To approve a pending QMB application, complete the Form 552 used to register the application or a blank Form 552 as described in WAG 25-08-02-b with the following exceptions:
- Item 2 - Line through the previous entry and enter the 4-digit effective month and year of the approval or action to restore assistance. This date is the month following the month of the QMB eligibility determination.
- Items 19 & 20 - Complete if information is available, otherwise leave blank.
- Item 39 - Enter code 80 or 92. See WAG 17-02-00 for a complete description of Item 39 coding.
- Item 60 - Enter the Medicare claim number.
- Enter the QMB status indicator code (see WAG 27-60-09). An HIB status indicator code is required in this item. Enter the SMIB status indicator code, if needed (see
- Items 64, 65, 67, 68, & 70 - Complete if information is available, otherwise leave blank.
- Item 77 - Leave blank.
For detailed information on processing a QMB application, see WAG 06-12-02.