NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 4000

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CODES APPENDIX

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EIS 4000 CODES APPENDIX TABLE OF CONTENTS


I. DSS-8124/8125/8126 CODES

II. DMA-2041 CODES

III. DMA-5022 CODES

I. DSS-8124/8125/8126 CODES

I. DSS-8124/8125/8126 CODES Cont’d

II. DMA-2041 CODES

III. DMA-5022 CODES


Previous PageTable Of ContentsNext Page

EIS 4000 CODES APPENDIX TABLE OF CONTENTS

REVISED 10/01/12 – CHANGE NO. 01-13

Top Of Page

I. DSS-8124/8125/8126 CODES

REISSUED 02/01/11 – CHANGE NO. 03-11

Table Of Contents (Cont’d)

Top Of Page

II. DMA-2041 CODES

Top Of Page

III. DMA-5022 CODES

*** The following appendices contain Change, Disposition, Termination, and Transfer Codes for all aid program/categories.

REVISED 02/01/11 – CHANGE NO. 03-11

EIS 4000 – CODES APPENDIX

Top Of Page

I. DSS-8124/8125/8126 CODES

AID PROGRAM/CATEGORY/BENEFITS

AID

PROGRAM

AID

CATEGORY

DESCRIPTION

BENEFITS

A AF

Work First Assistance

B

H SF

Foster Care - Non Title IV-E Foster Care

M

I AS

Title IV-E Adoption Subsidy/Foster Care

M

M AA

Medicaid-Aid to the Aged

M

M AB

Medicaid-Aid to the Blind

M

M AD

Medicaid-Aid to the Disabled

M

M AF

Medicaid-Aid to Families with Dependent Children

M

M IC

Medicaid-Infants and Children

M

M PW

Medicaid-Pregnant Woman

M

M QB

Medicaid-Qualified Beneficiary

M

M RF

Medicaid-Refugees

M

M SB

Medicaid-Special Assistance to the Blind –obsolete effective 9/1/2010

M

R RF

Refugee Assistance

B

S AA

Special Assistance-Aid to the Aged

B

S AD

Special Assistance-Aid to the Disabled

B

S CD

Special Assistance-Certain Disabled

C

 

B=Both Cash and Medicaid C=Cash Only M=Medicaid Only

ALIEN ID

This code reflects a unique identification/file number assigned by USCIS (US Citizenship & Immigration Services-formally INS) to every alien who is admitted to the U.S. or who otherwise comes into contact with the agency. Key only the numeric part of the Alien ID. Most current Alien numbers are 8 or 9 digits, often with leading zeros.

AMBULATION CAPACITY

CODE

VALUE

 

A

Ambulatory (1995 Disenfranchised)

S

Semi-ambulatory (1995 Disenfranchised)

B

Basic SA (Non-Disenfranchised)

H

In Home Program

C

SA/ACH Special Care Unit

E

Basic SA (Exempt)

REVISED 02/01/11 – CHANGE NO. 03-11

Top Of Page

I. DSS-8124/8125/8126 CODES Cont’d

APPLICATION TYPE

CODE

VALUE

 

1

New Application

2

Reapplication

3

Administrative Add-An-Individual Application

4

New Application with Retroactive Benefits - Medicaid Only

5

Reapplication with Retroactive Benefits - Medicaid Only

6

Add-An-Individual Application

7

Administrative New Application (MAF and MIC Only)

AUTHORIZED REPRESENTATIVE RELATIONSHIP HIERARCHY

Hierarchy

Relationship Type

EIS Code

First

Legal Guardian (includes DSS with custody or guardianship)

A

Second

Power of Attorney

B

Third

Health Care Power of Attorney

C

Fourth

Department of Social Services (placement responsibility only)

D

Fifth

Spouse (Not separated)

E

Sixth

Parent (for children under 21, a parent who is not the casehead but who lives in the home).

F

Seventh

Authorized Representative (An individual designated in writing by the applicant/recipient to assist with eligibility issues and who can have access to the information in the case file.)

G

Eighth

Authorized Representative as designated by SSA on SDX

H

CASE STATUS

CODE

VALUE

   

R

Recipient (See WF700 CODES for additional codes)

REISSUED 10/01/12 – CHANGE NO. 01-13

CITIZEN/ID

Individual Data (ID) Codes

CODE

DESCRIPTION

DATE – Required

(MMCCDDYY)

10

A document from chart 1 was used to document citizenship and identity.

Date documentation was received

11

Citizenship and identity was verified by Social Security Administration.

EIS will automatically enter date SSA response was received

12

Citizenship and identity was verified but Social Security states there is an indication of death.

Date SSA response was received

25

A document from chart 2 was used to document citizenship and a document from chart 5 was used to document identity.

Date documentation was received

35

A document from chart 3 was used to document citizenship and a document from chart 5 was used to document identity.

Date documentation was received

45

A document from chart 4 was used to document citizenship and a document from chart 5 was used to document identity.

Date documentation was received

50

Medicare, SSI, individuals receiving Social Security benefits on the basis of a disability (SSDI), Lawful Permanent Resident (LPR) recipient, or Title IV-B (HSF) child eligible under MIC. These individuals are excluded from documentation of citizenship and identity.

Date code entered in EIS

97

The applicant has indicated Y-Yes for citizenship but the SSA response does NOT indicate citizenship.

Date the first request for information is sent to the recipient for documentation of citizenship and identity.

98

Individual declares citizenship but there is no documentation in the record.

Date the record was checked

(Ongoing NCHC cases prior to January 1, 2010 only)

REISSUED 10/01/12 – CHANGE NO. 01-13

Individual Data (ID) Codes

CONT’D

99

Exparte situations where the individual is not required to provide citizenship and identity documentation until the next redetermination.

Date code entered in EIS.

51

Documentation of Lawful Permanent Resident status and identity.

Date documentation was received.

60

Documentation of REFUGEE status and identity.

Date documentation was received.

61

Documentation of ASYLEE status and identity.

Date documentation was received.

62

Documentation of CUBAN/HAITIAN status and identity.

Date documentation was received.

63

Documentation of AMERASIAN status and identity.

Date documentation was received.

64

Documentation of TRAFFICKING VICTIM status and identity.

Date documentation was received.

65

Documentation of “SI” (Special Immigrant) status and identity.

Date documentation was received.

66

Documentation of “SQ” (Special Immigrant) status and identity.

Date documentation was received.

REVISED 10/01/12 – CHANGE NO. 01-13

CITIZEN/ID CONT’D

DSS-8124 Application SSA Response Codes

A

SSN is verified, there is no indication of death, and the allegation of citizenship is consisistent with SSA data.

B

SSN is verified, there is no indication of death, and the allegation of citizenship is NOT consistent with SSA data.

C

SSN is verified, there is indication of death, and the allegation of citizenship is consistent with SSA data.

D

SSN is verified, there is indication of death, and the allegation of citizenship is NOT consistent with SSA data.

E

Name, Date of Birth, or SSN not matching with SSA data.

V

Citizenshp and Identity was previously verified.

Refer to MA-3330, Citizen/Alien Requirements, to reference the documentation charts.

EXCEPTION: The following recipients do not require a code, but you may enter a code for the individual.

    * SCD

    * MPW presumptive

    * HSF and IAS

    * Automatic newborn

Administrative applications are exempt from citizenship entry. So are appeal reversals when the original date of application on the date screen is prior to 9/1/06.

You may enter a code for any individual that is active in EIS, including SSI Medicaid recipients. An individual only has one CITIZEN/ID code and date at a time. If a new code is entered, EIS uses the following hierarchy list to determine if the prior code is overlayed or does not change.

HIERARCHY: 10 overlays 25, 35, 45, 50, or 99

    11 overlays anything except 10 or 25

    12 overlays anything except 10, 11 or 25

        25 overlays 35, 45, or 99

        35 overlays 45 or 99

        45 overlays 99

        50 overlays 35, 45, or 99

        97 can be overlaid by anything except 98 and 99

        98 can be overlaid by anything except 99

        99 can be overlaid by anything

        51 and 60-66 can be overlaid by any code

        50 can be overlaid by 51 and 60-66

        NOTE: 10 can not be overlaid by any code.

If the wrong code is entered and it is not an overlay based in this list, your must delete the code. If the code is deleted, the date is deleted automatically. See EIS 3100 for how to delete data.) Key the correct code and date the next workday.

If the code is overlayed, the date is not changed unless you entered a new date when entering the new code.

REISSUED 02/01/11 – CHANGE NO. 03-11

COUNTY NAME/NUMBER

01 Alamance

26 Cumberland

51 Johnston

76 Randolph

02 Alexander

27 Currituck

52 Jones

77 Richmond

03 Alleghany

28 Dare

53 Lee

78 Robeson

04 Anson

29 Davidson

54 Lenoir

79 Rockingham

05 Ashe

30 Davie

55 Lincoln

80 Rowan

06 Avery

31 Duplin

56 Macon

81 Rutherford

07 Beaufort

32 Durham

57 Madison

82 Sampson

08 Bertie

33 Edgecombe

58 Martin

83 Scotland

09 Bladen

34 Forsyth

59 McDowell

84 Stanly

10 Brunswick

35 Franklin

60 Mecklenburg

85 Stokes

11 Buncombe

36 Gaston

61 Mitchell

86 Surry

12 Burke

37 Gates

62 Montgomery

87 Swain

13 Cabarrus

38 Graham

63 Moore

88 Transylvania

14 Caldwell

39 Granville

64 Nash

89 Tyrrell

15 Camden

40 Greene

65 New Hanover

90 Union

16 Carteret

41 Guilford

66 Northampton

91 Vance

17 Caswell

42 Halifax

67 Onslow

92 Wake

18 Catawba

43 Harnett

68 Orange

93 Warren

19 Chatham

44 Haywood

69 Pamlico

94 Washington

20 Cherokee

45 Henderson

70 Pasquotank

95 Watauga

21 Chowan

46 Hertford

71 Pender

96 Wayne

22 Clay

47 Hoke

72 Perquimans

97 Wilkes

23 Cleveland

48 Hyde

73 Person

98 Wilson

24 Columbus

49 Iredell

74 Pitt

99 Yadkin

25 Craven

50 Jackson

75 Polk

100 Yancey

DEDUCTIBLE BALANCE

CODE

VALUE

   

D

Deductible Balance

EDUCATION HISTORY

CODE

VALUE

   

MM

Mail

MF

Face to Face/Individual

MP

Phone

MG

Group

EDUCATIONAL LEVEL (SEE WF700 CODES)

EPICS INDICATORS

CLAIM INDICATOR

DISQUALIFICATION INDICATOR

CODE

VALUE

CODE

VALUE

 

N

No Claims

N

No Disqualification

Y

One or more claims

W

Work First Only Disqualification

 

F

Food Assistance Only Disqualification

 

B

Both Work First and Food Assistance

REISSUED 02/01/11 – CHANGE NO. 03-11

ETHNICITY

CODE

VALUE

 

N

Not Hispanic/Latino

U

Unreported

C

Hispanic Cuban

H

Hispanic Other

M

Hispanic Mexican American

P

Hispanic Puerto Rican

FAMILY STATUS

CODE

VALUE

 
   

A

Adult

 
     
 

Only for Medicaid, Refugee, or Special Assistance/Aged, Blind, Disabled, and Medicaid/Special Assistance for the Blind and Special Assistance/Certain Disabled. Describes the applicant/casehead who is

 
 

1.

Age 19 or over

 
 

2.

Age 18-19 for whom no parental financial responsibility exists.

 
     

P

Parent (or expectantParent or expectant parent)

 
 

Only for Medicaid, Medicaid Pregnant Woman, and Refugee Assistance describes:

 
       
 

1.

The only parent in the case; or

 

2.

If both parents are in the case, the parent that is not incapacitated; or

 

3.

A stepparent who receives for his children by a previous marriage.

 

4.

Both parents if unemployed parent case and no incapacity involved.

 

5.

Family Planning (MAF-D) – Use this code if the individual has children.

 

I

Incapacitated Parent

 

Only for Medicaid and Refugee Assistance. Describes

an incapacitated parent when the other parent/stepparent is in the case.

REISSUED 02/01/11 – CHANGE NO. 03-11

FAMILY STATUS CONT’D

S

Stepparent

 

Only for Medicaid and Refugee Assistance. Describes the stepparent when:

 

1.

The parent is incapacitated and both are in the case; or

 

2.

The parent is not in the case and the stepparent is acting as the specified relative.

 

0

Other Specified Relative

 

Only for Medicaid and Refugee Assistance. Describes any specified relative other than the parent or stepparent.

Family Planning (MAF-D) – Use this code if the individual has no children.

 

N

Needy/Essential Spouse

 

Only for Medicaid.

          NOTE: MEDICAID MUST BE CATEGORICALLY NEEDY WITH

            GRANDFATHERED PROTECTION

C

Child

 

Use in any aid program/category except Special Assistance cases. Describes any individual defined as a child by the policy of the appropriate program.

 

D

Child Custodial Parent

 

Only for AAF. Describes any individual defined as a child by AAF policy who is also a parent.

            FEDERAL POVERTY LEVEL

CODE

VALUE

 

2H

Equal to or less than 100% FPL

3A

101% up through 150% FPL

4A

151% up through 200% FPL

GRANDFATHERED STATUS CODES

MEDICAID ONLY

CODE

VALUE/EFFECTIVE DATE

 

1

Money payment case in 12-73 with essential spouse/enter 0174

2

Money payment case in 12-73 without essential spouse/enter 0174

3

Medicaid only Categorically Needy - No Money Payment case in
12-73/enter 0174

4

Medicaid Only Medically Needy Case in 12-73/enter 0174

5

Grandfathered State Residence/enter 0980

REVISED 10/01/12 – CHANGE NO. 01-13

SPECIAL ASSISTANCE CASES

CODE

VALUE

 

6

Money Payment case in 12-73 (Group I)/enter 0174

GRANT RECOUPMENT (See WF700) for additional codes

CODE

VALUE

 

A

Agency Errors

V

Intentional Program Violation

H

Inadvertent household Errors

HOW APPLICATION RECEIVED

CODE

VALUE

 

A

Aging Center

D

Department of Social Services

H

Health Departments

L

Low Income Subsidy from Social Security

M

Mail

P

Prison

S

School

JOBS/WORK PARTICIPATION/EXEMPTION CODES (See WF 700 CODES)

JOBS/WORK REQUIREMENT SAVINGS CODES (See WF 700 CODES)

LANGUAGE PREFERENCE

CODE

VALUE

CODE

VALUE

CODE

VALUE

 

EN

English

HI

Hindi

PC

Portuguese Creole

SP

Spanish

HM

Hmong

PG

Portuguese

AR

Arabic

HU

Hungarian

PO

Polich

CA

Cambodian

IT

Italian

RU

Russian

CH

Chinese

JA

Japanese

SC

Serbo-Croatian

FC

French Creole

KO

Korean

TA

Tagalog

FR

French

LA

Laotian

TH

Thai

GE

German

MI

Miao

UR

Urdu

GR

Greek

MK

Mon-Khmer

VI

Vietnamese

GU

Gujarati

PE

Persian

OT

Other

LIVING ARRANGEMENT

CODE

VALUE

 

10

Private Living Arrangement (not 1/3 reduction)

11

Private Living Arrangement (with 1/3 reduction) (Medicaid Only)

12

Living with Another Work First Family

13

Living with SSI Recipient(s)

REVISED 02/01/11 – CHANGE NO. 03-11

LIVING ARRANGEMENT CONT’D

      Long-Term Care (MA)

50

Skilled Nursing Facility

58

Intermediate Care Facility

59

Intermediate Care Facility/Mental Retardation Center

60

Hospital, Over Thirty Days/Psychiatric Residential Treatment Facility (PRTF)

      State Mental Hospitals

70

Cherry Hospital

71

Dorothea Dix Hospital

72

Umstead Hospital

73

Broughton Hospital

75

Other Medical Institution

76

Central Regional Hospital

      Residential Care (SA or Foster Care)

51

Domiciliary Care, Five or Fewer Beds (SAA, SAD)

52

Domiciliary care, Six or More Beds (SAA, SAD)

53

Foster Care (MAF, MIC, HSF, IAS)

56

Adult Group Home (SAA, SAD, MAF, MRF)

57

Children's Group Home (MAF, MIC, MAF, HSF, IAS)

80

Adoptive Home (MAF, MIC, MRF, HSF, IAS)

CODE

PACE (Program of All Inclusive Care For the Elderly)

 

14

PACE Private Living Arrangement

15

PACE Living With SSI Recipient(s)

54

PACE Living in Nursing Facility

CODE

MEDICAID SUSPENSION

   

16

Medicaid suspended – Incarcerated (MAA, MAD, MIC-N, IAS, HSF, MPW, MAB, and MAF - excluding MAFD. NOTE: Exclude these Medicaid classes regardless of aid –program/category: F, H, O, R, U, or V.) program/category)

17

Medicaid suspended – Institution for Mental Diseases (IMD) (MAA, MAD, MIC-N, IAS, HSF, MPW, MAB, and MAF - excluding MAFD. NOTE: Exclude these Medicaid classes regardless of aid program/category: F, H, O, R, U, or V.)

MEDICAID CLASSIFICATION

Categorically Needy - The Medicaid Effective Date must be the first day of the month. (Authorization begins with the first day of the month all eligibility factors are met.)

REISSUED 02/01/11 – CHANGE NO. 03-11

MEDICAID CLASSIFICATION (CONT’D)

Medically Needy – The Medicaid Effective Date can by any day of the month.

(Authorization begins the date all eligibility criteria are met. In cases of excess resources and/or deductible that is the date countable resources are reduced to the resource limit or the date the deductible is met, whichever is later.)

Exception: MPW(P6)Presumptive Eligibility and Undocumented Alien Emergency Services – The Medicaid Effective Date can be any day of the month.

CODE

VALUE

B

Categorically Needy (Used only with MAABD or MQB)

C

Categorically Needy

D

Categorically Needy (Used only as MAF-D – Limited to Family Planning Services)

N

Categorically Needy- No Money Payment

Q

Categorically Needy (Used Only With Dually Eligible Cases or M-QB Cases)

F

Categorically Needy – No Money Payment – Emergency services for non-qualified aliens (includes non-immigrants and illegal and undocumented aliens)

G

Categorically Needy – No Money Payment – Full Medicaid coverage for qualified aliens (after 5 year ban or when five year ban does not apply)

H

Categorically Needy – No Money Payment – Emergency services for qualified aliens (during five year ban)

I

Categorically Needy – No Money Payment – Full Medicaid coverage for pregnant qualified alien

M

Medically Needy

X

Not applicable to the case

O

Medically Needy - Emergency services for non-qualified aliens (includes nonimmigrants and illegal and undocumented aliens)

P

Medically Needy – Full Medicaid coverage for qualified aliens (after 5 year ban or when five year ban does not apply)

R

Medically Needy - Emergency services for qualified aliens (during 5 year ban)

E

Qualifying Individual (Used Only With MQB).

1

Categorically Needy – No Money Payment (Used only as MIC-1-Expanded Medicaid) 185-200% (Under 1) 133-200% (Age 1-5)

NC HEALTH CHOICE CLASSIFICATION

CODE

NC HEALTH CHOICE VALUE

   

A

No Enrollment Fee (Federally Recognized Native Americans and Alaskan Natives/At or Below 150% FPL)

J

No Enrollment Fee

K

Enrollment Fee

L

Optional Extended Coverage

S

No Enrollment Fee (Federally Recognized Native Americans and

Alaskan Natives/Above 150% FPL)

REISSUED 07/01/10 – CHANGE NO. 0111

BREAST AND CERVICAL CANCER MEDICAID CLASSIFICATION

CODE

BCCM VALUE

   

W

Full Regular Coverage (non-alien)

T

Full Coverage (qualified alien-after 5 year ban or 5 year ban does

not apply)

U

Emergency Coverage (qualified alien-during 5 year ban)

V

Emergency Coverage (non-qualified alien; includes non-immigrant,

Illegal, and undocumented)

MEDICAID STATUS

CODE

VALUE

 

A

Authorized

D

Deductible

PATIENT MONTHLY LIABILITY

CODE

VALUE

 

P

Patient Monthly Liability

PAYMENT TYPE

CODE

VALUE

 

1

One Payment Monthly

2

Two Payments Monthly (Prior to 04-01-2000)

 

Pay-After-Performance (Effective 04-01-2000)

 

Work First Benefits (Effective 10-01-2009)

4

Four Months Continued Medicaid (Child or Spousal Support)

5

Transitional Medicaid Only

6

Retention Services Only (Obsolete 11-09-1998)

7

Transitional Medicaid and Retention Services (Obsolete 11-09-1998)

9

Medicaid only

S

Suspended Case (No longer valid 04-01-2000)

Work First Sanctioned case (Effective 01-01-2005)

REISSUED 07/01/10 – CHANGE NO. 01-11

PROVIDER CODES

AUTO ASSIGN INDICATOR

Code

Value

   

Y

Yes, PCP/HMO was assigned to the recipient

N

No, recipient chose PCP/HMO

CHANGE REASON CODES

Code

Value

   

01

Recipient moved or PCP office moved; transportation impedes access

02

Recipient’s PCP joined CA program recently

03

Third Party Insurance conflict

04

Recipient’s medical needs changed, i.e., another provider type needed

05

Recipient filed complaint against provider and desires to change

06

Recipient is linked to PCP or HMO in error

07

PCP or HMO disenrolls from program

08

Recipient is involuntarily disenrolled by PCP or HMO

09

Other (to be used for waiver tracking purposes and not lock-in)

10

Mass change – going from one PCP number to another PCP number

11

Mass change – PCP number to exempt number

12

Mass change – HMO to HMO

DISTANCE TO PCP L/M INDICATOR

Code

Value

   

L

Less than 30 miles or 45 minutes

M

More than 30 miles or 45 minutes

RACE

CODE

VALUE

 

A

Asian

 

B

Black

 

I

American Indian

 

P

Native Hawaiian or Other Pacific Islander

 

U

Unreported

 

W

White

 

REISSUED 11/01/10 – CHANGE NO. 02-11

REFUGEE STATUS CODE

CODE

VALUE (Country of Origin)

 

CODE

VALUE (Country of Origin)

         

AF

Afghanistan

 

LG

Latvia

AL

Albania

 

LI

Liberia

AO

Angola

 

MK

Macedonia

AM

Armenia

 

ML

Mali

AJ

Azerbaijan

 

MR

Mauritania

BO

Belarus

 

MX

Mexico

BN

Benin

 

MD

Moldova

BT

Bhutan

 

MW

Montenegro

BK

Bosnia & Herzegovina

 

NP

Nepal

UV

Burkina FASO (Uvolta)

 

NU

Nicaragua

BM

Burma

 

NG

Niger

BY

Burundi

 

NI

Nigeria

CB

Cambodia

 

MU

Oman

CM

Cameroon

 

PK

Pakistan

CT

Central African Republic

 

PN

Palestine

CD

Chad

 

PL

Poland

CH

China

 

RE

Reunion

CO

Columbia

 

RS

Russia

CF

Congo-Brazzaville

 

RW

Rwanda

HR

Croatia

 

SG

Senegal

CU

Cuba

 

SR

Serbia

CG

Democratic Republic of Congo (formerly Zaire)

 

SL

Sierra Leone

EG

Egypt

 

SO

Somalia

ER

Eritrea

 

SU

Sudan

ET

Ethiopia

 

TH

Thailand

GA

Gambia

 

TO

Togo

GH

Ghana

 

TU

Turkey

GV

Guinea

 

UR

USSR (old)

HA

Haiti

 

UG

Uganda

HO

Honduras

 

UP

Ukraine

IR

Iran

 

VE

Venezuela

IZ

Iraq

 

VM

Vietnam

IV

Ivory Coast

 

YM

Yemen

KZ

Kazakhstan

 

YO

Yugoslavia (old)

KE

Kenya

 

ZI

Zimbabwe

LA

Laos

 

OT

Other

RELATIONSHIP TO PAYEE (CASEHEAD)

CODE

VALUE

   

A

Spouse

B

Son

C

Daughter

D

Step Son

E

Step Daughter

F

Mother

G

Father

REISSUED 11/01/10 – CHANGE NO. 02-11

RELATIONSHIP TO PAYEE (CASEHEAD) (CONT’D)

CODE

VALUE

   

H

Mother-in-law

I

Father-in-law

J

Grandchild

K

Student

L

Self

M

Brother

N

Sister

O

Nephew

P

Niece

Q

Foster Child

R

Child Under Legal Guardianship/Custody

S

Other

(If SSI Medicaid, S-AA, or S-AD only valid code = L; If M-RF only valid codes = A or L)

SEX

CODE

VALUE

 

F

Female

M

Male

SPECIAL COVERAGE GROUP

CODE VALUE/DATE

    NOTE: The “UP” code is no longer valid for MAF effective 08/01/1999, or for AAF effective 10/01/2005.

    Case-Applicable to S-AA and S-AD Cases

LT Special Assistance Cases Awaiting a Higher Level of Care: Enter the six digit begin date that the FL-2/MR-2 is received recommending the higher level of care. Enter the six digit end date when an Fl-2/MR-2 is received indicating the recipient's condition has improved, and domiciliary care remains the appropriate level of care.

    Community Alternative Program

AI-CAP/AIDS ICF-Obsolete 12/31/06

HC-CAP/Children Hospital-eff.11/01/95

AS-CAP/AIDS SNF-Obsolete 12/31/06

SC-CAP/Children SNF-effective 11/01/95

CI-CAP/DA ICF level of care

IC-CAP/Children ICF-Obsolete 08/01/10

CS-CAP/DA SNF level of care

CC-CAP/Children-prior to 11/01/95

CM-CAP-MR/DD ICF MR level of care (Comprehensive Waiver)

    C2-CAP-MR/DD ICF MR level of care (Supports Waiver) effective 11/01/08

REVISED 02/01/11 – CHANGE NO. 03-11

SPECIAL COVERAGE GROUP (CONT’D)

ID-CAP CHOICE ICF level of care-in Duplin and Cabarrus counties – eff. 01/01/2005; in Forsyth and Surry counties – eff. 08/01/2007. Statewide eff. 01/01/2011

SD-CAP CHOICE SNF level of care-in Duplin and Cabarrus counties – eff. 01/01/2005; in Forsyth and Surry counties eff. 08/01/2007. Statewide eff. 01/01/2011

SPECIAL NEEDS

Code

Definition

Aid progam/category

 

1

SSI children and other disabled children who are not SSI eligible

MAD

MAB

SAD

EIS inserts special needs code 1

2

In foster care or other out-of-home placement

HSF

EIS inserts special needs code 2

2

In foster care or other out-of-home placement

MIC/MAF

Worker entry

3

Receiving foster care or adoption assistance

IAS

EIS inserts special needs code 3

3

Receiving adoption assistance

MIC/MAF

Worker entry

4

Self-identified

All except MAA and MQB

Worker entry

SPECIAL REPORTING

CODE

VALUE

 

U

Principal Wage Earner (No longer valid for MAF effective 08/01/1999, or for AAF effective 10/01/2005)

M

Minor Mother

I

Indian on Reservation

P

Passalong (Obsolete as of 12/02/2002)

L

Legally Designated Unearned Income

E

Employed

D

Disabled individual

C

Caretaker of deprived, dependent child (parent is only person in the case; child receives SSI)

REVISED 02/01/11 – CHANGE NO. 03-11

SPECIAL REVIEW

CODE

VALUE

DATE TO ENTER

1

Delete 1/3 disregard

Month and year disregard is to end

2

Income to begin

Month and year income to begin

3

Income to change

(include receipt of

seasonal income)

Month and year income to change

4

Income to end

Month and year income to end

5

Medical review

Month and year review is due

6

Reserve to increase

Month and year reserve to increase

7

Social Security/SSI

(follow-up to application)

Month and year 90 days following application for Social Security/SSI

8

Follow-up to temporary age determination

 

9

Follow-up to projected date of final order of adoption

Month and year review is due

A

Adoptive child reaches age 18

Month and year case is to be terminated

B

Baby Due

Month and year baby is due

C

Review for contributions

Month and year review is due

D

Delete $30 disregard

Month and year disregard is to end

E

Earned income, disregard ends

Month and year the earned income disregard ends

(Obsolete as of 08/16/03)

F

Disregard of full-time student's income ends

Month and year 6 months exclusions of earned income ends

G

Grant Recoupment Ends

Month and year Grant Recoupment Ends

H

Hardship Exemption Ends

Month and Year Hardship Exemption Ends (See WF700)

I

IV-E Foster Care child reaches age 19

Month and year case is to be terminated (Obsolete as of 11/22/2010)

J

Job Bonus Ends

Month and year that Job Bonus Ends Obsolete as of 11/6/00)(See WF700)

K

Work Exemption To End MMCCYY

Month and year work exemption is to end

L

Review for Living With

Month and year review is due

M

Review for Sale of Property

Month and year review is due

P

Evaluate Work First Benefits

Month and year to be evaluated

Q

Eval for sanction ending MMCCYY

Month and year to be evaluated

R

Real Prop Exclusion Ends

Month and year Real Property Exclusion from Reserve Ends

REVISED 02/01/11 – CHANGE NO. 03-11

SPECIAL REVIEW (CONT’D)

S

FL-2/MR-2 due

Month and year level of care review is due

T

Transitional to Terminate

Month and year transition period ends

U

Medicare Eligible

Month and year Medicare begins

V

Verify Current Alien Status

Month and year verification is due

W

Review for Work Registration

Month and year review is due

X

Rev Disqualification

Month and year review is due

Y

Review of Countable Resource

Month and year review is due

Z

Citizenship/Identity Due

Month and year documentation is due

DR

Delete Authorized Representative (Applicable to SAA/SAD and Medicaid cases only)

Month and year review is due

SPECIAL REVIEW CODES APPLICABLE TO SAA/SAD CASES WITH SSI INCOME AND THE TOTAL COUNTABLE MONTHLY INCOME (TCMI) IS LESS THAN THE FEDERAL BENEFIT RATE(FBR)

CODE

VALUE

DATE TO ENTER

E

SSI 1/3 reduced ending (Effective 11/22/2010)

Month and year review is due

I

SSI In-Kind support/maint ending(Effective 11/22/2010)

Month and year review is due

N

SSI Couple deeming (Valid only with Ambulation Capacity Code ‘H’)

Month and year review is due

RS

SSI/SS recoupment

Month and year review is due

LI

Life Insurance cash accruing face value greater than $1500.

Month and year review is due

VA

VA only or SSI/VA only

Month and year review is due

SPECIAL REVIEW CODES (APPLICABLE TO SAA/SAD CASES WITH COMBINATION OF INCOME (RSDI, SSI, VA, etc)AND THE TOTAL COUNTABLE MONTHLY INCOME IS LESS THAN THE FEDERAL BENEFIT RATE:

CODE

VALUE

DATE TO ENTER

E

SSI 1/3 reduced ending

Month and year review is due

I

SSI In-Kind support/maint ending

Month and year review is due

N

SSI Couple deeming (Valid only with Ambulation Capacity Code ‘H’)

Month and year review is due

RS

SSI/SS recoupment

Month and year review is due

LI

Life Insurance cash accruing face value greater than $1500.

Month and year review is due

VA

VA only or SSI/VA only

Month and year review is due

REISSUED 02/01/11 – CHANGE NO. 03-11

SPECIAL USE DATA

CODE

VALUE/DATE

 
 
 

Case - Applicable to H-SF only.

 

*HS

Prior to conversion 3/1/90, this case was in aid program/category H-SF. Child in foster care.

 

*PS

Prior to conversion 3/1/90, this case was in aid program/category P-SF. Child in adoptive placement.

 

*MR

Prior to conversion 3/1/90, this case was in aid program/category M-RC. Child in county custody.

 

*PR

Prior to conversion 3/1/90, this case was in aid program/category P-RC. Child in adoptive placement.

 
 

Case - Applicable to I-AS and H-SF only.

 

FC

Enter for out-of-state foster care children along with the two digit alpha code for the state from which a child was placed in North Carolina. Refer to EIS 4050, III.

   

AS

Enter for out-of-state adoption assistance children along with the two digit alpha code for the state from which a child was placed in North Carolina. Refer to EIS 4050, III.

 

Case - Applicable to I-AS only.

   

IF

Child in foster care. Enter the six digit date Medicaid eligibility begins.

   
 

Case – Applicable to SAA and SAD only.

   

LI

Life Insurance Face Value Over $1500

REISSUED 02/01/11 – CHANGE NO. 03-11

SPECIAL USE DATA (CONT’D)

 
 

Case - Applicable to M-AF only.

 

*MR

Prior to conversion 3/1/90, this case was in aid program/category M-RC or P-RC. Child in long-term care.

 

*THIS IS A SYSTEM CODE GENERATED AT 3/1/90 CONVERSION. DO NOT ENTER.

 
 

Case - Applicable to M-PW only cases dispositioned with codes “P1”, “P2”, “P3”, “P4”, or “P6”.

   

PT

Provider Referred Timely: Enter the seven digit provider number preceded with zeroes.

PL

Provider Referred Late: Enter the seven digit number preceded with zeroes.

 
 

Individual

   

SN

No longer valid. Effective 6/4/2001 Special Needs information is entered in the Individual Special Needs field.

   
 

Individual - Aliens

   

CH

Qualified alien under age 19 for whom the 5 year ban of Medicaid eligibility does not apply. Enter the code “CH” along with the six digit month and year (MMCCYY) that eligibility begins and the six digit month and year (MMCCYY) that the child turns 19. The end date includes the month of the 19th birthday.

   

P1

1st pregnancy – Qualified alien who is pregnant for whom the 5 year ban of Medicaid eligibility does not apply. Enter the code “P1” along with the six digit month and year (MMCCYY) that eligibility begins and the six digit month and year (MMCCYY) that the postpartum period ends for the individual’s first pregnancy authorized under Medicaid.

   

P2

2nd pregnancy – Qualified alien who is pregnant for whom the 5 year ban of Medicaid eligibility does not apply. Enter the code “P2” along with the six digit month and year (MMCCYY) that eligibility begins and the six digit month and year (MMCCYY) that the postpartum period ends for the individual’s second pregnancy authorized under Medicaid.

REISSUED 02/01/11 – CHANGE NO. 03-11

SPECIAL USE DATA (CONT’D)

P3

3rd pregnancy – Qualified alien who is pregnant for whom the 5 year ban of Medicaid eligibility does not apply. Enter the code “P3” along with the six digit month and year (MMCCYY) that eligibility begins and the six digit month and year (MMCCYY) that the postpartum period ends for the individual’s third pregnancy authorized under Medicaid.

P4

4th pregnancy – Qualified alien who is pregnant for whom the 5 year ban of Medicaid eligibility does not apply. Enter the code “P4” along with the six digit month and year (MMCCYY) that eligibility begins and the six digit month and year (MMCCYY)that the postpartum period ends for the individual’s fourth pregnancy authorized under Medicaid.

   

P5

5th pregnancy – Qualified alien who is pregnant for whom the 5 year ban of Medicaid eligibility does not apply. Enter the code “P5” along with the six digit month and year (MMCCYY) that eligibility begins and the six digit month and year (MMCCYY) that the postpartum period ends for the individual’s fifth pregnancy authorized under Medicaid.

   

P6

6th pregnancy – Qualified alien who is pregnant for whom the 5 year ban of Medicaid eligibility does not apply. Enter the code “P6” along with the six digit month and year (MMCCYY) that eligibility begins and the six digit month and year (MMCCYY) that the postpartum period ends.

   
 

Individual – Hurricane Certification Period Extensions

   

AL

Hurricane Katrina (DMA Administrative Letter No. 11-05)

F1

Hurricane Frances (DMA Administrative Letter No. 03-05)

FL

Hurricane Floyd (DMA Administrative Letter No. 12-00, Addendum 2)

I1

Hurricane Isabel-1st extension(DMA Administrative Letter No. 04-04)

I2

Hurricane Isabel-2nd extension(DMA Administrative Letter No. 04-04, Addendum 1)

LA

Hurricane Katrina (DMA Administrative Letter No. 11-05)

LR

Hurricane Rita (DMA Administrative Letter No. 11-05)

MS

Hurricane Katrina (DMA Administrative Letter No. 11-05)

TX

Hurricane Rita (DMA Administrative Letter No. 11-05)

   
 

Individual - IEVS

 

CR

Enter the code “CR” along with the six digit date you are completing the data entry form. The code “CR” is used when an applicant/recipient has presented his social security card as verification of his number.

 

SS

Enter the code “SS” along with the six digit date the SS-5 or the DSS-8174 is submitted.

REISSUED 02/01/11 – CHANGE NO. 03-11

SPECIAL USE DATA (CONT'D)

 

VM

Enter the code “VM” along with the six digit date of the Enumeration Data Sheet or the date you resolve any discrepancy due to an invalid welfare ID on the Enumeration Error Report or a discrepancy in name, date of birth and/or sex from the report of social security numbers sent for revalidation.

 

VB

Enter the code “VB” along with the six digit date you are completing the data entry form. The code “VB” indicates a social security number verified by BENDEX or Third Party Query.

   

VC

Enter the code “VC” along with the six digit date you are completing the data entry form. The code “VC” indicates a social security number verified by MCI when a “V” is present on the validation screen.

 

VS

Enter the code “VS” along with the six digit date your are completing the data entry form. The code “VS” indicates a social security number verified by SDX.

   
 

Individual - Medical Coverage Groups

 

NB

Newborn: Enter the six digit date coverage under this group begins and the last day of the month the child becomes one year old or the date coverage ends.

   

B1

(HCWD) Health Coverage for Workers with Disabilities-Basic Coverage Group – Equal to or less than 150% Federal Poverty Level. Effective May 1, 2009, B1 is obsolete as an individual Special Use indicator and was converted in EIS to a Sub Program indicator on the Medicaid Eligibility (IE) segment.

   

M5

(HCWD) Health Coverage for Workers with Disabilities-Medically Improved Coverage Group – Equal to or less than 150% Federal Poverty Level. Effective May 1, 2009, M5 is obsolete as an individual Special Use indicator and was converted in EIS to a Sub Program indicator on the Medicaid Eligibility (IE) segment.

   
 

Individual – Passalong (Dates Not Required)

   

PC

Passalong Cola

PD

Passalong Disabled Adult Child (DAC)

PW

Passalong Widow(er)

   

REISSUED 02/01/11 – CHANGE NO. 03-11

          SPOUSE INDICATOR (Valid Only For MAA, MAB, MAD and MQB)

CODE

VALUE

 

Y

Yes (There is a spouse in the home or community spouse for LTC)

N

No (There is not a spouse in the home or community spouse for LTC)

STEPPARENT INDICATOR

(Financially Responsible Adults)

The following codes apply only to RRF, MAF, MIC, and MRF.

CODE

VALUE

 

0

No financially responsible adult other than those included in the case

1

Stepparent with earned income

2

Stepparent with no earned income

3

Parent or legal guardian of a minor parent with earned income

4

Parent or legal guardian of a minor parent with no earned income

5

Other financially responsible adult with earned income

6

Other financially responsible adult with no earned income

SUB PROGRAM

CODE

VALUE

 

B1

(HCWD) Health Coverage for Workers with Disabilities–Basic Coverage Group-Equal to or less than 150% Federal Poverty Level

M5

(HCWD) Health Coverage for Workers with Disabilities-Medically Improved Group-Equal to or less than 150% Federal Poverty Level

B2

(HCWD) Health Coverage for Workers with Disabilities-Basic Coverage Group-151% through 200% Federal Poverty Level. (Suspended Effective 12/1/09).

M6

(HCWD) Health Coverage for Workers with Disabilities-Medically Improved Group-151% through 200% Federal Poverty Level. (Suspended Effective 12/1/09).

MF

Money Follows the Person for CAPMR, CAPDA, CAP Choice, PACE individuals transitioning from institutional care into a qualified residence in the community

REISSUED 02/01/11 – CHANGE NO. 03-11

SUBSTITUTE PAYEE

CODE

VALUE

 

10

Legal Guardian

11

Personal Representative

12

Payee for Protective Payment

13

Trustee

14

Clerk of Superior Court (Name of Clerk)

      NOTE: WHEN A SUBSTITUTE PAYEE IS ENTERED ON THE DSS-8125, THE SUBSTITUTE PAYEE NAME AS WELL AS THE CASEHEAD/PAYEE NAME IS PRINTED ON THE CHECK.

VETERAN ASSISTANCE PAYMENT STATUS

CODE

VALUE

 

Y

Yes (receiving VA benefits)

N

No (not receiving VA benefits)

WORK EXPERIENCE (See WF 700 CODES)

WORK FIRST CHILD ONLY CASE REASON CODES (See WF 700 CODES)

Top Of Page

II. DMA-2041 CODES

INSURANCE TYPE

CODE

VALUE

 

00

Major Medical

01

Basic Hospital Surgical

02

Basic Hospital

03

Dental

04

Cancer

05

Accident

06

Indemnity

07

Nursing Home

08

Medicare Supplement

10

Major Medical and Dental

11

Major Medical and Nursing Home Coverage

12

Intensive Care Coverage

13

Hospital Outpatient Only Coverage

14

Physician Only Coverage

15

Heart Attack Only Coverage

16

Prescription Drugs Only Coverage

17

Vision Care Coverage

REISSUED 02/01/11 – CHANGE NO. 03-11

RELATIONSHIP

CODE

VALUE

 

A

Spouse

B

Son

C

Daughter

D

Step Son

E

Step Daughter

F

Mother

G

Father

H

Mother-in-law

I

Father-in-law

J

Grandchild

K

Student

L

Self

M

Brother

N

Sister

O

Nephew

P

Niece

Q

Foster Child

THIRD PARTY INSURANCE COMPANIES ADDRESSES AND CODES

A listing of insurance company names, addresses, and codes is available online. For inquiry procedures, refer to Third Party Recovery Inquiry,
EIS 1055
. If you have any questions regarding a specific company or code that is not listed, contact TPR at the Division of Medical Assistance. Refer to
EIS 1200
for State Office contact information.

Top Of Page

III. DMA-5022 CODES

SECTION B

CODE

VALUE

 

DB

Deductible Balance Amount

PML

Patient Monthly Liability Amount

Pay Type

Payment type on the case for the period of time for which Medicaid is authorized

REISSUED 02/01/11 – CHANGE NO. 03-11

SECTION C

AMBULATION CAPACITY (AMB.CAP.)

CODE

VALUE

 

A

Ambulatory (1995 Disenfranchised)

S

B

H

D

C

Semi-Ambulatory (1995 Disenfranchised)

Basic SA (Non-Disenfranchised)

In Home Program

2003 Disenfranchised

SA/ACH Special Care Unit

E

Basic SA (Exempt)

CATEGORY OF ASSISTANCE (CAT OF ASST)

CODE

VALUE

 

A

Regular Work First Child Care

B

Work First UP Child Care (Effective 10/01/2005, the UP code is no longer valid for AAF)

C

Regular Work First JOBS Child Care

D

Work First UP JOBS Child Care (Effective 10/01/2005, the UP code is no longer valid for AAF)

E

Transitional Child Care

F

Regular Work First

G

Work First UP (Effective 10/01/2005, the UP code is no longer valid for AAF)

CODE

CODE

VALUE

 

I

Indian On A Reservation

R

Refugee

LEVEL OF CARE (LVL OF CARE)

CODE

VALUE

   

1

Center

2

Family Day Care Home

3

Care provided by a relative - in child's home

4

Care provided by a non-relative - inside child's home

5

Care provided by a relative - outside child's home

ISSUED 02/01/11 – CHANGE NO. 03-11

TYPE

STATE ISSUED CHECKS

CODE

VALUE

 

2

Adjusted Payment

3

Prior Month Request

5

SA Partial Payment Request

8

State Alexander V. Hill Penalty (Obsolete as of 05/02)

9

County Alexander V. Hill Penalty (Obsolete as of 05/02)

COUNTY ISSUED CHECKS

CODE

VALUE

 

6

Adjusted Payment

7

Regular Issue Request

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