100-09 Medicare Contractor Beneficiary and Provider Communications Manual: Chapter 2 - Beneficiary Customer Services

Medicare Contractor Beneficiary and
Provider Communications Manual
Chapter 2 - Beneficiary Customer Services
Table of Contents
(Rev. 41, 02-08-19)
Transmittals for Chapter 2
10 - Introduction
20 – Beneficiary Customer Services (BCS)
20.1 – Escalation of Complex Beneficiary Inquiries to the MACs by the
Beneficiary Contact Center (BCC)
20.1.1 – Next Generation Desktop (NGD) Training
20.1.2 – Disclosure of Information (Adherence to the Privacy Act and the
Health Insurance Portability and Accountability Act (HIPAA) Privacy
Rule)
20.1.3 – Screening of Beneficiary Complaints Alleging Fraud or Abuse
20.1.4 – Medicare Customer Service - Next Generation Desktop (MCSC-
NGD) Client Installation and Configuration Requirements
20.1.5 – Call Center User Group (CCUG)
20.2 – Complex Beneficiary Inquiries
20.2.1 – Handling Complex Beneficiary Inquiries
20.2.2 – Controlling Complex Beneficiary Inquiries
20.2.3 – E-mail and Fax Responses to Complex Written Beneficiary
Inquiries
20.2.4 – Telephone Responses to Complex Beneficiary Inquiries
20.2.5 – Written Responses to Complex Beneficiary Inquiries
20.2.6 – Timeliness of Responses to Complex Beneficiary Inquiries
20.3 – Congressional Beneficiary Inquiries
20.4 – Surveys
20.5 – Urgent Need Regional Offices Casework

10 - Introduction
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
This chapter contains general instructions and requirements for the Fee-for-Service
Medicare Administrative Contractors (MACs). While the Centers for Medicare and
Medicaid Services (CMS) have separately contracted for direct beneficiary
communication with the Beneficiary Contact Center (BCC) contractor, MACs receive
complex beneficiary inquiries from the BCC and Regional Offices (ROs) in accordance
with National Operating Procedure NP 1.0 (complex inquiries), for response. As a
result, MACs are required to respond to complex beneficiary inquiries. This chapter
provides instructions and guidance for MACs in handling, controlling, and responding to
complex beneficiary inquiries, including Congressional inquiries written on behalf of
beneficiaries.
20 - Beneficiary Customer Services (BCS)
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
CMS’s goal is to continuously improve the Medicare experience through the delivery of
high quality and cost-effective customer service. The CMS’ vision is for customer
service to be responsive to the needs of diverse groups, a trusted source of accurate and
relevant information, convenient and accessible assistance, and courteous and
professional. The following guidelines are designed to help MACs to ensure CMS’ goal
and vision are met.
20.1 - Escalation of Complex Beneficiary Inquiries to the MACs by the
Beneficiary Contact Center (BCC)
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
The BCC Customer Service Representatives (CSRs) escalate any complex beneficiary
inquiries that they receive to the appropriate MAC through the Next Generation Desktop
(NGD) in accordance the Complex Inquiry Escalation National Operating Procedure, NP
1.0. This procedure can be found at
https://trainingresources.tanagerinc.com/MTKRSite/index.htm, under the National
Operating Procedures section.
20.1.1 - Next Generation Desktop (NGD) Training
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
The development of the NGD training materials will be done by CMS and it is not
expected that there will be any costs to the MACs to use these training materials.
Standardized training materials and other training information is available at the
following Website:
https://trainingresources.tanagerinc.com/MTKRSite/index.htm, under the All Learning
Resources section. MACs shall check this website monthly for updated training
materials.

20.1.2 - Disclosure of Information (Adherence to the Privacy Act and
the Health Insurance Portability and Accountability Act (HIPAA)
Privacy Rule)
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
MACs shall protect the confidentiality of Medicare beneficiary personally-identifiable
information (PII) and protected health information (PHI) in accordance with the Privacy
Act of 1974 and the HIPAA of 1996.
20.1.3 - Screening of Beneficiary Complaints Alleging Fraud or Abuse
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
The BCC will complete the first-level fraud/abuse screening (see IOM Pub. 100-08
Medicare Program Integrity Manual (PIM)), Chapter 4, §4.6-4.6.2).
Candidate cases that merit second-level screening will be forwarded to the appropriate
MAC through NGD as a complex beneficiary inquiry in accordance with National
Operating Procedure NP 1.0. MACs shall follow the instructions in IOM Pub. 100-08
Medicare PIM, Chapter 4, sections 4.6-4.6.2 for working these cases.
20.1.4 - Medicare Customer Service - Next Generation Desktop (MCSC-
NGD) Client Installation and Configuration Requirements
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
MACs shall meet the following hardware, software, and installation instructions for the
MCSC-NGD equipment.
Minimum Hardware and Software Requirements:
Minimum Hardware and Software Requirements for an NGD Personal Computer
Processor: 	500MHz PII or comparable AMD
800MHz Celeron or comparable AMD
Disk Space: 	100MB available
Memory: 	288 MB for Windows XP
Operating
System:
Windows XP Service Pack 2 or later
Browser: 	Internet Explorer 6.0 - Service Pack 1 with Cumulative security update for SP 1 (KB867801) or
above
NOTE: More than one instance of NGD open at a time is not supported.
Internet Explorer 8.0 with MS10-002: Cumulative security update
NOTE: More than one instance of NGD open at a time is not supported. (i.e.
can have only one active NGD session per IE 8 instance. )
Java: 	Sun J2SE v1.5 or higher Java Runtime Environment (JRE). The Sun J2SE
can be downloaded from Sun’s web site at http://java.sun.com. Do not
download the Software Development Kit (SDK). Installation instructions are
on this site.

Monitor: 	21”
Pointing Device: 	Mouse with scroll
Network
Interface:
Network Interface Card compatible with the call center LAN, which will
ultimately allow workstation access to CMSNET
Word Processor: 	Microsoft Office 2002 (or higher version) – Required only for generation of
correspondence.
Viewers: 	Microsoft Word Viewer (provided free by Microsoft) and Adobe Acrobat
Reader (v4.05 or v5.0 free from Adobe) are required.
Desktop Configuration:
Note: You must set the following configurations in the user’s profile. This can be done
by logging into the workstation as the user and making the changes.
General Desktop Configurations:
General Desktop Configurations 	How to Configure
Set the screen resolution to 1024 X
768 pixels
Select Display from the control panel, then 	the
settings tab. This can be set in the Screen Resolution
field.
Create a shortcut to the desktop 	The URL should start with “https://” and end with
“/fins.enu/”
Please provide your IT person with
this information for the PSS Site
Please contact your IT Dept. to use PSS you have to be
able to telnet to port 443 on the IP address of
32.91.253.217.
command - telnet 32.91.253.217 443 This is not an
internet connection. This needs to route out of your
CMSNet connection.
General Internet Explorer Configurations:
Note: Make the following Internet Explorer settings changes by selecting Internet
Options under Tools in the browser.
Internet Explorer Configurations 	How to Configure
Configure IE to automatically check
for newer versions of stored pages.
Click Settings on the General tab, then select
Automatically
Increase the “Amount of disk space to
use” for the Temporary Internet files
folder to at least 150 MB.
Click Settings on the General tab, then increase the
disk space size
Delete the XRPC Class file and the
Winhook Class file if they exist.
Click Settings on the General tab, then View Objects to
get to these files
Add the necessary Sites to the
appropriate web content zone list in
Varies depending on network topology.

the Security tab.
Enter the appropriate address in the
Proxy Settings exceptions if necessary.
Varies depending on network topology.
Internet Explorer Advanced Tab
Settings
Selected/Deselected
Disable Script Debugging 	Selected
Do not save encrypted pages to disk 	Deselected
Reuse windows for launching
shortcuts
Deselected
Internet Explorer Security Settings:
Note: The following Security Settings for the web content zones (under Custom Level)
must be set. These are also accessible by selecting Internet Options under Tools in the
browser.
Note: The zone assigned to the following settings is dependent on the MAC’s network
setup and recognition of the NGD application. If the MAC is treating the NGD
application like an internet application, then the MAC will want to use the “Trusted
Sites” zone and configure NGD as a trusted site. If the MAC is accessing NGD as though
it is part of the Intranet, then the Intranet zone should be used.
Note: To run NGD in the Internet Security zone, it is required to set the "Download signed
ActiveX controls" setting to Enable and to set the "Automatic prompting for ActiveX controls"
to Enable. Without setting these properties as such, ActiveX controls cannot be downloaded, and
the application will not function properly. Note that this requirement has not changed from
Microsoft Windows XP SP1 to Microsoft Windows XP SP2. In Microsoft Windows XP SP2,
however, the defaults for these settings have changed to Disable for sites running in the Internet
Security zone.
Note: The default setting for applications running in the Local Intranet Security zone and for
Trusted sites are suitable for downloading of the Siebel ActiveX controls. If the Siebel
application is in one of these Security zones, no action should be required to adjust this setting.
Active X Controls and
Plug-ins
Required 	Comments
Download signed Active X
Controls
Enable 	Disabling Active X will remove
application functionality such as
Keyboard Accelerators
Download unsigned ActiveX
controls
Enable
Initialize and script ActiveX
controls not marked as safe
Enable
Run ActiveX controls and
plug-ins
Enable
Script ActiveX controls 	Enable

marked safe for scripting
Automatic prompting for
Active X controls
Enable
Downloads 	Required 	Comments
File download 	Enable 	Needed to allow attachment
functionality
Font download 	Enable
Java / Microsoft VM 	Required 	Comments
Java permissions 	Low Safety
Java Console(for CTI
Toolbar)
Required 	Comments
Use SSL 2.0 compatible
ClientHello format
Disable 	This setting can be found in
Java Control Panel under
Advanced > Security tab.
Disable per Mitre.
Use SSL 3.0 	Disable 	This setting can be found in
Java Control Panel under
Advanced > Security tab.
Disable per Mitre.
Use TLS 1.0 	Enable 	This setting can be found in
Java Control Panel under
Advanced > Security tab.
Enable per Mitre.
Miscellaneous 	Required 	Comments
Access data sources across
domains Prompt
Allow META REFRESH 	Enable 	This setting is for Internet Explorer 6
only.
Display mixed content 	Enable 	This setting is for Internet Explorer 6
only. May be required on a secured
site that can display secured content
and non-secured one. Note: This
setting must be enabled in the
Internet zone along with the
selected zone being configured. This
is the only exception in configuring
zones. If the setting is not enabled

an additional pop-up error message
will be displayed to the user.
Don’t prompt for client
certificate selection when no
certificate or only one
certificate exists
Enable
Drag and Drop or Copy and
Paste files
Enable
Installation of Desktop items 	Prompt
Launching programs and files in
an IFRAME
Prompt 	May be required if templates are
configured to use IFRAMEs
Navigate sub-frames across
different domains
Enable
Software Channel permissions 	Medium
Safety
Submit non-encrypted form data 	Enable
User persistence 	Enable
Use TLS 1.0 	Enable
Use SSL 2.0 	Disable 	Disable weak security cipher SSL v2
per Mitre.
Use SSL 3.0 	Disable 	Disable weak security cipher SSL v3
per Mitre.
Scripting 	Required 	Comments
Scripting is used in relation to the Interaction Manager that handles the
additional functionality provided by Siebel in High Interactivity mode
such as the ability to edit within a list and many other functions. There
is also Siebel Applet Browser scripting in the Siebel object model for
things like validations and calls to do things like interact with MS Word
or export data.
Active Scripting 	Enable
Allow paste operations via
script
Enable
Scripting of Java applets 	Enable
User Authentication 	Required 	Comments
Logon 	Automatic
logon only in
Intranet Zone
Note: When enabled, Pop-up Manager blocks most pop-up windows from appearing on the personal computer. End users
and IT administrators must allow Siebel pop-ups to appear by including the NGD address in the Pop-up Manager's
Allowed Sites list. It is a requirement that the NGD address be added to this list.
Note: Sites in the Trusted Sites and Local Intranet zones never have their pop-up windows blocked. If the NGD address is
in one of these security zones, no action is required to adjust this setting.

Connecting to the NGD Application:
Note: The Siebel High Interactivity Framework file and Smart Scripts can be downloaded and installed from any NGD
8.1 environment. The Siebel Browser Check can also be resolved when connected to any NGD 8.1 environment.
Siebel High Interactivity Framework:
The first time the client connects to NGD, the Siebel High Interactivity Framework is
automatically downloaded and installed into the browser. The Siebel High Interactivity
Framework is also automatically downloaded and installed any subsequent time that the
client connects to NGD without it installed. The Siebel High Interactivity Framework is a
necessary component in order to successfully login and use NGD.
To install the Siebel High Interactivity Framework, the NGD user needs to have at least
Power User level rights to their local machine. When they next login to NGD, it will
automatically be downloaded and installed.
Some call centers restrict the rights that their users have to their local machines. These
sites may choose to pre-load the Siebel High Interactivity Framework component so that
their users do not need Power User rights. However, sites that choose to do this need to
understand that if the Siebel High Interactivity Framework becomes corrupted, they will
need to reinstall it. Also, any future enhancements or versions to the Siebel High
Interactivity Framework file will need to be loaded as well.
To pre-load the Siebel High Interactivity Framework, a user with Power User or
Administrative rights to the local machine must login to NGD from that machine.
The recommended procedure is to grant Power User level rights to all NGD users. Sites
that choose to not grant Power User level rights to their users do so at their own risk. The
NGD Help Desk will not support the pre-loading of the Siebel High Interactivity
Framework.
Smart Script:
The first time the Smart Script is activated in NGD; the Smart Scrip is automatically
downloaded and installed into the browser. The Smart Script is a necessary component in
order to successfully use Smart Scripts in NGD.
To install the Smart Script, the NGD user needs to have at least Power User level rights to
their local machine. When they next activate a Smart Script in NGD, it will automatically
be downloaded and installed.
Some call centers restrict the rights that their users have to their local machines. These
sites may choose to pre-load the Smart Script so that their users do not need Power User
rights. However, sites that choose to do this need to understand that if the Smart Script
becomes corrupted, they will need to reinstall it. Also, any future enhancements or
versions to the Smart Script will need to be loaded as well.

To pre-load a Smart Script, a user with Power User or Administrative rights to the local
machine must login to NGD from that machine and activate a Smart Script.
The recommended procedure is to grant Power User level rights to all NGD users. Sites
that choose to not grant Power User level rights to their users do so at their own risk. The
NGD Help Desk will not support the pre-loading of the Smart Script.
Siebel Browser Check:
Each time a client connects to NGD, the Siebel Browser Check applet checks the local
browser for missing components (such as Sun’s JVM) and verifies the current
configuration. If there are any missing components or recommended changes the current
configurations, the Siebel Browser Check dialog box will appear while the user is logging
into NGD and offer to load the necessary components or change the recommended settings.
You may instruct your users to select Auto Fix to automatically take the recommended
action.
Otherwise, if it is a setting that is not listed in this document and you do not want it
changed (such as printing background colors and images), simply select the box next to
“Please do not warn me again about recommended settings” and click Exit.
Troubleshooting:

There are many erratic behaviors that can occur in NGD when the Siebel High
Interactivity Framework file or Smart Script files become corrupted on the local machine.
The best method to troubleshoot NGD issues is to begin by deleting the Siebel High
Interactivity Framework and Smart Script files, then restarting the browser. Those files
will then need to be reinstalled (see section 3.1 and 3.2).
To delete these files, do the following:
• 	Select Tools => Internet Options from the browser menu
• 	Click on the Settings button from the Temporary Internet Files section of the
General tab
• 	Click on View Objects from the Settings box
• 	Select and delete the Siebel High Interactivity Framework and Smart Script files
• 	Restart the browser
Third Party Applications:
Third party applications can interfere with the NGD application and cause it to freeze.
Specifically, third party browser tool bars such as Comet Cursor, My Web, My Web
Search, Google, Yahoo Toolbar, etc., as well as memory defrag (scrubbers) tools need to
be removed. Be aware that any third party application (such as call monitoring software)
can interfere with NGD. The NGD team will ask for third party applications to be
removed if they discover that it is interfering with NGD.
20.1.5 - Call Center User Group (CCUG)
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
MACs are required to participate in CCUG calls. The CCUG sessions provide a forum
for CMS to discuss new and ongoing projects related to telephone customer service, for
MACs to surface issues for CMS resolution, and call centers to share best practices in
telephone customer service delivery. The call center manager or a designated
representative shall participate at a minimum.
20.2 - Complex Beneficiary Inquiries
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
Although MACs may receive beneficiary inquiries (letters, faxes, e-mails, and, rarely,
telephone calls) through a number of portals, under the current design, the MACs are
responsible for responding only to the complex beneficiary inquiries that are referred to
them by the (BCC) or the CMS ROs. If MACs receive beneficiary inquiries that are of a
general nature, such as, specific billing questions and questions about claims, medical
records, or expenses. MACs shall refer the inquiring beneficiaries to the BCC at 1-800-
MEDICARE, or TTY # 1-877-486-2048. MACs may also provide the beneficiaries with
the address to which they may send correspondence: Centers for Medicare & Medicaid
Services, P.O. Box 39 Lawrence, KS 66046.

20.2.1 - Handling Complex Beneficiary Inquiries
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
Complex beneficiary inquiries will be identified and referred to the MACs by the BCC or
the ROs via NGD and may include, but are not limited to, telephone, written, and e-mail
inquiries. Once a complex beneficiary inquiry is referred to a MAC, the Provider
Relations Research Specialists (PRRS) shall take ownership of the inquiry and be
accountable for its resolution. While the PRRS is held accountable for the response, the
MAC may use other resources to develop the response, as appropriate. If PRRS transfers
a complex beneficiary inquiry to a MAC department that has its own separate control
process and timeliness standards (e.g., appeals), PRRS may close the inquiry in NGD.
PRRS will document reliable and accurate information into the resolution details field,
including guidance on how the inquirer/beneficiary can contact the MAC regarding the
nature of the case (e.g., checking the status, asking follow-up questions). The MAC shall
respond directly to the beneficiary via telephone, written mail, fax, or e-mail and
document the response in NGD. Complex inquiries from beneficiaries shall receive the
same priority and attention as complex inquiries from providers.
The MAC shall have adequate language capabilities (English, Spanish, and TTY/TDD) to
handle written and telephone communications with beneficiaries.
The MACs shall not be required to install a separate TTY/TTD for complex beneficiary
inquiries.
The MAC shall obtain foreign language support service by contract for languages other
than Spanish.
Additionally, the MAC shall fog written responses for reading level (8th grade or less).
The MAC shall provide feedback via NGD to the BCC identifying inappropriate referrals
to the PRRS (such as general or routine inquiries that should have been handled by the
BCC). Every beneficiary shall receive direct, final responses to their complex inquiries
that accurately and completely address the issues contained in the inquiries. This extends
to an overall approach to beneficiary inquiry handling that aims to result in a high
standard of accuracy, professionalism and timeliness.
20.2.2 - Controlling Complex Beneficiary Inquiries
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
The MACs shall control all complex beneficiary inquiries until they are closed by the
PRRS. NGD will be maintained with accurate information so that if the beneficiary calls
the BCC for information related to the initial inquiry, the BCC can address status and
outcome and determine if additional follow up is necessary.
Unless they meet the exception for second level Benefit Integrity escalations described in
section 20.1.3, inquiries referred to other MAC departments by the PRRS may close the

inquiry in NGD as long as accurate and reliable information is documented in the
resolution details field, including the nature of referral (e.g., appeals, MSP, etc.).
20.2.3 - E-mail and Fax Responses to Complex Written Beneficiary
Inquiries
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
In some cases, complex written beneficiary inquiries can be responded to by e-mail or
fax. Since both represent official correspondence with the public, it is paramount that
MACs use sound e-mail and fax practices and proper etiquette when communicating
electronically. MACs shall ensure that e-mail and fax responses follow the same
timeliness and quality guidelines that pertain to all written inquiries. Responses that
contain financial or PHI shall be transmitted in accordance with the “CMS Acceptable
Risk Safeguard Controls for Secure Communications” and not sent by e-mail. When
responding via fax, MACs shall first confirm the fax number with the intended recipient.
If the e-mail or fax response contains financial, or PHI, the response may be mailed in a
hardcopy format to the beneficiary or a telephone response may be used. E-mail content,
as well as attachments to e-mails, must be Section 508 compliant. (See
http://www.cms.gov/web/508/accessiblefiles/checklists.html for information about
Section 508 compliancy).
20.2.4 - Telephone Responses to Complex Beneficiary Inquiries
(Rev. 41; Issued: 02-08-19; Effective: 03-12-19; Implementation: 03-12-19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary’s Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
MACs may respond to complex written beneficiary inquiries by telephone if, in their
discretion, MACs determine that a telephone response is appropriate.
For tracking and evaluation purposes, MACs shall develop a report of contact for each
telephone response to a complex written beneficiary inquiry. The report of contact shall
be retained in the same manner and time frame as written responses to complex written
beneficiary inquiries. All reports of contact shall contain the following information:
• 	Beneficiary name;
• 	Telephone number;
• 	Medicare beneficiary identifier;
• 	Date of contact;
• 	Internal inquiry control number;
• 	Subject/nature of inquiry
• 	Summary of discussion;

• 	Status - closed/pending research/ open
• 	Follow - up action required (if any); and
• 	Name of the PRRS correspondent who handled the inquiry
If the beneficiary requests a copy of the report of contact, a response letter containing all
the information in the “Summary of Discussion” shall be sent. MACs may send the
information via e-mail or fax if requested by the beneficiary and if the response does not
contain any financial or PHI. It is not acceptable to send the report of contact itself. All
timeliness and quality guidelines for a written response apply to the response containing
the “Summary of Discussion.”
If the MAC cannot reach the beneficiary by telephone, the MAC shall develop a written
response. It is not acceptable to leave a message/response on the beneficiary’s voicemail
containing financial, PII, or PHI.
20.2.5 - Written Responses to Complex Beneficiary Inquiries
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
MACs shall ensure that the written responses to complex beneficiary inquiries are
accurate, complete, responsive, clearly written and presented in a professional manner.
Written responses to complex beneficiary inquiries shall adhere to the basics of the Plain
Writing Act of 2010, to the extent practicable. The Plain Writing Act of 2010 requires all
federal agencies and, by extension, their contractors to use plain writing in any document
that (1) is necessary to obtain a federal benefit or service, (2) gives information about a
federal benefit or service, and/or (3) explains how to comply with federal requirements.
MACs shall refer to the document entitled, “Toolkit for Making Written Material Clear
and Effective,” for assistance in meeting the requirements of the Plain Writing Act of
2010. The Toolkit is a health literary resource from CMS that consists of 11 parts. It is
available at http://www.cms.gov/Outreach-and-
Education/Outreach/WrittenMaterialsToolkit/index.html.
In addition, MACs shall use the CMS Writing Guide to assist in the preparation of
written responses to complex beneficiary inquiries. The Writing Guide can be found on
the Quality Written Correspondence Monitoring (QWCM) website at:
https://www.qwcmscores.com/Docs/WritingGuideFINAL.pdf.
Because the Toolkit and the CMS Writing Guide cannot possibly address every issue
encountered in responding to complex written beneficiary inquiries, MACs may also use
other resources (e.g., grammar guides) to supplement their writing process.
20.2.6 - Timeliness of Responses to Complex Beneficiary Inquiries
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
MACs shall provide clear and accurate responses to complex beneficiary inquiries within
25 business days for at least 75 percent of inquiries referred by the BCC or the CMS

ROs; and within 45 business days for 100 percent of all inquiries referred by the BCC or
the CMS ROs.
This timeframe begins the day the inquiry is originally received in NGD (transferred into
NGD) and ends the day the MAC sends the final response. For Benefit Integrity Unit
escalations, the MAC shall consider the action complete and close the complex inquiry in
NGD when the Benefit Integrity Unit referral is placed into the second-level screening
work flow, and not when the second-level screening is complete.
For those complex beneficiary inquiries that cannot be answered in final within 45
business days, MACs shall send an interim response acknowledging receipt of the inquiry
and explaining the reason for the delay. When possible, inform the beneficiary about
how long it will be until a final response will be sent. Sending an interim response does
not resolve the issue and the inquiry is not considered closed until the final response is
sent.
The final response shall be sent within 5 business days after receipt of the needed
information. Any interim responses for complex beneficiary inquiries will count toward
the MAC’s overall allowance of no more than 5 percent of interim responses for the
universe of complex beneficiary inquiries. Responses to complex beneficiary inquiries
shall be documented in NGD.
20.3 – Congressional Beneficiary Inquiries
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
Please refer to the Medicare Contractor Beneficiary and Provider Communications
Manual, Chapter 6, Provider Customer Service Program "Congressional Inquiries
Timeliness."
20.4 - Surveys
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
CMS may require periodic surveys of customer service operations to be completed by
each contractor within the time frames and in areas indicated on the specific notice.
Examples include staffing profiles and training needs.
20.5 – Urgent Need Regional Offices Casework
(Rev. 33, Issued: 10-02-15, Effective: 11-02-15, Implementation: 11-02-15)
The MAC shall provide a direct point of contact (POC) to CMS ROs for the purposes of
assisting them in resolving urgent need beneficiary inquiries involving any aspect of the
Medicare Parts A and B programs. An urgent need inquiry is one in which the
beneficiary is unable to access medically necessary medical services, equipment and/or
supplies in a timely manner; and without those services the beneficiary’s life is
endangered, medical condition will deteriorate and/or pain or discomfort will increase.
The CMS ROs will contact the MAC for assistance in resolving an urgent need inquiry

through a prearranged contact that includes an email address, telephone, and fax number.
The MAC POC shall coordinate resolution of the problem and involve appropriate
functional areas within the MAC as necessary. The RO will relay the resolution directly
to the beneficiary.

Transmittals Issued for this Chapter
Rev # 	Issue Date 	Subject 	Impl Date CR#
R41COM 02/08/2019 	Update to Publication (Pub.) 100-09 to
Provide Language-Only Changes for the New
Medicare Card Project
03/12/2019 11059
R33COM 10/02/2015 	Medicare Contractor Beneficiary and Provider
Communications Manual Beneficiary
Customer Services Pub. 100-09 Chapter 2-
Update
11/02/2015 9000
R12COM 07/15/2005 	Next Generation Desktop (NGD) Testing
Requirements
08/15/2005 3493
R11COM 06/03/2005 	FY 2005Beneficiary Telephone Customer
Services Replaced by Transmittal 11
07/05/2005 3737
R10COM 05/27/2005 	FY 2005Beneficiary Telephone Customer
Services Replaced by Transmittal 11
06/27/2005 3737
R08COM 02/18/2005 	Medicare Beneficiary Call Centers Will Begin
Offering Preventive Services Information
03/14/2005 3706
R05COM 04/23/2004 	Manual Instruction for Update Beneficiary
Services Sections 5104 (MCM) and 2958
(MIM), and Beneficiary Services Section 20
of the Internet-Only Manual (IOM)
05/24/2004 3097
R03COM 12/09/2003 	Renumbering Chapters 2 through 5 and
Revision of Chapter 4
N/A 	N/A
R01COM 10/01/2003 	Initial Issuance of Chapters 1 through 5 	N/A 	N/A
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