

Options:

· Active

· Inactive

Number of 1-800 Medicare Unique 

ID R Read Only Populated After Saving

Add Document N Button 5 Attachment Fields

Notes N Text Box N/A

User ID N Read Only Populated after saving

Team Member Activity Form

Object Name Required Object Type Input Options/Functions

Month R Drop Down

Options:

· January

· February

· March

· April

· May

· June

· July
SIRS Final Form Fields

5

· August

· September

· October

· November

· December

Year R Drop Down

Options:

· 2015

· 2016

· 2017

· 2018

· 2019

· 2020

Administrative Support (Minutes) N Numbers Field Utilizes the Total Time Spent 

calculator 

Distributing Information 

(Minutes) N Numbers Field Utilizes the Total Time Spent calculator 

Group Outreach and Education 

(Minutes) N Numbers Field Utilizes the Total Time Spent calculator 

Individual Interactions (Minutes) N Numbers Field Utilizes the Total Time Spent 

calculator 

Media Outreach and Education 

(Minutes) N Numbers Field Utilizes the Total Time Spent calculator 

SMP Program Management/ 

Team Member Management 

(Minutes)

N Numbers Field Utilizes the Total Time Spent 

calculator 

Training (Initial/Orientation) 

(Minutes) N Numbers Field Utilizes the Total Time Spent calculator 

Training (Update/Continuing 

Education) (Minutes) N Numbers Field Utilizes the Total Time Spent calculator 

Other SMP Activities (Minutes) N Numbers Field Utilizes the Total Time Spent 

calculator 

Calculated Time Spent R Read Only Calculator for Hours and 

Minutes Fields

Record Mileage N Numbers Field N/A

Record Non-Reimbursed Mileage N Numbers Field N/A

Notes N Text Box N/A

Interaction Form

Object Name Required Object Type Input Options /Functions
SIRS Final Form Fields

6

Type of Interaction R Drop Down

Options:

· Media Outreach and

Education

· Group Outreach and

Education

· Individual Interaction

Session Conducted by R Drop Down Auto-populated based on the 

Team Member logged in

Date of Interaction R Date Picker Default to today’s date

End Date (If Applicable) N Date Picker N/A

Zip Code R Numbers Field N/A

State R Drop Down

Auto-populated based on the 

Team Member logged in

List of States and Territories

County N Drop Down Auto-populated based on “Zip 

Code”

Title of Interaction N Text Field N/A

Time Spent in Hours N Numbers Field Utilizes the Calculated Time 

Spent calculator 

Time Spent in Minutes N Numbers Field Utilizes the Calculated Time 

Spent calculator

Calculated Time Spent (Minutes) R Numbers Field Calculator for Hours and 

Minutes Fields

Reference Number N Read Only Populated after saving

Organization R Read Only

Auto-populated based on the 

Team Member selected in 

Session Conducted By

Notes N Text Field N/A

Individual Interaction Form

Object Name Required Object Type Input Options /Functions

Beneficiary First Name N Text Field N/A

Beneficiary Last Name N Text Field N/A

Beneficiary Phone N Number Field N/A 

Beneficiary Email N Text Field N/A

Beneficiary Address N Text Field N/A

Beneficiary City N Text Field N/A

Beneficiary State N Drop Down List of States and Territories

Beneficiary Zip Code N Number Field N/A 
SIRS Final Form Fields

7

Race N Multi-select Field

Options:

· American Indian or Alaskan

Native

· Asian

· Black or African American

· Hispanic or Latino

· Native Hawaiian or Pacific

Islander

· White

· Not Collected

Gender N Drop Down 

Options:

· Male

· Female

· Other

· Not Collected

Date of Birth N Date Picker N/A

Medicare Number N Text Field N/A

Medicaid Number N Text Field N/A

Other Information N Text Field N/A

Permission to Contact 

Beneficiary N Radio Button

Options:

· Yes

· No

Topic(s) Discussed N Multi-select Field

Options:

· Conditional Payments

· Consumer Protection

· Durable Medical Equipment

(DME)

· Employer Health Plan

· General Fraud, Errors, and

Abuse

· Genetic/DNA Testing

· Home Health Care

· Hospice

· Medicaid

· Medical Identity Theft

· Medicare Advantage

· Medicare Card

· Medicare Part A and B

· Medicare Part D

· Medicare Summary Notice

· Medigap or Supplemental

Insurance
SIRS Final Form Fields

8

· Opioid Fraud and Abuse

· SMP Program Information

· SMP Volunteer Recruitment

· Social Security

· TRICARE

· Veteran's Health Benefits (VA)

· Other

Other Topics Discussed Details N Text Field

Informational Message: (Please 

enter an explanation into the 

Other Topics Discussed Details 

field.)

Add More Information? N Radio Button

Options:

· Yes

· No

Issue(s) N Multi-select Field

Options:

· Beneficiary Perpetrated Fraud

· Billing Error

· Billing for Services Different

From Received

· Billing for Services Not

Provided

· Compromised Medicare

Number

· Compromised Social Security

Number

· Double Billing

· Enrollment / Disenrollment

Issues

· Kickbacks

· Marketing Fraud

· Quality of Care Issues

· Scams

· Other Fraud, Error, or Abuse

Other Fraud Error or Abuse 

Details N Text Field

Informational Message: (Please 

enter an explanation into the 

Other Fraud, Error, or Abuse 

Details field.)

Is the Complainant different 

from the Beneficiary? N Radio Button

Options:

· Yes

· No

Complainant Last Name N Text Field N/A

Complainant First Name N Text Field N/A
SIRS Final Form Fields

9

Complainant Phone Number 

(xxx-xxx-xxxx) N Number Field N/A

Complainant Email N Text Field N/A

Complainant Relationship to 

Beneficiary N Drop Down 

Options:

· Spouse

· Family Member/Caregiver

· Health Care Provider

· Other

Complainant Address N Text Field N/A

Complainant State N Drop Down List of States and Territories

Complainant City N Text Field N/A

Complainant Zip Code N Number Field N/A

Permission to contact 

Complainant N Radio Button

Options:

· Yes

· No

Cost Avoidance on behalf of 

Medicare, Medicaid, 

Beneficiaries, or others (xxxx.xx)

N Number Field N/A

Expected Medicare Recoveries 

(xxxx.xx) N Number Field N/A

Additional Expected Medicare 

Recoveries (xxxx.xx) N Number Field N/A

Expected Medicaid Recoveries 

(xxxx.xx) N Number Field N/A

Additional Expected Medicaid 

Recoveries (xxxx.xx) N Number Field N/A

Actual Savings to Beneficiaries 

(xxxx.xx) N Number Field N/A

Other Savings (xxxx.xx) N Number Field N/A

Explanation N Text Field N/A

SMP Action(s) N Multi-select Field

Options:

· SMP contacted 1-800-

Medicare

· SMP contacted CMS Liaison

· SMP contacted CMS Regional

Office

· SMP contacted Federal Trade

Commission

· SMP contacted Medicare

Advantage Plan or Part D Plan

· SMP contacted Medicare PSC

or MEDIC Contractor
SIRS Final Form Fields

10

· SMP contacted MFCU or

Medicaid Office

· SMP contacted OIG

· SMP contacted Other CMS

Contractor

· SMP contacted

Provider/Practitioner

· SMP contacted Quality

Improvement Organization

(QIO)

· SMP contacted Secondary

Insurer/Plan

· SMP contacted SHIP

· SMP contacted SMP Resource

Center

· SMP contacted State

Insurance Department

· SMP contacted UPIC

· SMP sent Release of

Information Form and Request

Documents

· SMP reviewed Guidelines,

Policies, or Procedures

· Other SMP Action

Other SMP Action Details N Text Field

Informational Message: (Please 

enter an explanation into the 

Other SMP Action Details 

field.)

Referred Beneficiary to Action(s) N Multi-select Field

Options:

· Referred beneficiary to 1-800-

Medicare

· Referred beneficiary to an

Ombudsman

· Referred beneficiary to

contact Medicare Advantage

Plan or Part D Plan

· Referred beneficiary to

contact MFCU or Medicaid

Office

· Referred beneficiary to

contact Provider/Practitioner
SIRS Final Form Fields

11

· Referred beneficiary to

contact Quality Improvement

Organization (QIO)

· Referred beneficiary to

contact Secondary Insurer/Plan

· Referred beneficiary to

Federal Trade Commission

· Referred beneficiary to SHIP

Appeal N Radio Button

Options:

· Yes

· No

Add Documents N Button 5 attachment fields

Case Notes N Text Field N/A

Refer to OIG Hotline via ACL N Radio Button

Options:

· Yes

· No

Date Submitted to ACL N Read Only N/A

Date ACL Submitted to OIG N Date Picker N/A

ACL Comments N Text Field N/A

SMP Representative Name N Text Field N/A

SMP Representative Phone 

Number (xxx-xxx-xxxx) N Number Field N/A

SMP Representative Fax Number 

(xxx-xxx-xxxx) N Number Field N/A

SMP Representative Email 

Address N Text Field N/A

SMP Representative Mailing 

Address N Text Field N/A

Status of Interaction N Multi-select Field

Options: 

· Open – Research in progress

by SMP, less than one year

· Open – Awaiting Response to

Referral

· Closed – Reviewed Internally,

no issue identified

· Closed – Resolved by SMP

· Closed – Referral No Action

Required

· Closed – Action Taken By

Referent

· Closed – Handled by SHIP

· Closed – Other
SIRS Final Form Fields

12

· Suspended

Date of Last Status Update N Date Picker N/A

Subject Form

Object Name Required Object Type Input Options /Functions

Organization Name N Text Field N/A

First Name N Text Field N/A

Last Name N Text Field N/A

Phone Number (xxx-xxx-xxxx) N Numbers Field N/A

Provider Number N Text Field N/A

Email N Text Field N/A

Website N Text Field N/A

Address N Text Field N/A

City N Text Field N/A

State N Text Field N/A

Zip Code N Numbers Field N/A

Other Information N Text Field N/A

Group Outreach & Education Form

Object Name Required Object Type Input Options/Functions

ACL/SMP Consumer Alert R Radio Button 

Options:

· Yes

· No

Type of Event N Drop Down

Options:

· Community Event

· Group Education Session

Intended Audience R

Multi-select 

Field 

Options

· Beneficiaries

· Family Members/Caregivers

· General Audience

· Health Care Providers

· Law Enforcement

· Partner Organizations

· Other

Targeted Beneficiary Audience(s) N

Multi-select 

Field

Options:

· General
SIRS Final Form Fields

13

· Homebound

· Long Term Care Residents

· Low Income

· Native American

· Non-English Speaking

· People with Disabilities

· Racial/Ethnic Minority

· Rural

· Not Collected

· Other

Topics Discussed N

Multi-select 

Field

Options:

· Conditional Payments

· Consumer Protection

· Durable Medical Equipment

(DME)

· Employer Health Plan

· General Fraud, Errors, and

Abuse

· Genetic/DNA Testing

· Home Health Care

· Hospice

· Medicaid

· Medical Identity Theft

· Medicare Advantage

· Medicare Card

· Medicare Part A and B

· Medicare Part D

· Medicare Summary Notice

· Medigap or Supplemental

Insurance

· Opioid Fraud and Abuse

· SMP Program Information

· SMP Volunteer Recruitment

· Social Security

· TRICARE

· Veteran’s Health Benefits (VA)

· Other

Other Topics Discussed Details N Text Field

Informational Message: (Please 

enter an explanation into the 

Other Topics Discussed Details 

field.)
SIRS Final Form Fields

14

Estimated Number of People 

Reached

R Numbers Field N/A

In-Kind Match (xxxx.xx) N Numbers Field N/A

Media Outreach & Education Form

Object Name Required Object Type Input Options/Functions

ACL/SMP Consumer Alert

R Radio Button 

Options:

· Yes

· No

Type of Media N Multi-select Field

Options:

· Billboard

· Email

· Magazine

· Newsletter

· Newspaper

· Radio

· Social Media

· Television

· Website

· Other

Number of Airings N Number Field N/A

Geographic Coverage N Multi-select Field

Options:

· County or Counties

· Multi-State

· National

· Regional

· Statewide

· Zip Code

Specific Coverage Location N Text Field N/A

Intended Audience R Multi-select Field 

Options

· Beneficiaries

· Family Members/Caregivers

· General Audience

· Health Care Providers

· Law Enforcement

· Partner Organizations

· Other

Topics Discussed N Multi-select Field Options:

· Conditional Payments
SIRS Final Form Fields

15

· Consumer Protection

· Durable Medical Equipment

(DME)

· Employer Health Plan

· General Fraud, Errors, and

Abuse

· Genetic/DNA Testing

· Home Health Care

· Hospice

· Medicaid

· Medical Identity Theft

· Medicare Advantage

· Medicare Card

· Medicare Part A and B

· Medicare Part D

· Medicare Summary Notice

· Medigap or Supplemental

Insurance

· Opioid Fraud and Abuse

· SMP Program Information

· SMP Volunteer Recruitment

· Social Security

· TRICARE

· Veteran’s Health Benefits

(VA)

· Other

Other Topics Discussed Details N Text Field

Informational Message: 

(Please enter an explanation 

into the Other Topics 

Discussed Details field.)

Estimated Number of People 

Reached R Numbers Field N/A

Basis of Estimate for Number of 

People Reached R Text N/A

In-Kind Match (xxxx.xx) N Numbers Field N/A