Case Type
Consumer reported errors in the monthly Advanced Premium Tax Credit (APTC) amount.
What is Total Monthly APTC?
Do RCNO - Issuer and FFM Extract agree with each other?
FFM Extract shows:
Customer: Elizabeth Cantu; Policy: 50368682; Start Date:01/01/2019; End Date:4/30/2019; Premium: $297.95; APTC: $164; Benefit Status: Not Effectuated; Origin: Call Center; HIOS: 56503; Type: HLT
RCNO - Issuer Shows:
Customer: Elizabeth Cantu; Policy: 50368682; Start Date:01/01/2019; End Date:12/31/2019; Premium: $297.95; APTC: $164; Premium Paid Indicator: Canceled; HIOS: 56503; Batch:1917
Yes, both data shows the policy is not effectuated
Consumer reported the monthly premium amount is incorrect
What is Total Monthly Premium Amount?
How many issues is the consumer reporting and what is the case type based on the narrative?
Narrative:
Monthly premium amount is wrong on consumer's Form 1095-A. JOSE TELLEZ can be reached at (317) 251-7327. The consumer application ID is 910864791. The consumer's FFM ID number is 17834592. The correct monthly premium is $1,349.39. The incorrect monthly premium on the form is $1,348.72. Affected individuals: Jose Tellez, 01-17-1991, 359-56-1126. Frank Tellez, 12-29-2011, 314-62-1420. Preferred call back time: 10am-2pm Language Preference: English. Customer also reported, APTC should be $999.00 starting June, instead of April, and last through December 2019.
Consumer reported two issues: Monthly Premium amount and APTC amount. The case type is Multiple
Using the Decision Matrix, what should be the outcome of this case?
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Narrative: Coverage termination date is wrong on consumer's Form 1095-A. ELIZABETH CANTU can be reached at (786) 414-7750. The consumer’s application ID is 123850320. The consumer's FFM ID number is 17965694. The correct end date is 12/31/19. The incorrect end date on the form is 04/30/2019. Affected individuals: Elizabeth Cantu 5/12/87 123115678. Preferred call back time: Any Language Preference: Spanish. Consumer had coverage with Preferred Medical plan from 1/1/19 to 12/31/19. Consumer has confirmations of all premiums done monthly and needs a corrected 1095-A form where it reflects her coverage for the full year of 2019.
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RESEARCH SHOWS:
Plan & Issuer Concern Case found: According to the P&IC HICS case ID: E1705473577, consumer has been approved for a term date of 12/31/2019, Premium $300.72 with a tax credit of $118.00. A letter was sent to consumer advising them that the request is approved for policy ID 17965694 effective 1/1/2019 through 12/31/2019.
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Workbook Data
FFM Extract Shows:
Consumer: Elizabeth Cantu; Policy 17965694; Start Date: 1/1/2019; End Date: 4/30/2019; Premium $300.72; APTC: $118.00; Benefit Status: Effectuated; Origin: Call Center; HIOS: 12503; Type: HLT
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RCNO – Issuer Shows:
Consumer: Elizabeth Cantu; Policy 17965694; Start Date: 1/1/2019; End Date: 4/30/2019; Premium $300.72; APTC: $118.00; Premium Paid Indicator: Effectuated; HIOS: 12503; Batch: 1917
Submit a BUU request to correct the End date using the P&I HICS case value; Approved; 1095A PACO
Consumer reported the issuer name is incorrect.
What is Issuer Name?
Do RCNO - Issuer and FFM Extract agree with each other?
FFM Extract shows:
Customer: Carmen Moreno; Policy: 26354684; Start Date:01/01/2019; End Date:4/30/2019; Premium: $1,201.54; APTC: $965; Benefit Status: Effectuated; Origin: Call Center; HIOS: 56503; Type: HLT
RCNO - Issuer Shows:
Customer: Carmen Moreno; Policy: 26354684; Start Date:01/01/2019; End Date:08/31/2019; Premium: $1,201.54; APTC: $965; Premium Paid Indicator: Effectuated; HIOS: 56503; Batch:1917
No, they do not. Both shows effectuated policy, but different End dates.
Consumer reported they never received a 1095-A form.
What is a Missing 1095-A?
How many issues is the consumer reporting and what is the case type based on the narrative?
Narrative:
Consumer does not have an FFM account and did not receive Form 1095-A but insists that they had Marketplace coverage. Tyler King can be reached at (803) 321-7331. Information of the affected covered individuals: Affected individuals: Tyler King Jr. 12/10/2010, 234586910. The father believes that his son had coverage for the month of January. Issuer name is Blue Cross and Blue Shield of NC. The policy start/end date are 01/01/2019-01/31/2019. APTC amount is $118.00. Consumer's preferred spoken language is. Preferred call back time: Any Language Preference: English."
Consumer is reporting one issue: his son should have been covered for the month of January. The case type is Missing 1095-A / Not in FFM
Using the DM, what should be the outcome of this case?
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Narrative: Monthly premium amount is wrong on consumer's Form 1095-A. NOEMI ALVAREZ can be reached at (317) 251-7327. The consumer application ID is 910864791. The consumer's FFM ID number is 17834592. The correct monthly premium is $1,349.39. The incorrect monthly premium on the form is $1,348.72. Affected individuals: Noemi Alvarez, 01-17-1991, 359-56-1126. Alex Alvarez, 12-29-1990, 314-62-1420. Preferred call back time: 10am-2pm Language Preference: English. Customer also reported, APTC should be $999.00 starting June, instead of April, and last through December 2019.
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RESEARCH SHOWS:
Other HICS Case: No other HICS case found
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Workbook Data
FFM Extract shows:
No FFM data found
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RCNO – Issuer shows:
No issuer data found
Not enough info to resolve the case, submit DR; Leave disposition blank; 1095A Data Remediation Needed
Consumer reports errors in the individuals covered under the plan.
What is Covered Individual?
Do RCNO - Issuer and FFM Extract agree with each other?
FFM Extract shows:
Customer: Kim Welch; Policy: 53754001; Start Date:10/01/2019; End Date:12/31/2019; Premium: $647.57; APTC: $241; Benefit Status: Effectuated; Origin: Call Center; HIOS: 33602; Type: HLT
RCNO - Issuer Shows:
Customer: Kim Welch; Policy: 53754001; Start Date:10/01/2019; End Date:12/31/2019; Premium: $647.57; APTC: $241; Premium Paid Indicator: Effectuated; HIOS: 33602; Batch:1917
Yes, RCNO - Issuer and FFM Extract agree with each other. Both shows Policy: 53754001 is effectuated with same Start/End dates 10/01/2019 - 12/31/2019 as well as Premium & APTC amount.
Consumer reported the mailing address needs to be updated or corrected.
What is a Mailing Address Update?
How many issues is the consumer reporting and what is the case type based on the narrative?
Narrative:
Monthly premium amount is wrong on consumer's Form 1095-A. Noemi Alvarez can be reached at (937) 416-1111. The consumer’s application ID is 949592925. The consumer's FFM ID number is 14646153. The correct monthly premium is $597.08. The incorrect monthly premium on the form is 546.63. Affected individuals: Noemi Alvarez 6/24/1987 241687350. Preferred call back time: Any Language Preference: English.
Consumer reported one issue: Monthly Premium amount is incorrect. The case type is Total Monthly Premium Amount
Using the DM, what should be the outcome for this case?
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Narrative: Consumer had coverage but did not receive Form 1095-A and their form is not online. CARMEN MORENO can be reached at (914) 536-3099. The consumer's application ID is 2926424710. The consumer's insurance provider is Ambetter from Superior HealthPlan Ambetter Balanced Care 5 (2020) 29418TX0140059. Affected individuals: Carmen Moreno DOB:10/14/1987 SSN:644190564. Exchange Assigned Policy ID 69423848. Consumer stated she from the beginning of 2020 through October. Last App Updated By: N/A. Original App Source: N/A..
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RESEARCH SHOWS:
Other HICS Case: No other HICS case found
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FFM Extract Shows:
Consumer: Carmen Moreno; Policy 69423848; Start Date: 1/1/2020; End Date: 10/31/2020; Premium $534.72; APTC: $345.00; Benefit Status: Not Effectuated; Origin: Call Center; HIOS: 12503; Type: HLT
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RCNO – Issuer Shows:
Consumer: Elizabeth Cantu; Policy 69423848; Start Date: 1/1/2020; End Date: 10/31/2020; Premium $534.72; APTC: $345.00; Premium Paid Indicator: Effectuated; HIOS: 12503; Batch: 2034
Submit a BUU request using the RCNO Issuer value; Approved; 1095A PACO
Cases CMS has identified with alleged fraud and/or identity theft.
What is Alleged Fraud?
Do RCNO - Issuer and FFM Extract agree with each other?
FFM Extract shows:
Customer: Lilia Gallardo; Policy: 20754033; Start Date:01/01/2019; End Date:12/31/2019; Premium: $500.25; APTC: $500.25; Benefit Status: Effectuated; Origin: Call Center; HIOS: 33602; Type: HLT
RCNO - Issuer Shows:
Customer: Lilia Gallardo; Policy: 20754033; Start Date:01/01/2019; End Date:04/30/2019; Premium: $500.25; APTC: $500.25; Premium Paid Indicator: Effectuated; HIOS: 33602; Batch:1917
No, they do not agree with each other.
Though, both data shows policy is effectuated with the same financials, FFM Extract shows Start/End dates of January through December whereas RCNO - Issuer reflects January through April.
Consumer received Form 1095-A but states that they should not have received a Form 1095-A.
What is a Coverage Discrepancy?
How many issues is the consumer reporting and what is the case type based on the narrative?
Narrative:
Coverage termination date is wrong on consumer's Form 1095-A. JOSE TELLEZ can be reached at (786) 414-7750. The consumer’s application ID is 123850320. The consumer's FFM ID number is 17965694. The correct end date is 12/31/19. The incorrect end date on the form is 04/30/2019. Affected individuals: Jose Tellez 05/12/1987 123115678. Preferred call back time: Any Language Preference: Spanish. Consumer had coverage with Preferred Medical plan from 1/1/19 to 12/31/19. Consumer has confirmations of all premiums done monthly, and needs a corrected 1095-A form where it reflects her coverage for the full year of 2019
Consumer reported only one issue: coverage termination date is incorrect. The case type is Coverage Start/End Date
Using the DM, what should be the outcome?
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Narrative: Coverage start date is wrong on consumer's 1095-A form. KIM WELCH can be reached at (262) 707-3530. The consumer's application ID is 3319711798. The consumer's FFM ID number is 84179728. The correct start date is 2/1/2019. The incorrect start date on the form is 1/1/2019. Affected individuals: Kim Welch, DOB: 5/9/1957, SSN: 390-52-7867. Exchange Assigned Policy ID 82633972. Last App Updated By: N/A. Original App Source: N/A.
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RESEARCH SHOWS:
Other HICS Case: No other HICS case found
FFM Extract Shows:
Consumer: Carmen Moreno; Policy 69423848; Start Date: 1/1/2019; End Date: 12/31/2019; Premium $397.52; APTC: $322.00; Benefit Status: Canceled; Origin: Call Center; HIOS: 12503; Type: HLT
Consumer: Carmen Moreno; Policy 84179728; Start Date: 2/1/2019; End Date: 12/31/2019; Premium $397.52; APTC: $322.00; Benefit Status: Effectuated; Origin: Call Center; HIOS: 12503; Type: HLT
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RCNO – Issuer Shows:
Consumer: Elizabeth Cantu; Policy 69423848; Start Date: 1/1/2019; End Date: 12/31/2019; Premium $397.52; APTC: $322.00; Premium Paid Indicator: Not Effectuated; HIOS: 12503; Batch: 1917
Consumer: Elizabeth Cantu; Policy 84179728; Start Date: 1/1/2019; End Date: 12/31/2019; Premium $397.52; APTC: $322.00; Premium Paid Indicator: Effectuated; HIOS: 12503; Batch: 1917
FFM Extract data agrees with the narrative, no change is needed. Submit a reprint based on the FFM Extract data; Approved; 1095A PACO
Consumer does not have an FFM account and did not receive Form 1095-A but insists that they had Marketplace coverage.
What is a Missing 1095-A / Not in FFM
Do RCNO - Issuer and FFM Extract agree with each other?
FFM Extract shows:
Customer: Noemi Alvarez; Policy: 20115772; Start Date:03/01/2019; End Date:05/31/2019; Premium: $736.28; APTC: $508.25; Benefit Status: Effectuated; Origin: Call Center; HIOS: 33602; Type: HLT
RCNO - Issuer Shows:
Customer: Noemi Alvarez; Policy: 20115772; Start Date:03/01/2019; End Date:05/31/2019; Premium: $736.28; APTC: $508.25; Premium Paid Indicator: Non-Effectuated; HIOS: 33602; Batch:1917
No, they do not agree with each other. Both data shows same Start/End dates of March through May with the same financials, FFM Extract shows Policy: 20115772 is effectuated whereas RCNO - Issuer shows Policy: 20115772 is not effectuated
Consumer reported more than one issue within a single case (Example: policy end date and premium annual total).
What is multiple case type?
How many issues is the consumer reporting and what is the case type based on the narrative?
Narrative:
APTC amount is wrong on consumer's Form 1095-A. ERIKA WATSON can be reached at (717) 653-8000. The consumer’s application ID is 907641875. The consumer's FFM ID number is 9154015. The correct APTC amount is 300.00. The incorrect APTC amount on the form is 428.00. Affected individuals Erika Watson 2/6/1984 207448855. Preferred call back time: 10am-2pm Language Preference: English.
Consumer reported one issue: monthly APTC amount is incorrect. The case type is Total Monthly APTC amount
Using the DM, what should be the outcome of this case?
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Narrative: Monthly APTC amount is wrong on consumer's Form 1095-A. ANTARIO JONES can be reached at (937) 416-1111. The consumer’s application ID is 949592925. The consumer's FFM ID number is 14646153. The correct monthly APTC amount is $597.08. The incorrect monthly APTC amount on the form is 546.63. Affected individuals: Antario Jones 6/24/1987 241687350. Preferred call back time: Any Language Preference: English.
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RESEARCH SHOWS:
Other HICS Case: No other HICS case found
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Workbook Data
FFM Extract Shows:
Consumer: Antario Jones; Policy 14646153; Start Date: 1/1/2019; End Date: 7/31/2019; Premium $600.63; APTC: $556.63; Benefit Status: Effectuated; Origin: Call Center; HIOS: 12503; Type: HLT
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RCNO – Issuer shows:
Consumer: Antario Jones; Policy 14646153; Start Date: 1/1/2019; End Date: 7/31/2019; Premium $600.63; APTC: $457.52; Premium Paid Indicator: Effectuated; HIOS: 12503; Batch: 1917
If the FFM Extract and RCNO Issuer data do not agree with each other, request Issuer Outreach; Leave disposition blank; 1095A Issuer Info Needed