NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 4100

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EIS 4100–Community Care of North Carolina/CAROLINA ACCESS


I. GENERAL INFORMATION

II. Enrollment IN CCNC/CA

III. CHANGES TO ENROLLMENT

IV. Entering CA Data in EIS


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EIS 4100–Community Care of North Carolina/CAROLINA ACCESS

REISSUED 08/01/11 – CHANGE NO. 01-12

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I. GENERAL INFORMATION

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II. Enrollment IN CCNC/CA

REVISED 08/01/11 – CHANGE NO. 01-12

II. (CONT’D)

      3. Review the recipient’s medical history, location of residence and type of medical care.

      The Managed Care Provider (MP) screen in EIS allows the user to view information on practices in the CA program. Refer to MA-3435 or MA-2425, for more information on the MP screen.

    C. Key the PCP or exempt number on the DSS-8125. Each family member may have a different PCP or exempt number. The appropriate exempt number is automatically entered by EIS for an individual who has a living arrangement of 16 (incarcerated) or 17 (in an Institution for Mental Disease (IMD)).

    D. The effective date of enrollment is always the ongoing month after the action processes in EIS, depending on the system cut-off this may be the next month or the following month. The system cut-off for all programs is the fourth work night from the end of the month.

    E. Mandatory Enrollment

      A recipient must enroll in CA when the recipient:

      1. Is eligible for Medicaid in the following Aid Program/Categories (AAF, MAF, MAABD without Medicare, MIC-N, MIC-1, MSB, SAD without Medicare, SAA without Medicare), or is eligible for NC Health Choice (MIC, A, K, S, J), and
      2. Has a living arrangement code of 10, 11, 12, 13, 51, 52, 53, 56.

    F. Ineligible For Enrollment

      Do not enroll in CA when the recipient:

      1. Is ineligible for CA (MQB, MRF, RRF, aliens eligible for emergency Medicaid only, Family Planning (MAF-D), Breast & Cervical Cancer Medicaid (MAF-W), NC Health Choice (MIC, L), or
      2. Has a living arrangement code of 16, 17, 50, 58, 59, 60, 70, 71, 72, 73, 75, or
      3. Meets the deductible later than the second month of the certification period, or
      4. Is a CAP recipient with a monthly deductible, or
      5. Has no ongoing eligibility open/shut/retroactive eligibility only, or
      6. Is in a Benefit Diversion case.

REVISED 08/01/11 – CHANGE NO. 01-12

II. (CONT’D)

    G. Optional Enrollment

      A recipient can be enrolled in CA; however, it is NOT required in the following situations:

      1. MPW
      2. HSF
      3. IAS
      4. MAABD (with Medicare)
      5. SAD (with Medicare)
      6. End Stage Renal Disease Patients
      7. SSI recipients under age 19
      8. Self-identified children with special health care needs
      9. Native Americans
      10. SAA (with Medicare)

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III. CHANGES TO ENROLLMENT

    You must manually remove the CA provider when:

    A. Keying a county transfer (non-SSI).

      1. When a non-SSI recipient transfers from one county to another county, manually delete the CA number (EIS will not process the transfer until removed). EIS automatically assigns the 9900029 exempt code on the last working day of the month when the county transfer processes.
      2. When a SSI recipient transfers from one county to another county, EIS automatically inserts one of the following exempt codes in the provider field:

        9900010-the individual is not Medicare eligible (Mandatory Participant)

        9900011-the individual is Medicare eligible (Optional Participant)

    B. Changing individuals from authorized to deductible status.

    C. Changing individuals from NC Health Choice (MIC with Medicaid Class A, J, K, or S) to NC Health Choice Optional Extended Coverage (MIC with Medicaid Class L).

REISSUED 08/01/11 – CHANGE NO. 01-12

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IV. Entering CA Data in EIS

    This section contains general information needed to enter CA data correctly in EIS.

    When approving an application, completing a redetermination, or changing CA enrollment:

    A. Enter one of the following in the Carolina Access field on the DSS-8125.

      1. Carolina Access Exempt Number (Refer to MA-2425 or MA-3435, Community Care of North Carolina/Carolina Access, for a list of appropriate exempt numbers).
      2. Carolina Access Provider Number

    B. Enter data to track the CA provider/exempt information.

      1. Change Reason (The reason the recipient changed provider).
        a. Change Reason is required when the current Managed Care is a CA provider and it is changed to another CA provider.
        b. Change Reason is NOT required when:
          1. No current Managed Care to exempt.
          2. No current Managed Care to a CA provider.
          3. CA provider to exempt.
          4. Exempt to CA provider.
          5. Exempt to exempt.
          6. NC Health Choice recipient (MIC, Medicaid Class J, K, A, and S).
      2. Auto-Assign (The provider was automatically assigned to the recipient).
        a. Auto Assign is required when:
          1. No Managed Care to a CA provider.
          2. CA provider to a CA provider.
          3. Exempt to CA provider.
          4. NC Health Choice individual has a provider number that has been keyed and the Auto Assignment field is blank, EIS automatically enters “N” in that field.

REISSUED 05/01/09 – CHANGE NO. 03-09

IV. B. 2. (CONT’D)

        b. Auto Assign is NOT required when:
          1. No current Managed Care to exempt.
          2. CA provider to exempt.
          3. Changing from exempt provider to another exempt provider.
          4. There is no change in provider. Recipient will keep the same provider.

            Example: At reapplication approval, PCP number remains the same. Auto Assign is not allowed.

          5. NC Health Choice individual has an exempt provider number or is blank, the Auto Assignment field then must be blank.
      3. Distance (How far is the recipient from the provider).
        a. The Distance to Provider is required when:
          1. No current Managed Care to CA provider.
          2. CA provider to a CA provider.
          3. Exempt to a CA provider.
        b. The Distance to Provider is Not required when:
          1. No current Managed Care provider to exempt.
          2. CA provider to exempt.
          3. Exempt to exempt.
          4. NC Health Choice recipient (MIC with Medicaid class of J, K, A, or S).

    C. EIS displays the change code, auto-assign indicator, and distance indicator on the EIS Individual Profile (IP) screen and the EIS Individual Eligibility (IE) screen.

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