For Professionals: Medicare Basics

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1-800 MEDICARE CSRs Can Perform the Activities Shown Below

The appropriate CSR level for each topic is also listed below. Higher/different levels of CSRs do not have access to different (or more) information than the CSR tier shown below.

Subject Comment CSR Level
Prospective Disenrollment GM Tier I CSR determines if a disenrollment is applicable. If so, the CSR will transfer to a Disenrollment CSR.

Disenrollment CSR

(Note: If the caller wants to 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 Plans Tool

Plan Compare is available on the web to SHIPs and beneficiaries


File PDP Complaints

Contact a GM Tier I CSR only after you or the beneficiary has contacted the plan and the issue has not been resolved.


Provide Enrollment Status

Enrollment status is available on the web and in the IVR to SHIPs and beneficiaries


Provide LIS eligibility Information

LIS status is available on the web and in the IVR to SHIPs and beneficiaries


Send out a LIS application

LIS applications are available on SSA’s website


Medicare Secondary Payer

(Simple Termination – when a person retires or terminates insurance that pays before Medicare.)

A simple termination is performed by adding an “end” date to an existing Working Aged MSP record using Next Generation Desktop (NGD).

Claims Tier I Part A, Part B, or DME CSRs

Note: in some instances, only COBC can perform the simple termination. In that case, the caller will be referred to COBC.

Premium Withhold

The CSR can verify if the 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.



GM Tier I CSR can determine 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 inquiries

GM Tier I CSRs can handle 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 should check the MSN prior to contacting 1-800 MEDICARE and to determine whether the claim is a Part A, B or DME service. Claims Tier I CSRs can provide 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.

Claims Tier I CSRs

Note: Claims CSRs are specific to the line of business – Part A, Part B, or DME.

Complex Inquiries

Certain complex inquiries will need to be referred to the claims processing contractor (FI, Carrier, or DMAC) for further research action. Examples would include reissuing checks, investigation of claims suspended for long periods of time, reprocessing of claims.

Claims Tier I CSRs

Note: These CSR will refer complex inquiries to FFS claims processing contractors through the CSR desktop. This is not a live transfer. The FFS contractor does the research and takes appropriate actions offline.

SPAPs (State Prescription Assistance Programs) and PAPs (Plan Administered Pharmaceutical Assistance Programs) questions

Ships can find information on SPAPs and PAPs via From the home page, select “Lower Your Costs During the Coverage Gap.” This will take you to a page with links to information 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.

GM Tier 1 CSR

Drug Coverage Fraud Marketing Sales

If the beneficiary received misleading or false 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

GM Tier 1 CSR.

1-800 MEDICARE CSRs Cannot

Subject Comment

Provide Status of a complaint

CSRs do not have access to CTM. 1-800 MEDICARE 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 Retro-enrollment

Recon Enrollment

CMS policy allows the GM CSR to perform a prospective enrollment. If the caller requires a retro-enrollment, the CSR will transfer the call to a Help Queue CSR to file a complaint. For 2007 retrospective enrollments, you can also contact the plan directly.

Help beneficiaries complete LIS application

SSA must assist a beneficiary

Make a LIS determination

SSA must make a determination and can provide status

Perform Retroactive Disenrollment

1-800 MEDICARE CSRs submit as a complaint to CTM. For 2007 retroactive disenrollments, you can also contact the plan directly. * CMS is currently exploring the feasibility of 1-800 MEDICARE CSRs performing Retroactive Disenrollments.

Medicare Secondary Payer Issues
ex: WC/Liability, Disability

CSRs perform simple terminations for Working Aged MSP records only. All other MSP issues are referred to COBC, MSPRC, etc. for resolution depending on the type of insurance.

Medicare Reconsiderations & Appeals

Submitted in writing. Appeal rights and where to send the reconsideration request or appeal are on the back of the MSN.

Resolving LIS discrepancies

Plans can review evidence of LIS/dual status and 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 Issues (e.g., beneficiary’s enrollment is not in the CMS system)

Working directly with the plan will result in the most expeditious resolution. CSRs can file a complaint on behalf of callers. If the enrollment was submitted via the online enrollment center, 1-800 CSRs can check to see 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 Subsidy (RDS)

Working directly with the plan will result in the 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.

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