State of Michigan department of HEALTH AND human services Lansing GRETCHEN WHITMER governor ELIZABETH HERTEL director
[Month] [XX], 20XX	[Incident #] [Batch Date]
[Batch #] [Envelope #]
[XXX County FOC]
[FOC Address]
[City] [State] [Zip Code]
Dear [FOC Medical Contact]:
Enclosed please find one or more National Medical Support Notices (NMSNs) that the NMSN Processing Unit staff were unable to process. The NMSN(s) attached to this letter has been returned because:
The NMSN(s) is blank.
There is a discrepancy between the employee’s/member’s name and/or Social Security number (SSN) that is listed on the NMSN(s) and the Michigan Child Support Enforcement System (MiCSES).
The employer who responded to the NMSN(s) is not listed in MiCSES for the employee/member.
The employer has determined the NMSN(s) is not a qualified medical child support order (QMCSO). The employer has noted specific missing information (SSN, address information, etc.) on the NMSN(s).
The employer has not been cooperative when the NMSN Processing Unit has contacted him/her to locate necessary health care coverage information, and the NMSN(s) is incomplete. (If this box is selected, a spreadsheet containing a list of the NMSN[s] will also be attached to this letter. The spreadsheet is organized alphabetically by employer. It lists the attempts that were made to elicit insurance information from the employer and the date of each attempt. The employee/member name and docket number are also listed for your convenience.)
Other:
If you have any questions, please contact us at 517-318-4740. When the issue(s) is resolved and the NMSN(s) is completed, send this form and the NMSN(s) to: NMSN Processing Unit, PO Box 30027, Lansing, MI 48909.
Sincerely, NMSN Processing Unit
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.
AUTHORITY: 45 CFR 264.30 CFR 433.147, 7 USC 2015, R 400.33007, .3009, .3010 MCA COMPLETION: Required when applicable. PENALTY: Ineligibility for Family Independence Program (FIP), medical assistance, food assistance, or Child Development and Care assistance.