NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 4200

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SSI MEDICAID-APPLICATIONS - PART SEVEN

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EIS 4200 – SSI MEDICAID-APPLICATIONS PART SEVEN


I. MAABD-RETROACTIVE TO SSI MONTH OF APPLICATION

II. FAMILY AND CHILDREN MEDICAID RETROACTIVE TO SSI MONTH OF APPLICATION

III. REAPPLICATION WHEN SSI TERMINATES


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EIS 4200 – SSI MEDICAID-APPLICATIONS
PART SEVEN

REVISED 10/01/02 - CHANGE NO. 02-03

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I. MAABD-RETROACTIVE TO SSI MONTH OF APPLICATION

REVISED 10/01/02 - CHANGE NO. 02-03

I.(CONT'D)

REVISED 10/01/02 - CHANGE NO. 02-03

I.C. (CONT'D)

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II. FAMILY AND CHILDREN MEDICAID RETROACTIVE TO SSI MONTH OF APPLICATION

REISSUED 10/01/02 - CHANGE NO. 02-03

II.(CONT’D)

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

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III. REAPPLICATION WHEN SSI TERMINATES

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

III. (CONT'D)

REISSUED 09/01/06 - CHANGE NO. 02-07

III. (CONT’D)

REVISED 09/01/06 - CHANGE NO. 02-07

REVISED 10/01/02 - CHANGE NO. 02-03

 

MAABD-RETRO TO SSI MONTH OF APPLICATION

8124

1 part, new application (Type 1)

8124 DOA

Day applicant/representative applies at DSS

APC

MAA, MAB, MAD

IF MAD N

N in retro DIS/DET field, if disability is already established

IF MAD Y

Y in retro DIS/DET field, if disability must be established

   

DATE SCREEN

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RETRO DATE

SCREEN

Yes

ONGOING DATE

SCREEN

No

RSDI or SSI

APPEAL

REVERSAL/SSI

APPL

S

ORIG DATE OF

APP

SSI Date of Application

EXCL RSN CDE

Exclusion Reason Code, if appropriate

BEGIN DTE

If EXCL RSN CDE entered

END DTE

If EXCL REASON CDE and BEGIN DATE are entered, enter END DATE before disposition.

DDS REQ.

Brought forward from 8124, if MAD-

Enter Y, if needed and not present.

   

8125

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8125

DISPOSITION

Retro disposition reason and date

CASE TERM.

Term date must be last day of month before month of SSI app

MED EFF DATE

No

CP FROM

No

CP THRU

No

MED CLASS

No

RETRO MA 1

Begins with 1st month of eligibility and ends with last month of determined eligibility

MED CLASS

N or M

RETRO MA 2

If Needed

   

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