NL 00720: Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program
TN 2 (09-11)
PAY032 DUAL ENTITLEMENT (CHECKS COMBINED) — AUXILIARY/SURVIVOR AWARD AFTER PRIMARY (A42)
(Requested)
Caption: What We Will Pay
(1) benefit is (2) as a (3) . This is in addition to the benefit of (4) on (5) own earnings record.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: Your
Choice 2: His
Choice 3: Her
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (3) Systems Generated
Choice 1: (A) wife
Choice 2: (B) husband
Choice 3: (C) widow
Choice 4: (D) widower
Choice 5: (E) mother
Choice 6: (F) father
Choice 7: (G) disabled widow
Choice 8: (H) disable widower
Choice 9: (I) disabled divorced widow
Choice 11: (J) disabled divorced widower
Choice 12: (K) child
Fill-in (4) Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (5) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
PAY067 PMA PAYMENT REDUCED BY AMOUNT OF CRITICAL PAYMENT (B55)
(System Generated)
Caption: What We Will Pay
We will subtract (1) from your next check. This is the amount we paid you before we finished work on (2) claim.
Fill-in values:
Fill-in (1)
CPA in format 99,999.99
Fill-in (2)
Choice 1: your
Choice 2: Beneficiary's Name Possessive
PAY068 CMA ONLY PAYMENT DUE - CRITICAL PAYMENT DEDUCTION MADE (B58)
(System Generated)
Caption: What We Will Pay
When we figured how much to pay you through (1) , we subtracted the money which we already paid you while we finished work on (2) claim.
Fill-in values:
Fill-in (1)
If LAF equals C: CMA minus one month in format January 1993. If LAF does not equal C: find first EFD with equal RFD to current LAF and is greater than DOEC. This Fill-ins is EFD minus one month in format January 1993.
Fill-in (2)
Choice 1: your
Choice 2: full name Possessive
PAY072 EXPLANATION THAT FIRST CHECK INCLUDES AN INSTALLMENT AMOUNT (B50)
(Requested)
Caption: What We Will Pay
This check includes (1) regular monthly payment of (2) for (3) .
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (2) Systems Generated
Amount
Fill-in (3) Systems Generated
Month and Year
PAY073 PAYMENT OF PAST-DUE BENEFITS WILL BE PAID IN INSTALLMENTS (B51)
(Requested)
Caption: What We Will Pay
(1) still due back payments of (2) for past months. (3) will receive this money over a period of months. We will send (4) (5) more each month with (6) regular payment until all of the extra money is paid.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You are
Choice 2: He is
Choice 3: She is
Fill-in (2) Systems Generated
amount of past due benefit payable
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (4) Systems Generated
amount of installment
Fill-in (5) Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (6) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
PAY161 CMA or MBP = $0.00 After Adjustments (G07)
(System Generated)
Caption: None
No payment is due at this time because of adjustments made to (1) benefits.
Fill-in values:
Fill-in (1)
Choice 1: his
Choice 2: her
Choice 3: your
Choice 4: Beneficiary's Name
PAY176 IRMAA – CHANGE RESULTS IN PREMIUM REFUND (HB2)
(Requested/Generated)
Caption: What We Will Pay and Why
Based on the information we have, (1) (2) due a Medicare Part B premium refund.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: Beneficiary's Name
Choice 2: you
Fill-in (2) Systems Generated
Choice 1: is
Choice 2: are
PAY180 CHECK PARAGRAPH USED WHEN ARF AND/OR DRC NOT PROPERLY APPLIED (B20)
(System Generated)
Caption: What We Will Pay
(1) next check for (2) includes additional benefits through (3) .
After that, (4) will receive a new regular monthly payment of (5) .
Fill-in values:
Fill-in (1)
Choice 1: Your
Choice 2: Beneficiary's name possessive
Fill-in (2)
Amount
Fill-in (3)
Month/Year (PMA)
Fill-in (4)
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5)
Amount of new MPA
PAY181 PAYMENT RESUMED AFTER SOME WITHHOLDING (M15)
(Requested)
Caption: Your Benefits
Since we withheld (1) , we can pay (2) beginning (3)
Fill-in values:
Fill-in (1) Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (2) Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (3) Requested As A Date In Format Shown Below
MM/CCYY
PAY182 PAYMENT STOPPED (M16)
(Requested)
Caption: Your Benefits
We are stopping (1) benefits beginning (2) .
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: your
Choice 2: Beneficiary's name possessive
Fill-in (2) Requested As A Date In Format Shown Below
MM/CCYY
PAY183 ADDITIONAL WITHHOLDING REQUIRED (M18)
(Requested)
Caption: Your Benefits
Since we withheld (1) , we must withhold (2) more.
Fill-in values:
Fill-in (1) Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount
PAY184 INCORRECT EARNINGS OVERPAYMENT CAUSED BY REDUCTION IN BENEFIT AMOUNT (M26)
(Requested)
Caption: Your Benefits
We reviewed our records, and found that a mistake was made when (1) benefit amount was increased. In (2) (3) earned (4) instead of (5) , which was the amount we used when we figured (6) payment. We have now corrected our records, and found that we paid (7) (8) too much in benefits.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: your
Choice 2: Beneficiary's name possessive
Fill-in (2) Requested As A Date In Format Shown Below
CCYY erroneous earnings posted
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) Requested As A Money Amount In Format $$$$$.¢¢
Amount of correct earnings
Fill-in (5) Requested As A Money Amount In Format $$$$$.¢¢
Amount of incorrect earnings
Fill-in (6) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (8) Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment
PAY212 INITIAL PARTIAL AWARD/PARTIAL MONTH BENEFITS PAID (B78)
(Requested)
Caption: Your Benefits
We used (1) (2) (3) (4) (5) to decide how much to pay (6) . We are still working on (7) claim. When we make a final decision about the (8) , we will figure the amount of (9) payments. We will send you another letter to let you know if there will be any change in (10) payments.
Fill-in values:
Fill-in (1) Requested As A One Position Alpha Character
Choice 1: (A) a date of birth of
Choice 2: (B) a date of marriage of
Choice 3: (C) wages through
Fill-in (2) Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/DD/CCYY
Fill-in (3) Requested As A One Position Alpha Character
Choice 1: (A) for
Choice 2: (B) null
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Choice 3: null
Fill-in (5) Requested As A One Position Alpha Character
Choice 1: (A) husband
Choice 2: (B) null
Fill-in (6) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (7) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) Systems Generated
Choice 1: (A) date of birth
Choice 2: (B) wages
Choice 3: (C) date of marriage
Fill-in (9) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (10) Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
PAYB15 SINGLE PAYMENT FOLLOWED BY SUSPENSION/TERMINATION (B29)
(Requested)
Caption: What We Will Pay
(1) will receive (2) around (3) . This is the money, after all deductions, (4) due for (5) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (2) - Systems Generated
Amount of benefits after deductions
Fill-in (3) - Systems Generated
MM/DD/CCYY
Fill-in (4) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (5) - Systems Generated
MM/CCYY