Referral of Critical Cases to the Regional Office

40.4 - Referral of Critical Cases to the Regional Office (Rev. 4009, Issued: 03-23-18, Effective: 04-23-18, Implementation: 04-23-18) When the MAC identifies a claim meeting the criteria listed below, it contacts the RO via established referral methods. The MAC identifies the beneficiary by name and MBI, specifies the nature of the problem, states that the criteria are met, and gives the dates of all actions. The MAC provides all available supporting documentation. Examples of such documentation are: • Social Security Administration's (SSA) reply to Form CMS-1980 in the case of entitlement questions; and • A copy of the Health Insurance Master Record Entitlement Status Query (ESQ) received from an SSA District Office. The criteria are: • Two follow-ups have been made to the Social Security Office (SSO) and the CWF Master Record has not been corrected; • At least 60 days have elapsed since the correction procedures were initiated; • A serious hardship to the beneficiary or a public relations problem has developed; • Corrections or changes to HMO termination dates are necessary; and • The SSO response indicates that both the MBR and HI Master Records are correct. The MAC marks the information "CRITICAL CASE." The MAC flags the file for special handling and expedites the claim as soon as the reply is received. The MAC must diary the case for 30 calendar days. By that time the RO should have a response and advise the MAC. If the MAC receives a positive basic reply record before hearing from the RO, it notifies the RO.