Releasing Any Beneficiary-Specific Information

Release any requested beneficiary-specific information when the caller is… / And … / Additional steps / Notes
  • The beneficiary
/ You obtain the following information:
  • Beneficiary’s name, Medicare number, date of birth, and one additional piece of information such as SSN, address, phone number, effective date(s), or whether the beneficiary has Part A and/or Part B coverage.
  • If the parent or legal guardian, verification that the caller’s name matches the parent’s or legal guardian’s name listed in your files.
/ Release any entitlement and claim information and answer any questions pertaining to the beneficiary’s Medicare coverage. Do not evaluate the diagnosis reported on the claim.
1)If the caller makes a mistake in providing disclosure information, ask him or her to repeat the information.
2)If the caller again makes a mistake, encourage the caller to ask someone to help him or her find the information OR to look at the Medicare paperwork.
3)If the caller cannot provide the correct information, you cannot release any beneficiary-specific information. / There is a 2-year tolerance for the year of birth. For a beneficiary born on 3/12/31 you may accept the year of birth as 1929, 1930, 1931, 1932, or 1933 – 2 years prior to and 2 years after the correct year of birth. The month and day, however, must match exactly.
The beneficiary’s spouse, relative, friend, or advocacy group (excluding State Health Insurance Assistance Program (SHIP) employees and volunteers) /
  • The caller provides the beneficiary’s full name, date of birth, Medicare number, and one additional piece of information such as SSN, address, phone number, effective date(s), or whether the beneficiary has Part A and/or Part B coverage.
  • Current written consent/ authorization is on file for the caller.
/ Release any beneficiary-specific information if the written consent/authorization does not limit the caller’s access to information. / Written consent/authorization includes either of the following:
  • Indication on the desktop that written consent/authorization is on file
  • A signed disclosure form or other written consent/authorization on file including the following:
Beneficiary signature and date
Name of individual, 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 an ongoing release.
Continued on next page.
The beneficiary’s spouse, relative, friend, or advocacy group (excluding State Health Insurance Assistance Program (SHIP) employees and volunteers) (continued) / 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.
The beneficiary’s spouse, relative, friend, or advocacy group (excluding State Health Insurance Assistance Program (SHIP) employees and volunteers) / You obtain verbal consent/authorization from the beneficiary by doing the following:
1)Ask the caller to put the beneficiary on the line.
2)Obtain the beneficiary’s name, date of birth, Medicare number, and one additional piece of information such as SSN, address, phone number, effective date(s), or whether the beneficiary has Part A and/or Part B coverage. / Release any beneficiary-specific information.
Encourage the caller to ask the beneficiary to provide written consent/authorization. / The beneficiary does not have to remain on the line or even be at the same place as the caller. You may obtain the beneficiary’s consent/authorization to speak with the caller via another line or three-way calling.
Verbal consent/authorization is valid for 14 days.
The beneficiary’s spouse, relative, friend, or advocacy group (excluding State Health Insurance Assistance Program (SHIP) employees and volunteers) requesting information about a deceased beneficiary / You have proof of death.
Proof of death includes:
  • Date of death shown on CWF
  • Date of Death shown on the MBR
  • OR a copy of the death certificate.
AND the caller provides the beneficiary’s name, Medicare number, date of birth, and one additional piece of information such as SSN, address, phone number, effective date(s), or whether the beneficiary has Part A and/or Part B coverage. / When a beneficiary is deceased, he or she is no longer protected under the Privacy Act; therefore any information may be released as long as it is not harmful to the family or to the estate. / (Note: The HIPAA privacy regulation will extend privacy protections to the deceased. The compliance date for privacy regulation is April 2003.)
The Parent (legal guardian) of a beneficiary who is a minor child OR
The Legal guardian of a person declared to be incompetent by the court
The Parent (legal guardian) of a beneficiary who is a minor child OR
The Legal guardian of a person declared to be incompetent by the court (continued) / You obtain the following information:
  • Beneficiary’s name, Medicare number, date of birth, and one additional piece of information such as SSN, address, phone number, effective date(s), or whether the beneficiary has Part A and/or Part B coverage.
  • Verification that the caller’s name matches the parent’s or legal guardian’s name listed in your files.
/ Release any entitlement and claim information and answer any questions pertaining to the beneficiary’s Medicare coverage. Do not evaluate the diagnosis reported on the claim.
A legal representative as defined by the State
A legal representative as defined by the State (continued) /
  • The representative’s name matches the representative’s name on file.
  • The representative also provides the beneficiary’s name, date of birth, and Medicare number, and one additional piece of information such as SSN, address, phone number, effective date(s), or whether the beneficiary has Part A and/or Part B coverage.
/ You may assume that the legal representative can receive all information on behalf of the beneficiary unless there is documentation stating that he or she represents the beneficiary for limited services. / A beneficiary must provide a written request for a legal representative in order to verify the relationship.
To answer any questions via the telephone, you must have proof of the arrangement for services on file or the representative’s name must appear on the system (e.g., Master Beneficiary Record (MBR), Supplemental Security Income Record (SSR), Health Insurance Master Record (HIMR), or Inquiry Response
Numident Identification Screen (QRID)).
A beneficiary may have more than one legal representative.
An SSA-Appointed Representative Payee /
  • The SSA-Appointed Representative Payee provides the beneficiary’s full name, date of birth, and Medicare number, and one additional piece of information such as SSN, address, phone number, effective date(s), or whether the beneficiary has Part A and/or Part B coverage.
  • You verify that the caller’s name matches the representative payee listed in your files.
/ You may release any beneficiary-specific information and answer any questions pertaining to the beneficiary’s Medicare coverage. / To answer any questions via the telephone, you must have proof of the arrangement for services on file or the representative’s name must appear on the system (e.g., Master Beneficiary Record (MBR), Supplemental Security Income Record (SSR), Health Insurance Master Record (HIMR), or Inquiry Response Numident Identification Screen (QRID)).
A CMS employee
A CMS employee (continued) / You are reasonably certain that you are speaking to a CMS employee.
The caller provides the beneficiary’s full name, date of birth, Medicare number, and one additional piece of information such as SSN, address, phone number, effective date(s), or whether the beneficiary has Part A and/or Part B coverage. / Release any claim information and answer only questions pertaining to the beneficiary's Medicare coverage. / There are three ways that a CSR may verify that he/she is speaking with a CMS employee.
  1. Both parties on the call look at the CWF or MBR record (or other beneficiary record to which they both have access). The CSR or CMS employee can name a field on the CWF or MBR and ask that the other party identify what is in that particular field.

OR

  1. The CSR may ask for the CMS employee’s phone number and call him/her back, making sure that the area code and exchange is correct for the CO or RO location.
NOTE: Caller ID or similar service may be used to verify the area code and exchange in lieu of a callback.
OR
The CSR may take the name 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.
Releasing Any Beneficiary-Specific Information Training Guide / Page - 1