NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 2011

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EIS 2011 - COMPLETING AN APPLICATION FORM FOR NEW APPLICATIONS AND REAPPLICATIONS MEDICAID TO THE AGED, BLIND, AND DISABLED


I. GENERAL INFORMATION

II. COMPLETING AN APPLICATION FORM

III. OUTPUT

IV. ADMINISTRATIVE APPLICATIONS


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EIS 2011 - COMPLETING AN APPLICATION FORM FOR NEW APPLICATIONS AND REAPPLICATIONS MEDICAID TO THE AGED, BLIND, AND DISABLED

REISSUED 02/01/11 - CHANGE NO. 03-11

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I. GENERAL INFORMATION

The DSS-8124 Application for Medicaid and SA is the computer input screen and paper document used to enter a Medicaid application into EIS. The information required to enter the application into EIS is listed in II. below.

NOTE: FOR KEYING INSTRUCTIONS, SEE EIS 4900.

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II. COMPLETING AN APPLICATION FORM

A. Use the following instructions to complete the application. If a numeric field requires less digits than spaces available, precede with zeroes.

REVISED 02/01/11 - CHANGE NO. 03-11

II. A. (CONT'D)

      8. Enter the CITY, STATE, and ZIP CODE. Refer to EIS 4050, Mailing Address Appendix, to determine the appropriate state abbreviation.
      9. APPLICATION TYPE
        a. Enter “1” (New Application) or “4” (New Application with Retroactive Benefits); or
        b. Enter “2” (Reapplication) or “5” (Reapplication with Retroactive Benefits).

      10. CASE ID
        a. New Application - Do not complete. A Case ID is assigned by the system for each new application at the time the application is initially entered and accepted into the system. This becomes the permanent Case ID for the case.
        b. Reapplication
          (1) Case - Enter the Case ID from the most recent Case Profile or from Name Search Inquiry.
          (2) Withdrawn or Denied Application - Enter the application number, including the suffix of the withdrawn or denied application from Name Search Inquiry.
      11. HOW APP RECEIVED?- Enter one of the following codes to indicate the source from which the MAABD or MQB application (when application date is 10/1/05 or later) was received:
        a. “A” Aging Centers
        b. “M” By Mail
        c. “D” County Department of Social Services
        d. “L” Low Income Subsidy (LIS). Medicaid applications received from the Social Security Administration.

        e. “P” Division of Prisons

REVISED 02/01/11 - CHANGE NO. 03-11

II. A. (CONT'D)

12. Enter the appropriate AID PROGRAM/CATEGORY code.

        M-AA

        Medicaid Aid to the Aged

        M-AB

        Medicaid Aid to the Blind

        M-AD

        Medicaid Aid to the Disabled

        M-QB

        Medicare Qualified Beneficiary

      13. If the application is for a Qualifying Individual enter “Y” for “MQB-QI1?”. Enter “N” if not for QI.
      14. Enter “Y” for ADMIN if the application is administrative.
15. Do not use the TRANSITIONAL field. It does not apply to MAA, MAB, MAD, or MQB.
      16. Enter the TOTAL NUMBER OF PEOPLE ON THIS APPLICATION. Include the casehead/payee in this count.
        a. The system does not allow more than one individual for new applications.
        b. Two persons may be entered on the same case for reapplications of grandfathered cases with an essential spouse.
      17. Enter C/H INCLUDED “Y”.
      18. Enter “Y” for MAD appplications that require a disability decision or “N” for MAD applications that do not require a disability decision in the DIS/DET field. Enter in ONGOING or RETRO for a one-part application or enter both ONGOING and RETRO for two-part applications.
      19. Enter a LINE NUMBER at the individual level.
      20. Enter the INDIV ID NUMBER for each person to be included on the application.

        NOTE: IF THE ID ENTERED IS UNKNOWN TO THE SYSTEM OR THE NUMBER DOES NOT MATCH THAT INDIVIDUAL, THE APPLICATION DOES NOT PROCESS. SEE EIS 1056, COMMON NAME DATABASE, FOR INSTRUCTIONS ON ID ASSIGNMENT.

REVISED 02/01/11 - CHANGE NO. 03-11

II. A. (CONT'D)

      21. Enter the following in the CTZ (Citzenship)field to document citizenship for each individual listed on the DSS-8124. There must be an entry for each individual listed on the DSS-8124.
        a. “Y” Individual is applying for assistance and states he is a U.S. Citizen.
        b. “N” Individual is applying for assistance and states he is not a U.S. Citizen.
        c. “X” Casehead is not applying for benefits or individual who states he is a U.S. Citizen and does not have a social security number.
22. Enter the APPLICATION DATE.
      23. APPLICANT’S/REPRESENTATIVE’S SIGNATURE
        a. The applicant or his representative must read and understand the statements on the back of the DSS-8124 before he signs the form. If he cannot read or does not understand, explain the statements to him in a manner he can understand.
        b. The applicant or his representative must sign his name the day he applies. If he cannot sign his name, have him make his mark, “X”, on the form. Two persons must witness his mark. The worker's signature serves as one of the witnesses.

      DISPOSITION FIELDS ARE NOT USED IN APPLICATION REGISTRATION. REFER TO THE DENIAL (EIS 2150) AND WITHDRAWAL (EIS 2200) SECTIONS FOR INSTRUCTIONS ON HOW TO DENY OR WITHDRAW THE APPLICATION AT REGISTRATION.

      23. When necessary, a WITNESS SIGNATURE may be entered.
      24. Sign the DSS-8124 in the CASEWORKER SIGNATURE field.
      25. The county director or his designee must sign and date the form in the DIRECTOR'S SIGNATURE and DATE field.

    B. Key the DSS-8124.

REISSUED 03/01/10 - CHANGE NO. 03-10

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III. OUTPUT

    A DSS-8124I Application Turnaround is produced overnight when the application is entered and accepted into the system and mailed to the county the next workday.

    NOTE: The name on the 8124I must match Social Security Records. Use the name on the SDX, BENDEX, SOLQ, TPQ, Social Security Card, or Medicare Card. If a discrepancy exists, use the name from the online verification.

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IV. ADMINISTRATIVE APPLICATIONS

    A. Administrative DSS-8124's do not have to be signed by the applicant. They are used as follows:

      1. To establish separate cases for which there is a signed application on file for all individuals listed.
      2. To re-establish a case closed in error by processing the DSS-8124 as a reapplication.
      3. At other times as required by policy.
      4. To establish a separate case for which there is a signed application on file for potentially dually eligible individuals (if date of application is 05-22-93 or later).

    B. To complete an administrative DSS-8124:

      1. Write “Administrative 8124” at the top of the form.
      2. Mark “1” (New Application) or “4” (New MA application with retroactive benefits).
      3. Follow the DSS-8124 instructions for completion of the form.
      4. Use the application date from the original application.
      5. Document the form number from the signed application.
      6. If potentially dually eligible, complete a NEW Administrative DSS-8124. Use the SAME date of application as indicated on the signed DSS-8124 (if Date of Application is 05-22-93 or later).

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