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REQUEST FOR RECORDS DISPOSITION                       AUTHORITY
                                                                                     tJ \-     ()4i -D1- ,
To'	       NATIONAL     ARCHIVES   &   RECORDS    ADMINISTRATION                  Date received
           8601                                          20740-6001
 1     FROM

                   ADELPHI   ROAD COLLEGE    PARK, MD
                                                                                      " \~-, IDl.o
                                                                                             •
          SOCial Secunty Adrmmstration                                                      NOTIFICA TION TO AGENCY


                                                                                  In accordance with the prOVISIOns of 44 U.S C.
       MAJOR	 SUBDIVISION
                                     .. efflce of Dlsabillty                and   3303a,    the   disposmon    request,   including
         , Income        Securlty          Programs         (ODISP)               amendments, IS approved except for Items that may
       MINOR SUBDIVISION
                                                         be marked     "disposmon    not approved"       or
                                                                                  "Withdrawn" In column 10.


4. NAME OF PERSON WITH WHOM TO                          TELEPHONE NUMBER          DATE              ARCHIVIST          OF THE UNITED
CONFER	                                                  410-965-5555
      Regma Martin, SSA Records Officer                  410-966-1704 (fax)       f'/~lo~           S~L?~~


     AGENCY CERTIFICATION
I hereby certify that I am authonzed to act for this agency m matters pertaining to the disposinon of ItS records and that the records
proposed for disposal on the attached       -4- page(s) are not needed now for the busmess for this agency or will not be needed after
the retention pen ods specified; and that wntten concurrence from the General Accounting Office, under the provisions of Title 8 of
the GAO Manual for GUidance of Federal Agencies,

           [8J IS not required                   D ISattached	                    D has been   requested

DATE	                                                                                        TITLE
                              ~AT~           1A~             :r.SENTATIVE
  If   /'1itJ t.                   rktl.          .
                                                                                             Records	 Officer

                                                                                        9 GRS OR
                              8 ~CRIPTION          OF ITEM AND PROPOSED	                                           10 ACTION TAKEN
7. ITEM NO	                                                                          SUPERSEDED JOB
                                                 DISPOSITION  •	                                                   (NARA USE ONLY)
                                                                                        CITATION
                                         SEE ATTACHED SHEETS

                     Medicare Claim File

                     Office of Origin:

                     Office of Disabihty and Income Secunty Programs, (ODISP)

                     SOCial Secunty Adrmmstration

                     6401 Secunty Boulevard

                     Baltimore, MD 21235-6401


                     Scheduling Authority:

                     SOCial Secunty Adrmmstration

                     Deputy Commissioner for Finance, Assessment

                     & Management

                     Center for History, Library & Records Management

                     Regma Martm, SSA Records Officer

                     Room 1500 Annex BUilding

                     6401 Secunty Boulevard

                     Baltimore, MD 21235-6401

                     410-965-5555





        115-109	                       PREVIOUS EDITION NOT USABLE                       STANDARD          FORM 115 (REV 3-91)            1
                                                                                                           Prescnbed    by NARA 36 CFR 1228
The schedule provides authontative instructions for the retention and destruction of matenal related
to Title XVIII of the Social Secunty Act regardless of media of the matenals. A Medicare claim
file record refers to "Medicare only claims" (no Social Secunty benefit entitlement), or "Medicare
Part D claims" processed by SSA It grants authonty for the disposinon of existing and future claim
file records.




       Temporary
       Delete/destroy after recordkeeping co            been placed m the claim file and venfied.

                                                                                    Nl-47-05-2
CLAIM FILE MATERIAL


       Medicare      I     lanns for Hospital Insurance (Part A) and/or Medical Insurance (Part B)
                  Entitlemeii      ed on disabihty - person attains age of 65 years or the medical
                  reexamination date        heduled to occur after attamrnent of full retirement age.
                         Temporal)'
                         Delete/destroy the clann file r      . 7 years after the date of latest allowance
                         award of Part A contained in the recor         e cntena noted above are met.
                         [NOTE- The claimfile recordfor a person plac            1 suspense Will not be
                         destroyed until the suspense IS lifted. Delete/destroy the       'mjile record 7
                        years after the date the suspense IS lifted if the rules above app y.
                                                                                              Nl-47-05-2

       Medicare On y        ims for Hospital Insurance (Part A) and/or Medical Insurance (Part B)
              Entitlement bas
                      Temporary
                      Destroy/delete the clam         6 years after the date of the latest allowance
                      award contained 111 the record.         'E The claim file record for person
                      placed 111 suspense will not be destroye        . the suspense IS lifted
                      Delete/destroy the claimfile record 6 years aftei          ate the suspense IS
                      lifted if the rules above apply J
                                                                                             Nl-47-05-2


       Medicare Only C a       or Hospital Insurance (Part A) and/or Medical Insurance (Part B)
              Entitlement based n        te Renal Disease (ESRD)
                      Temporary
                      Destroy/delete the claim file
                      contained on the record.
                                                                                    Nl-47-05-2

       Medicare Only        lS for Hospital Insurance (Part A) and/or Medical Insurance (Part B)
              Entitlement denie      terminated for medical reasons
                      Temporary
                      Delete/destroy the clann I        ord 5 years after the Agency's final derual or
                      termmation decision,
                                                                                     Nl-47-05-2
   ,   .


                          ims for Hospital Insurance (Part A) and/or Medical Insurance (Part B)
              Entitlement dem       tennmated for non-medical reasons
                      Temporary
                      Delete/destroy the claim fi e     .d 2 years after the Agency's final denial or
                      termmation deCISIOn.

                                                                                    Nl-47-05-2

       Medicare Only         for Hospital Insurance (Part A) and/or Medical Insurance (Part B)
              Enntlement derue 0        unated for ESRD
                     Temporary
                     Delete/destroy the clarm file rec
                     coverage.
                                                                              Nl-47-05-2

       Medicare Presc       n Drug (Part D) SUbSIdy
              Entitled for assista
                      Temporary
                      Delete/destroy 6 years after t ie      of the final determination (initial, appeal
                      or redetermmation, as appropnate).
                                                                                      Nl-47-05-2
       Medicare Pre        IOnDrug (Part D) Subsidy
            Entitlement for as       ice demed (termmated or claim cancelled)
                      Temporary
                      Delete/destroy 2 years afte         gency's final denial deCISIOn(claim
                      denied), after the claim m cancelled        lled claim), or after the Agency's
                      final terrmnanon decision (tenmnated claim).
                                                                                  NI-47-05-2
ITEM 10
GENERAL
       Temporary
       Delete/destroy   all post entitlement claim file records 6 years after the action ISprocessed to
       completion.

OUTPUTS

   Data Feeds to other SSA System(s)

   Accordmg to temlS of established agreements of partIes sharing data, venfy feed and follo\y

   dIspOSItion mstructIOns for related system(s).



  Ad Hoc Reports

     Temporary
     Delete/destroy     when no longer neede
                                                                                    Nl-47-05-2
         .'


     Correspondence, NotICes and Receipts
     File ..,nth or link to mdl'ndual claIm file, fo11O\',' dISposItIOn lI1stRlctIOnsof related claim file
     record.




                            that provide a narrative descnptIon of the electronic system; physical and
         technical charactensti    of the records, mcluding a record layout that descnbes each field
         mcludmg ItS name, Size, sta        or relative position; and a descnption of the form of the
         data (such as alphabetic, zoned e ral, packed decimal, or numeric); or a data dictionary or
         the equivalent information associated WI        database management system, includmg a
         descnption of the relationship between data e e        ItS 111 databases; and any other technical
         mformation needed to read or process the records. S             IS documentation may include
         such Items as manuals and software update documentation.

         Temporary
         Cut off when the system IS superseded and/or replaced - Delete/destroy           2 years
         or when no longer needed for reference, whichever ISlater

                                                                                            GRS 20. Item 11a

F.        CTRONIC MAIL AND WORD PROCESSING SYSTEM COPIES

         EJec Ol11C copies of records that are created on electronic mall and word processing systems
         and use solely to generate a recordkeepmg copy of the records covered by other Items 111
         this schedu . Also includes electronic copies of records created on electronic mall and
         word processi    systems that are mamtamed for updating, reVISIOn,or dissemmation.

     ITEM 13
        Copies that have no furf r adnurustrative value after the recordkeepmg copy IS made.
        Includes coptes mamtaine       individuals 111 personal files, personal electroruc mail
        directones, or other personal     ctones on hard disk or network drives, and copies on
        shared network drives that are use only to produce the recordkeepmg copy.

              Temporary
              Delete/destroy   withm 180 days after the ecordkeepmg copy has been produced.


         ITEM 14
         Copies used for dissemmation, revision, or updating that        ·e maintained    111   addition to the
            recordkeepmg copy.

              Temporary
              Delete/destroy   when dissernmanon, reVISIOn,or updating IS comp            ed.


                                                                                         GRS 20. Item 3
.J
                                       .-
                                                                                ••
                                                 Agencv Concurrence:


     I have reviewed the records and their respective proposed disposinons. I am of the OpInIOnthat the records will
     be mamtamed for a penod of time sufficient to protect the legal and financial nghts of the government and of
     the people directly affected by the Agency's activities




                                                                                              CJ~jQct?6
                                                                                               ~,
     SSi),General Counsel                                                                                       Date
          , II1C-TJ rJ&-




                                   =::
     ~~                                                                                                         Date




                                                                                                                Date




                                                                                                   I
                                                                                                               Date




           115-109              PREVIOUS EDITION NOT USABLE                    STANDARD    FORM 115 (REV 3-91)            6
                                                                                           Prescribed   by NARA 36 CFR 1228

				
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