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pdfConsolidated Claims Experience (CCE)
Medicare Claim Intake
Screen Package V 3.0
June 18, 2020
CCE Medicare Only Screen Package V 3.0
June 18, 2020
Page 1 of 101
Table of Contents
1.
Applicant Information – Organization is the applicant .............................................................................................................5
2.
Applicant Information – Claimant is the applicant: Contact method/Interview-Phone ............................................................6
3.
Applicant Information – Claimant is the applicant: Contact method/Interview-Office .............................................................7
4.
Applicant Information – Claimant is the applicant: Contact method/Mail................................................................................8
5.
Applicant Information – Privacy Act Statement ........................................................................................................................8
6.
Applicant Information – Other Individual is the applicant ........................................................................................................9
7.
Person Information ................................................................................................................................................................ 10
8.
Applicant Information – “Accept” is clicked ........................................................................................................................... 12
9.
Filing date – One lead: Using existed protective filing date .................................................................................................... 13
10.
Filing date – One lead: enter a different protective filing date ............................................................................................... 14
11.
Filing date – No leads: protective filing date exists before today............................................................................................ 15
12.
Filing date – No leads: no protective filing date exists before today....................................................................................... 16
13.
Filing date – No leads: eLAS exclusion .................................................................................................................................... 17
14.
Filing date – No leads: age alert.............................................................................................................................................. 18
15.
Contact Information – Default ................................................................................................................................................ 19
16.
Contact Information – Addresses on record: more info .......................................................................................................... 21
17.
Contact Information – Add New Address Modal with US Address .......................................................................................... 22
18.
Contact Information – Add New Address Modal with International Address ......................................................................... 23
19.
Contact Information – Multiple addresses on record ............................................................................................................. 24
20.
Contact Information – Manage Addresses: default ................................................................................................................ 26
21.
Contact Information – Manage Addresses: Add new address ................................................................................................. 27
22.
Contact Information – Manage Addresses: Select from existing address ................................................................................ 28
23.
Contact Information – Edit address ........................................................................................................................................ 29
24.
Contact Information – T2/T18 prior residence up to 5 years requirement.............................................................................. 30
25.
Contact Information – T2/T18 Residence history - Prior residence up to 5 years requirement ............................................... 32
26.
Contact Information – Add Period of residence ...................................................................................................................... 33
27.
Contact Information – T2/T18 Residence History – Warning – Gaps in residence information ............................................... 34
28.
Contact Information – T2/T18 Residence History – Error - Overlapping periods of residence ................................................. 35
29.
Earnings Information – Yes” to all .......................................................................................................................................... 36
30.
Earnings Information – “No” to all ......................................................................................................................................... 40
31.
Insured Status ........................................................................................................................................................................ 42
32.
Lawful Presence – Default View ............................................................................................................................................. 43
33.
Lawful Presence – Add new lawful presence: LAPR status, “Yes” to status ended. ................................................................. 44
34.
Lawful Presence – Add new lawful presence: LAPR status, “No” to status ended................................................................... 46
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June 18, 2020
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35.
Lawful Presence – Add new lawful presence: does not need reverification (other than LAPR) ............................................... 47
36.
Lawful Presence – Add new lawful presence: needs reverification (other than LAPR) ............................................................ 48
37.
Lawful Presence – Add new lawful presence: not lawfully present, “Yes” to physically present in the U.S. ........................... 49
38.
Lawful Presence – Add new lawful presence: not lawfully present, “No” to physically present in the U.S. ............................ 50
39.
Lawful Presence – Two rows .................................................................................................................................................. 51
40.
Lawful Presence – Three rows ................................................................................................................................................ 52
41.
Health Insurance – Default View ............................................................................................................................................ 53
42.
Health Insurance – Enroll SMI, “Yes” to all ............................................................................................................................. 55
43.
Health Insurance – Enroll SMI, “No” to all .............................................................................................................................. 60
44.
Health Insurance – Refuse SMI ............................................................................................................................................... 62
45.
Health Insurance – Enroll SMI, Add new benefits pop-up, Medicaid-cash benefits from the state, “Yes” to all ...................... 64
46.
Health Insurance – Enroll SMI, Add new benefits pop-up, Medicaid-cash benefits from the state, “Yes” to all, verified
through SSA system ......................................................................................................................................................................... 67
47.
Health Insurance – Enroll SMI, Add new benefits pop-up, Medicaid-cash benefits from the state, “No” to all ....................... 68
48.
Health Insurance – Enroll SMI, Add new benefits pop-up window, Medicaid-cash SSI ........................................................... 69
49.
Health Insurance – Enroll SMI, Add new benefits pop-up window, Medicaid only ................................................................. 70
50.
Health Insurance – Enroll SMI, Add new coverage pop-up, Group health plan, Yes to all ....................................................... 71
51.
Health Insurance – Enroll SMI, Civil Service Annuity, Yes to Claimant .................................................................................... 73
52.
Health Insurance – Enroll SMI, Civil Service Annuity, No to Claimant and Yes to Spouse ........................................................ 74
53.
Health Insurance – Receiving Medicaid table with row filled ................................................................................................. 75
54.
Health Insurance – Group Health Plan table with row filled ................................................................................................... 76
55.
Health Insurance – Enroll SMI, Add new coverage pop-up, Group health plan, “No” to all..................................................... 77
56.
Health Insurance – Enroll SMI, Group health plan for volunteer service – Yes ........................................................................ 78
57.
Health Insurance – Enroll SMI, Group health plan for volunteer service – Yes ........................................................................ 80
58.
Edits and Alerts ...................................................................................................................................................................... 81
59.
Pre-adjudicative Results ......................................................................................................................................................... 82
60.
Attestation and Printing – No previous record ....................................................................................................................... 84
61.
Attestation and Printing – No previous record: add oral signature ......................................................................................... 85
62.
Attestation and Printing – Oral signature added .................................................................................................................... 86
63.
Attestation and Printing – No previous record: add ink signature .......................................................................................... 87
64.
Attestation and Printing – Received signed ink signature ....................................................................................................... 88
65.
Attestation and Printing – Edit ink signature .......................................................................................................................... 89
66.
Attestation and Printing – View after Ink signature is added.................................................................................................. 90
67.
Attestation and Printing – Query mode: Oral signature ......................................................................................................... 91
68.
Attestation and Printing – Query mode: Ink signature ........................................................................................................... 92
69.
Attestation and Printing (Amended Application) – Default View............................................................................................ 93
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June 18, 2020
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70.
Attestation and Printing (Amended Application) – Add oral signature & Attestation ............................................................. 94
71.
Attestation and Printing (Amended Application) – View after Oral Signature and Attestation............................................... 95
72.
Attestation and Printing (Amended Application) – Add ink signature and Printing ................................................................ 96
73.
Attestation and Printing (Amended Application) – Received signed ink signature ................................................................. 97
74.
Attestation and Printing (Amended Application) – Edit signed ink signature ......................................................................... 98
75.
Attestation and Printing (Amended Application) – View after Ink Signature and Attestation ................................................ 99
76.
Attestation and Printing (Amended Application) – Query Only ............................................................................................ 100
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June 18, 2020
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1. Applicant Information – Organization is the applicant
Applicant type includes: Organization, claimant and other individual.
Note: This is the drop list for “Applicant Type”.
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June 18, 2020
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2. Applicant Information – Claimant is the applicant: Contact method/Interview-Phone
Contact Method includes: Interview-phone, Interview-office, and mail.
Note: This is a drop list for “Contact Method”.
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June 18, 2020
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3. Applicant Information – Claimant is the applicant: Contact method/Interview-Office
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June 18, 2020
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4. Applicant Information – Claimant is the applicant: Contact method/Mail
5. Applicant Information – Privacy Act Statement
PRIVACY ACT STATEMENT: Social Security is authorized to collect your information under sections 1836, 1840, and 1872 of the Social
Security Act, as amended (42 U.S.C. 1395o, 1395s, and 1395ii) for your enrollment in Medicare Part B. Social Security and the
Centers for Medicare & Medicaid Services (CMS) need your information to determine if you’re entitled to Part B.
While you don’t have to give your information, failure to give all or part of the information requested on this form could delay your
application for enrollment.
Social Security and CMS will use your information to enroll you in Part B. Your information may be also be used to administer Social
Security or CMS programs or other programs that coordinate with Social Security or CMS to: 1)Determine your rights to Social
Security benefits and/or Medicare coverage. 2) Comply with Federal laws requiring Social Security and CMS records (like to the
Government Accountability Office and the Veterans Administration). 3) Assist with research and audit activities necessary to protect
integrity and improve Social Security and CMS programs (like to the Bureau of the Census and contractors of Social Security and
CMS). We may verify your information using computer matches that help administer Social Security and CMS programs in
accordance with the Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503).
CCE Medicare Only Screen Package V 3.0
June 18, 2020
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6. Applicant Information – Other Individual is the applicant
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June 18, 2020
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7. Person Information
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June 18, 2020
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8. Applicant Information – “Accept” is clicked
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June 18, 2020
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9. Filing date – One lead: Using existed protective filing date
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June 18, 2020
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10. Filing date – One lead: enter a different protective filing date
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June 18, 2020
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11. Filing date – No leads: protective filing date exists before today
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June 18, 2020
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12. Filing date – No leads: no protective filing date exists before today
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June 18, 2020
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13. Filing date – No leads: eLAS exclusion
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June 18, 2020
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14. Filing date – No leads: age alert
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June 18, 2020
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15. Contact Information – Default
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16. Contact Information – Addresses on record: more info
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17. Contact Information – Add New Address Modal with US Address
Note: The “Current T2/T18 Residence start date” will be displayed only when “T2/T18 Residence” option is selected.
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June 18, 2020
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18. Contact Information – Add New Address Modal with International Address
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June 18, 2020
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19. Contact Information – Multiple addresses on record
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20. Contact Information – Manage Addresses: default
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June 18, 2020
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21. Contact Information – Manage Addresses: Add new address
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June 18, 2020
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22. Contact Information – Manage Addresses: Select from existing address
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June 18, 2020
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23. Contact Information – Edit address
Note: The Address fields can be populated with the “222 Elm St…” address with a single click by clicking the “Use this address”
button next to the address.
Similarly, to populate the address fields with the “333 Birch St…” address, the corresponding “Use this address button” must be
clicked.
The user can also manually overwrite the address fields at any time.
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June 18, 2020
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24. Contact Information – T2/T18 prior residence up to 5 years requirement
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25. Contact Information – T2/T18 Residence history - Prior residence up to 5 years
requirement
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26. Contact Information – Add Period of residence
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27. Contact Information – T2/T18 Residence History – Warning – Gaps in residence
information
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28. Contact Information – T2/T18 Residence History – Error - Overlapping periods of
residence
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29. Earnings Information – Yes” to all
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Note: This is the drop list for “Type of work” from last year total earnings.
Note: This is the drop list for “Proof” from last year total earnings.
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Note: This is the drop list for “Type of work” from current year total earnings.
Note: This is the drop list for “Proof” from current year total earnings.
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30. Earnings Information – “No” to all
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31. Insured Status
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32. Lawful Presence – Default View
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33. Lawful Presence – Add new lawful presence: LAPR status, “Yes” to status ended.
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Note: This is the drop list for “Lawful Presence Status”.
Note: This is the drop list for “Proof”.
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34. Lawful Presence – Add new lawful presence: LAPR status, “No” to status ended.
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35. Lawful Presence – Add new lawful presence: does not need reverification (other than
LAPR)
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36. Lawful Presence – Add new lawful presence: needs reverification (other than LAPR)
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37. Lawful Presence – Add new lawful presence: not lawfully present, “Yes” to physically
present in the U.S.
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38. Lawful Presence – Add new lawful presence: not lawfully present, “No” to physically
present in the U.S.
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39. Lawful Presence – Two rows
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40. Lawful Presence – Three rows
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41. Health Insurance – Default View
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42. Health Insurance – Enroll SMI, “Yes” to all
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Note: This is the drop list for “SMI Enrollment Options”.
Note: This is the drop list for “Civil Service Annuity Type”.
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Note: This is a more info pop-up for “Receiving Medicaid” question.
Note: This is the pop-up more info for “Equitable Relief”.
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Note: This is the pop-up more info for “Crimes Against the U.S.”.
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43. Health Insurance – Enroll SMI, “No” to all
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44. Health Insurance – Refuse SMI
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45. Health Insurance – Enroll SMI, Add new benefits pop-up, Medicaid-cash benefits from
the state, “Yes” to all
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Note: This is the drop list for “Type of Assistance”.
The valued in the dropdown are:
• 50 U.S. states
• District of Columbia
• Guam
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•
•
Northern Mariana Islands
Virgin Islands
Note: This is the drop list for “Contact Method”.
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46. Health Insurance – Enroll SMI, Add new benefits pop-up, Medicaid-cash benefits from
the state, “Yes” to all, verified through SSA system
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47. Health Insurance – Enroll SMI, Add new benefits pop-up, Medicaid-cash benefits from
the state, “No” to all
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48. Health Insurance – Enroll SMI, Add new benefits pop-up window, Medicaid-cash SSI
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49. Health Insurance – Enroll SMI, Add new benefits pop-up window, Medicaid only
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50. Health Insurance – Enroll SMI, Add new coverage pop-up, Group health plan, Yes to all
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Note: This is the drop list for “Plan Type”.
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51. Health Insurance – Enroll SMI, Civil Service Annuity, Yes to Claimant
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52. Health Insurance – Enroll SMI, Civil Service Annuity, No to Claimant and Yes to Spouse
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53. Health Insurance – Receiving Medicaid table with row filled
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54. Health Insurance – Group Health Plan table with row filled
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55. Health Insurance – Enroll SMI, Add new coverage pop-up, Group health plan, “No” to all
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56. Health Insurance – Enroll SMI, Group health plan for volunteer service – Yes
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57. Health Insurance – Enroll SMI, Group health plan for volunteer service – Yes
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58. Edits and Alerts
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59. Pre-adjudicative Results
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60. Attestation and Printing – No previous record
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61. Attestation and Printing – No previous record: add oral signature
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62. Attestation and Printing – Oral signature added
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63. Attestation and Printing – Print unsigned application (Ink signature)
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64. Attestation and Printing – View after printing unsigned application
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65. Attestation and Printing – Edit ink signature
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66. Attestation and Printing – View after Ink signature is added
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67. Attestation and Printing – Query mode: Oral signature
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68. Attestation and Printing – Query mode: Ink signature
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69. Attestation and Printing (Amended Application) – Default View
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70. Attestation and Printing (Amended Application) – Add oral signature & Attestation
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71. Attestation and Printing (Amended Application) – View after Oral Signature and
Attestation
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72. Attestation and Printing (Amended Application) – Add ink signature and Printing
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73. Attestation and Printing (Amended Application) – View after printing unsigned
Amended Medicare Statement
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74. Attestation and Printing (Amended Application) – Edit signed ink signature
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75. Attestation and Printing (Amended Application) – View after receiving ink signature
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76. Attestation and Printing (Amended Application) – Query mode (Oral signature)
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77. Attestation and Printing (Amended Application) – Query mode (Ink signature)
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| File Type | application/pdf |
| File Title | Consolidated Claim Experience Medicare Claim Intake Screen Package |
| Author | Fujitsu |
| File Modified | 2021-01-13 |
| File Created | 2021-01-07 |