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INSTRUCTIONS FOR USE AND COMPLETION

Part I. Instructions to Income Maintenance Caseworker

This form should be completed only after the following steps have been taken:

a. Ascertain that the applicant/recipient has enrolled in Medicare Part B. If a/r is not enrolled in Medicare Part B

(but should be), the IMC must contact the local SSA office regarding application for Medicare and complete the process on

the a/r ’s behalf.

b. Make sure that the Social Security Claim Number and Suffix as they appear on the Medicare card are

entered in EIS.

c. Allow 60-90 days after the correct Social Security claim number has been entered and appears on the case profile to allow

time for electronic accretion/deletion.

EXCEPTION: For persons erroneously deleted, submit form immediately with a copy of the deletion notice received from Social

Security attached.

Complete Part I legibly. Enter name, birth date and Social Security Claim Number as they appear in SSA records.

Verify information in Part I by one of the following methods and submit one copy to the Medicaid contractor for

processing. The county may wish to keep a copy in its files until the original is returned. Method of verification should be

indicated in Remarks Section of Part I.

Obtain verification from BENDEX, SDX, or SOLQ.

Verify using SSA-1610 already contained in case record.

Attach copy of award letter.

TPQY/SOLQ printout through EIS.

If none of the above verifications are available, submit one copy of DMA-5004 to SSA district or branch office

serving the county for verification. Upon return of this form, check SSA documentation on the DMA-5004 to

be sure that correct data is contained in EIS.

If corrections are needed, submit on DSS-8125 input form and allow 90 days for electronic accretion.

DO Not send DMA-5004 to the claims processing contractor if the client is not enrolled in Medicare Part B. See MA-2410,

Medicare Enrollment and Buy-In.

INSTRUCTIONS FOR TRANSMITTAL: Submit DMA-5004 to: Attention: Buy-In Unit, CSC, PO Box 300009, Raleigh, NC

27622-8009

Part II: Instructions to SSA Staff

Verify name, birth date, and Social Security claim number. If information is incorrect, please enter correct data

in red above the incorrect information and line through incorrect data with a single line.

If no record is found, this document should be treated as a LEAD. Indicate status of development in “Remarks” and return to

county.

Part III: Instructions to Contractor Staff

Complete Part III as indicated and return to DMA, Attention Claims Analysis Supervisor.

MA-2410-Figure 8, Page 2

DMA-5004

Rev. 08/13

Form Dma-5004 - Buy-In Clerical Action - North Carolina Department Of Health And Human Services Page 2