NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 2253

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EIS 2253 - APPROVING M-QB NEW APPLICATIONS OR REAPPLICATIONS


I. GENERAL INFORMATION

II. APPROVING APPLICATIONS

III. COMPLETING THE DSS-8125

IV. KEY THE DSS-8125.

V. OUTPUT

VI. AUTOMATED NOTICES


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EIS 2253 - APPROVING M-QB NEW APPLICATIONS OR REAPPLICATIONS

REVISED 08/01/04 - CHANGE NO. 01-05

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I. GENERAL INFORMATION

REISSUED 08/01/04 - CHANGE NO. 01-05

I. (CONT'D)

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II. APPROVING APPLICATIONS

REISSUED 11/01/10 - CHANGE NO. 2-11

II. (CONT’D)

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III. COMPLETING THE DSS-8125

REVISED 11/01/10 - CHANGE NO. 2-11

III. A. (CONT’D)

REISSUED 05/01/09 - CHANGE NO. 03-09

III. (CONT’D)

    C. CASE TERMINATION DATA

      1. If an appeal reversal and the individual is not eligible for ongoing benefits, approve the case in terminated status (Open/Shut). Enter the CASE TERMINATION REASON and DATE. The date must be the last day of the certification through month.

        NOTE: THE DISPOSITION DATE MUST BE THE ORIGINAL DISPOSITION DATE.

OR

        If approving retroactive coverage only in M-AA, M-AB, or MQB (for one or two part application), enter CASE TERMINATION REASON and DATE. The date must be the last day of the month before the month of application.

        See the Codes Appendix to determine the appropriate termination reason code.

        NOTE: DISPOSITION REASON CODE “B4” MUST BE ENTERED FOR MEDICAID CLASS “B” or “E”. (MQB ONLY).

      2. Enter the OLD CASE TERMINATION REASON and DATE if approving a reapplication and the case you are reapplying against is still open. The date must be the last day of the month before the ongoing month. See the Codes Appendix to determine the appropriate old case termination reason code.

    D. PAYMENT DATA Do not enter for M-QB.

REVISED 05/01/09 - CHANGE NO. 03-09

III. (CONT’D)

    E. MEDICAID DATA

      For approving ongoing or retroactive with ongoing coverage under M-QB:

      1. Do not enter MEDICAID STATUS. EIS automatically enters “A” for authorized.
      2. Enter MEDICAID EFFECTIVE DATE.
        a. This date must be the first day of the month following the month of disposition entered on the DSS-8125 if the Medicaid Class is “Q”.
        b. If the Medicaid Class is “B” or “E”, this date:
          (1) Must be the first day of the month of authorization, or
          (2) May be one, two, or three months before the month of application.
            (Class “E” cannot be prior to Jan 1st of the current calendar year.)
      3. Enter the CERTIFICATION FROM DATE.

        a. This date must be greater than or equal to the month of app.

        b. This date must be the first day of the month.

      4. Enter the CERTIFICATION THRU DATE.

        MQB-Q/B

        a. The date may be up to twelve months from the CERTIFICATION FROM DATE.
        b. If CASE TERMINATION DATE is present the CERTIFICATION THRU DATE must equal the month and year of termination.
        c. The date must be the last day of the month.

REVISED 07/01/01 - CHANGE NO. 01-02

III. E. (CONT'D)

        MQB-E

        a. For applications dated January 1 through October 31, the certification thru date is 12/31 of the current calendar year. This applies even when the application is completed after October 31.
        b. For applications dated on or after 11/1, the certification thru date is 12/31 of the next calendar year. This means the ongong certification period can be as much as 14 months.
        c. The date must be the last day of the month.
      5. Enter MEDICAID CLASS.
      6. Do not enter DB/PML type.
      7. Do not enter DB/PML AMOUNT.

    F. RETRO MA 1 and 2

      Complete RETRO MA 1 and 2 to authorize Medicaid prior to the month of application. If you are completing both RETRO MA 1 and 2, the earliest retroactive period must be entered in RETRO MA 1. For example, if the recipient is eligible for retroactive months 04/96 and 06/96, 04/96 must be entered in RETRO MA 1.

      1. RETRO MA 1
        a. Enter the AID PROGRAM/CATEGORY under which the retroactive coverage is given. This must be “M-AA”, “M-AB”, or “MQB”. For MQB-E approvals, the retro must be MQB-E.
        b. Enter AUTHORIZATION FROM and AUTHORIZATION THRU dates.
          (1) AUTH FROM DATE:
            (a) Must be before the month of application.
            (b) May be up to three (3) months before the month of application.

              (“MQB-E” cannot be prior to Jan 1st of the current calendar year.)

            (c) May be any day of the month.

REVISED 07/01/01 - CHANGE NO. 01-02

III. F. 1. (CONT'D)

          (2) AUTH THRU DATE:
            (a) Must be before the month of application.
            (b) Cannot be before the FROM DATE.
            (c) Must be the last day of the month.
            (d) Must be before the RETRO MA 2 FROM DATE if RETRO MA 2 information is entered.
        c. Enter MEDICAID CLASS for the retroactive period. This must be “E” if the MQB-QI1 indicator on the application is “Y”.
        d. Enter DB/PML if applicable for the retroactive period. DB/PML is required if the Retro MA 1 FROM DATE is not the first day of the month. (N/A to MQB-E)
        e. Enter DB/PML AMOUNT if DB/PML type is entered.
      2. RETRO MA 2

        Do not enter RETRO MA 2 unless RETRO MA 1 has been completed. If there is a break in the retroactive coverage, complete RETRO MA 2.

        a. Enter the AID PROGRAM/CATEGORY under which the retroactive coverage is given. This must be M-AA,
        M-AB, or M-QB. For MQB-E approvals, the retro must be MQB-E.
        b. Enter AUTHORIZATION FROM AND AUTHORIZATION THRU DATES.

          The RETRO MA 2 FROM AND THRU DATES must be after RETRO MA 1 THRU DATE.

          (1) AUTH FROM DATE:
            (a) Must be before the month of application.
            (b) May be up to three (3) months before the month of application.

              (“MQB-E” cannot be prior to Jan 1st of the current calendar year.)

            (c) May be any day of the month.
            (d) Must be before the MEDICAID EFFECTIVE DATE if MEDICAID EFFECTIVE DATE is entered.

REVISED 3/01/98 - CHANGE NO. 8-98

III. F. 2. (CONT'D)

          (2) AUTH THRU DATE:
            (a) Must be before the month of application.
            (b) Cannot be before FROM DATE.
            (c) Must be the last day of the month.
        c. Enter MEDICAID CLASS for the retroactive period. This must be “E” if t he MQB-QI1 indicator on the application is “Y”.
        d. Enter the DB/PML if applicable for the retroactive period. The DB/PML is required if the Retro MA 2 FROM DATE is not the first day of the month.
        (N/A to MQB-E.)
        e. Enter DB/PML AMOUNT if DB/PML type is entered.
        f. If a PML is entered and you need the DMA-5016 to go to a different facility than indicated in the address section, enter the three character facility code for the facility which is to receive the DMA-5016 for the Retro MA 1 period. (See EIS-1063 for instructions on determining the facility code.)

    G. EARNED INCOME (IF ZERO, LEAVE BLANK)

      All fields must be in dollars and cents.

      1. Enter the amount of GROSS EARNED INCOME. Amount must be entered if WORK EXPENSES, DISREGARD, or NET EARNED INCOME are entered.
      2. Enter the WORK EXPENSES.
      3. Do not enter CHILD/ADULT CARE.
      4. Enter the amount of DISREGARD.
      5. Enter the amount of NET EARNED INCOME.
      6. Do not enter GRANT RECOUPMENT CODE, AMOUNT or END DATE.

REISSUED 3/01/98 - CHANGE NO. 8-98

III. (CONT'D)

    H. UNEARNED INCOME (IF ZERO, LEAVE BLANK)

      All fields must be in dollars and cents.

      1. Enter the RSDI AMOUNT.
      2. Enter the TOTAL NET UNEARNED INCOME. Must be more than or the same as the RSDI Amount if RSDI entered.

    I. NEEDS

      1. Enter the MAINTENANCE AMOUNT. The amount must be dollars and cents.
      2. Do not enter AMBULATION CAPACITY.
      3. Do not enter DOMICILIARY RATE.
      4. Enter TOTAL COUNTABLE MONTHLY INCOME. The amount must be in dollars and cents. If entered, Total Net Unearned Income or Net Earned Income must be entered.

    J. SPECIAL DATA

      1. Do not enter FOOD STAMP NUMBER.
      2. Do not mark STEPPARENT INDICATOR.
      3. Do not enter GRANDFATHER STATUS CODE and DATE.
      4. Mark “YES” or “NO” for VA PAYMENT.
      5. Enter SPECIAL REVIEW TYPE and DATE if applicable.
      6. Do not enter JOBS/WORK REQUIREMENT SAVINGS REASON and AMOUNT.
      7. Enter SPECIAL USE CODE and DATA if applicable.

    K. SPECIAL COVERAGE GROUPS (INCLUDING SPECIAL NEEDS)

      1. Do not enter CODE, BEGIN DATE or END DATE. There are no special coverage groups for M-QB.
      2. Do not enter SPECIAL NEEDS INDIVIDUAL ID, SPECIAL NEEDS CODE, SPECIAL NEEDS FROM DATE, or SPECIAL NEEDS THRU DATE.

REISSUED 10/01/08 - CHANGE NO. 01-09

III. (CONT'D)

    L. SUPPLEMENTAL NOTICE INFORMATION

      The following three data elements have been added to the DSS-8125 Data Entry screen. A recommended form in which to enter the information can be found at the end of this section. This form should be attached to your DSS-8125 when submitting to Data Entry for keying.

      1. Authorized Representative Name and Address

        If an applicant had an authorized representative acting in his behalf, the authorized representative's name and address may be entered for the purpose of mailing an automated notice to the authorized representative in addition to the applicant.

      2. Secondary Notice Code

        This code may be used in addition to the disposition code at approval time only. You may use it in situations when additional information is needed. Refer to Secondary Notice Codes in the Codes Appendix.

      3. Notice Text

        This section may be used to provide additional information to the applicant, when a Secondary Notice Code is not applicable.

        NOTE: If you are approving both parts of a two-part application at the same time, and you use two different disposition codes, you cannot enter the Secondary Notice Code or Notice Text.

    M. INDIVIDUAL DATA

      The casehead name and the individual data for the individual included on the case will be brought forward from the case or the application and cannot be changed. When a DSS-8125 is keyed, EIS reads the common name database to retrieve the individual assigned to the case id with a casehead/payee status of “P”. If any of the individual data is incorrect, use the NAME CHANGE screen to make the appropriate correction(s).

      Enter the following data:

      1. Do not enter INDIVIDUAL TERMINATION DATE.
      2. Enter CASE STATUS of “R”.
      3. Enter the RSDI CLAIM NUMBER. The RSDI CLAIM NUMBER:
        a. Can not be blank or zeroes,

REVISED 10/01/08 - CHANGE NO. 01-09

III. M.(CONT'D)

        b. Suffix can not be “Z”.
        c. Must be the individual’s Social Security number if the RSDI CLAIM NUMBER suffix is A, M, or T.
      4. Enter “Y” in MEDICARE A.
      5. Enter “Y” or “N” in MEDICARE B to indicate whether or not the individual has Medicare B.
      6. Enter FAMILY STATUS of “A” for adult or “C” for child.
      7. Enter LIVING ARRANGEMENT CODE. See the Codes Appendix for the appropriate living arrangement code.
      8. Enter SPECIAL REPORT CODE if applicable. See the Codes Appendix to determine the appropriate special report code.
      9. Do not enter JOBS/WORK REGISTRATION/EXEMPTION.
      10. Enter SPECIAL USE CODE and DATA if applicable. See the Codes Appendix to determine the appropriate Special Use codes and Data. Do not enter if CASE TERMINATION REASON and DATE are entered.
      11. Enter the REFUGEE STATUS CODE and U.S. ENTRY DATE (in MMCCYY format), if applicable. See the Codes Appendix to determine the appropriate Refugee Status Code.
      12. Enter DATE OF DEATH if applicable.
        a. If entered, CASE TERMINATION REASON and DATE are required.
        b. The DATE OF DEATH must be before or the same as the CASE TERMINATION DATE.
        c. DATE OF DEATH must be before or the same as the current date.
      13. Enter the two digit CITIZEN/ID code and the date (in MMDDCCYY format)if applicable. Enter Citizen/ID codes for refugee, asylee, Cuban/Haitian status, Amerasian, trafficking victim or special immigrant. See the Codes Appendix to determine the appropriate Citizen/ID code and what the date reflects.
      14. Enter Alien ID number, if applicable. Key only the numeric parts of the Alien ID number. Do not enter the alpha “A”.
      15. Enter the RELATIONSHIP TO PAYEE code. See Codes Appendix to determine the appropriate code.

REVISED 10/01/09 - CHANGE NO. 01-10

III. M. (CONT'D)

      16. Do not enter JOBS/WORK REQUIREMENT SAVINGS REASON and AMOUNT.
      17. Do not enter WORK EXPERIENCE.
      18. Do not enter GROSS EARNED INCOME.
      19. Do not enter WORK EXPENSES.
      20. Do not enter CHILD/ADULT CARE.
      21. Do not enter NET EARNED INCOME.
      22. Do not enter EDUCATIONAL LEVEL.
      23. Enter type and date of EDUCATION provided. Refer to EIS 4100, Community Care of North Carolina, for more information.
      24. Enter “Y” or “N” for ISSUE CARD. If the individual has an annual Medicaid card from a prior time, enter “N”. A new card will not be issued. If the individual states they do not have an annual Medicaid card, enter “Y”. A new card will be produced the night the approval processes and mailed the following workday.
      25. Do not enter COMMUNITY CARE OF NORTH CAROLINA (CCNC) provider or exempt number.

    N. SIGNATURES AND DATE

      1. Enter DATE COMPLETED by the worker.
      2. Write WORKER'S SIGNATURE.
      3. The county director or his designee must sign the form in the DIRECTOR'S SIGNATURE field.

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IV. KEY THE DSS-8125.

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V. OUTPUT

      When the DSS-8125 has processed successfully, the following are received:

    A. BENEFITS ISSUED

      An annual Medicaid identification card for each individual on the case is produced the night the approval processes and mailed to the recipient the following workday.

REISSUED 10/01/09 - CHANGE NO. 01-10

V. (CONT'D)

    B. DMA-5016 (Patient Liability Notification)

      DMA-5016(s) are automatically printed and mailed for the retro period(s) authorized MAAB, if applicable, to the appropriate facility as indicated by the facility code(s) entered on the DSS-8125.

    C. CASE PROFILE

      A Case Profile is produced the night the approval processes and is mailed to the county the following workday.

    D. APPLICATION TURNAROUND DOCUMENT

      If one part of a two part application is approved, an Application Turnaround Document is received for the second part of the application still pending.

    E. CASEWORKER SUPERVISOR REPORT

      1. The application approval is reported on the Caseworker Supervisor Report. The number of approvals completed is determined from the WORKER NUMBER.
      2. For dual applications, the Caseworker Supervisor Report will display both application dispositions after completion.

REVISED 10/01/09 - CHANGE NO. 01-10

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VI. AUTOMATED NOTICES

    A. An automated notice (DSS-8108A) is produced for each MQB approval the night the DSS-8125 processes in the system unless “Y” is entered for “NOTICE OVERRIDE”.

    B. The DISPOSITION REASON CODE, the Secondary Notice Code, and the Notice Text entered on the DSS-8125 determines the text of the notice.

    C. The system calculates the 60th calendar day for the notice.

    D. The date of the automated notice is the next state workday after the DSS-8125 processes. This is the date the notice is mailed to the recipient. A copy of the notice will be sent to the authorized representative, if the authorized representative name and address fields were entered on the DSS-8125.

    E. A Notice Register Report is produced each night and is mailed to the county the following workday. This report lists vital information related to all automated notices produced for that day. See EIS 2304 for more information regarding the Notice Register Report.

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