CMS Pub. 100-09, ch. 2, § 20.2.1

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.