NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 4300

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NC HEALTH CHOICE APPLICATION DISPOSITIONS - PART FOUR

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EIS 4300 - NC HEALTH CHOICE APPLICATION DISPOSITIONS – PART FOUR


I. DENYING AN APPLICATION

II. WITHDRAWING AN APPLICATION

III. APPROVING THE APPLICATION

IV. ADD-ON APPLICATION APPROVALS


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EIS 4300 - NC HEALTH CHOICE APPLICATION DISPOSITIONS – PART FOUR

REVISED 07/01/06 – CHANGE NO. 01-07

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I. DENYING AN APPLICATION

REISSUED 07/01/06 – CHANGE NO. 01-07

I. G. (CONT’D)

ISSUED 10/01/98 – CHANGE NO. 7-99

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II. WITHDRAWING AN APPLICATION

ISSUED 10/01/98 – CHANGE NO. 7-99

II. G. (CONT’D)

REVISED 03/01/10 – CHANGE NO. 03-10

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III. APPROVING THE APPLICATION

REISSUED 03/01/10 – CHANGE NO. 03-10

III. (CONT’D)

REVISED 10/01/12 – CHANGE NO. 01-13

III. G. 1. (CONT’D)

REVISED 10/01/12 – CHANGE NO. 01-13

III. (CONT’D)

REVISED 12/01/03 – CHANGE NO. 04-04

III. K. (CONT’D)

      5. Enter MEDICAID CLASS. The valid classifications are as follows:
        a. “A” - Cases with income 150% or less of the poverty income level and are members of a Federally Recognized Native American Tribe or Alaskan Native.
        b. “J” - Cases with income of 150% or less of the Federal Poverty Income Level.
        c. “K” - Cases with income in excess of 150% up to 200% of the Federal Poverty Income Level.
        d. “S” - Cases with income in excess of 150% up to 200% of the poverty income level and are members of a Federally Recognized Native American Tribe or Alaskan Native.
        e. “L” – as an optional extended coverage for cases with income in excess of 200% up to 225% of the poverty income level.

        NOTE: “L” CAN ONLY BE USED WHEN REOPENING A NCHC CASE THAT CLOSED DUE TO THE FAMILY NOT RETURNING THE REENROLLMENT FORM TIMELY BUT DID RETURN IT WITHIN THE FIRST 10 DAYS OF THE FOLLOWING MONTH AND IS NOW DETERMINED TO BE ELIGIBLE FOR THE EXTENDED COVERAGE.

        ONLY INDIVIDUALS ON THE CASE AT TERMINATION CAN BE APPROVED IF REOPENING INTO “L”.

      6. Do not enter DEDUCTIBLE BALANCE/PATIENT MONTHLY LIABILITY (DB/PML) Type or DB/PML AMOUNT.

    L. Earned Income (IF ZERO, LEAVE BLANK)

      The amounts must be dollar and cents.

      1. Enter the GROSS EARNED INCOME.
      2. Enter the WORK EXPENSES.
      3. Enter CHILD/ADULT CARE.
      4. Do not enter DISREGARD.
      5. Enter the NET EARNED INCOME.
      6. Do not enter GRANT RECOUPMENT CODE, AMOUNT or END DATE.

REISSUED 12/01/03 – CHANGE NO. 04-04

III. (CONT’D)

    M. Unearned Income (IF ZERO, LEAVE BLANK)

      The amounts must be dollar and cents.
      1. Enter the RSDI AMOUNT. If entered, RSDI CLAIM NUMBER is required.

      2. Enter the TOTAL NET UNEARNED INCOME.

    N. Needs

      1. Enter the MAINTENANCE AMOUNT. The amount must be a whole dollar amount. The amount must be more than or the same as the TOTAL COUNTABLE MONTHLY INCOME.
      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. This is a critical field as this determines the amount of co-payments the family is responsible for paying.

    O. Special Data

      1. Enter the FOOD STAMP NUMBER if known.
      2. Mark “YES” or “NO” for VA PAYMENT.
      3. Enter SPECIAL REVIEW TYPE and DATE if needed.
        a. If entered, the DATE must be after the ongoing month.
        b. Not allowed for Open/Shut approvals.
        c. See the Codes Appendix to determine the appropriate special review code and date.
      4. Do not enter JOBS/WORK REGISTRATION/EXEMPTION data.
      5. Enter SPECIAL USE CODE and DATA if needed. This is not allowed for Open/Shut approvals. See the Codes Appendix for codes and date information.

    P. Do not enter Special Coverage Group Data.

REVISED 10/01/12 – CHANGE NO. 01-13

III. (CONT’D)

    Q. Individual Data

      The casehead name and the individual data for the individual(s) included on the case is 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 corrections.

      EIS requires children in the household who are eligible for NC Health Choice to be on the same case in EIS even if they are budgeted separately. This does not apply to individuals eligible for Optional Extended Coverage (L class).

      Enter the following data:

      1. Enter the INDIVIDUAL TERMINATION DATE if an individual is not eligible in the ongoing case.
        a. Do not enter if there is only one individual on the case.
        b. This date must be the last day of the month of eligibility.
        c. This date may be the date of application. This should only be entered if an individual is on the application but should not be included on the case.
        d. This date must be before or the same as the current calendar month.
        e. If DATE OF DEATH is entered, do not enter.
      2. Do not enter CASE STATUS. EIS automatically enters “C”.
      3. Enter the RSDI CLAIM NUMBER if the individual has Social Security benefits.
      4. Enter “N” in MEDICARE A & B fields.
      5. Do not enter FAMILY STATUS. EIS generates.
      6. Enter a LIVING ARRANGEMENT CODE. This code must be the same for all individuals on the case. See the Codes Appendix in EIS 4000 to determine the appropriate living arrangement code.
      7. Do not enter SPECIAL REPORT CODE.

REISSUED 10/01/12 – CHANGE NO. 01-13

III. Q. (CONT’D)

      8. Do not enter JOBS/WORK REGISTRATION/EXEMPTION.
      9. Enter SPECIAL USE DATA CODE and DATA if needed. Do not enter if the approval is Open/Shut. See the Codes Appendix in EIS 4000 to determine the appropriate special use code and dates.
      10. Do not enter REFUGEE STATUS CODE and U.S. ENTRY DATE.
      11. Enter DATE OF DEATH, if applicable.
        a. If the deceased is the only individual in the case, CASE TERMINATION REASON 52 is required if the date of death is entered.
        b. The DATE OF DEATH must be before or the same as the CASE TERMINATION DATE.
        c. The DATE OF DEATH must be less than or equal to the current date.
      12. Enter CITIZEN/ID code and date.
      13. Do not enter JOBS/WORK REGISTRATION/EXEMPTION data.
      14. Do not enter WORK EXPERIENCE.
      15. Do not enter GROSS EARNED INCOME.
      16. Do not enter WORK EXPENSES.
      17. Do not enter CHILD/ADULT CARE.
      18. Do not enter NET EARNED INCOME.
      19. Do not enter EDUCATIONAL LEVEL.

      NOTE: WHEN THERE IS MORE THAN ONE INDIVIDUAL, USE A DSS-8126 AS A CONTINUATION OF THE DSS-8125 TO ENTER INDIVIDUAL DATA. If there are three or more individuals, use a second DSS-8126.

    R. Signatures and Date

      1. Enter DATE COMPLETED and WORKER’S SIGNATURE field if using a paper form.
      2. The county director or his designee must sign the form in the DIRECTOR'S SIGNATURE field if using a paper form.

    S. Key the DSS-8125 and DSS-8126's.

REVISED 10/01/12 – CHANGE NO. 01-13

III. (CONT’D)

    T. Output

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

      1. Benefits Issued

        The Division of Medical Assistance (DMA) will issue a NC Health Choice identification card to each eligible recipient at the initial application approval; when a replacement card is request; and on the one year anniversary of the last card issuance date. Additionally, certain individual and case changes automatically generate at the issuance of a replacement card. Refer to EIS 3000

        NOTE: The Division of Medical Assistance (DMA) WILL NOT ISSUE AN IDENTIFICATION CARD FOR “L” CASES. IF RECIPEINTS PAY THE MONTHLY PREMIUMS, THE ORGINIAL NCHC CARD MUST BE USED TO VERIFY ELIGIBILITY.

      2. Case Profile

        EIS produces a Case Profile the night the approval processes. The profile is mailed to the county the following workday.

    U. Caseworker Supervisor Report

      The application approval is reported on the Caseworker Supervisor Report. The number of approvals completed is determined from the WORKER NUMBER. Cases approved for NC Health Choice appear as M-IC on the Caseworker Supervisor Report.

    V. Automated Notices

      1. EIS produces an automated notice (DSS-8108A) for each NC Health Choice approval the night the DSS-8125 processes in the system.
      2. The DISPOSITION REASON CODE entered on the DSS-8125 determines the text of the notice.
      3. EIS calculates the 60th calendar day for the notice.
      4. The date of the automated notice is the next county workday after the DSS-8125 processes. This is the date the notice is mailed to the recipient. A copy of the notice is not mailed to the county.

REISSUED 10/01/12 – CHANGE NO. 01-13

III. V. 5. (CONT’D)

      5. A Notice Register Report is produced each night and is mailed to the county the following workday. NC Health Choice cases appear as M-IC on the Notice Register Report. 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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IV. ADD-ON APPLICATION APPROVALS

    A. General Information

      Use these instructions to complete the DSS-8125 screen. Ensure the fields HOW APP RECEIVED and HLTH CH? are completed on the DSS-8124 before approving the application.

      NOTE: For keying instructions, see EIS 4900, Appendix B.

    B. EIS retains data previously entered on the DSS-8124 screen. This information is brought forward on the DSS-8125 at application approval. For this reason, most of the information entered on the DSS-8124 screen need not be re-entered when the application is approved.

    C. Use the NAME CHANGE screen to change or correct the following data before keying the DSS-8125 for approval:

      1. Name
      2. Social Security Number
      3. Date of Birth
      4. Sex
      5. Race

    D. Use the DSS-8124 screen to correct the following items before keying the DSS-8125 for approval.

      1. County Number
      2. Aid Program/Category
      3. Individual ID Number
      4. How App Received
      5. Health Choice indicator

REVISED 03/01/10 – CHANGE NO. 03-10

IV. D. (CONT’D)

      6. The “Z” (Citizenship) Code

        If there is a change of payee, see EIS-3101, Making Changes to Medicaid Applications. Other data may be changed or corrected on the DSS-8125 at approval.

    E. A DMA-2041 is required when an applicant/recipient has health and/or accident insurance other than comprehensive health insurance. For example, a child is covered with dental insurance. This insurance must be reported to TPR.

      Refer to EIS 3350, Instructions for Third Party Health and Accident Resources Information (DMA-2041).

    F. Completing the DSS-8125 screen

      If a numeric field requires less digits than spaces available, precede with zeroes.

      1. CASE IDENTIFYING INFORMATION
        a. Do not enter the CASE ID. The CASE ID is brought forward from the application and may not be changed.
        b. Enter your WORKER NUMBER.
        c. Enter your COUNTY NUMBER.
        d. Enter the COUNTY CASE NUMBER.
        e. Enter the DISTRICT NUMBER.
        f. Do not enter COUNTY REASSIGNMENT NEW COUNTY.
        g. Do not enter COUNTY REASSIGNMENT EFFECTIVE DATE.
        h. Enter “M” “IC” for AID PROGRAM/CATEGORY. If a change is needed, it must be entered on the DSS-8124 screen before approval is keyed.
        i. Do not enter CASEHEAD/PAYEE NAME. If there is a change in Casehead/payee, refer to EIS 3101.
        j. Enter ADDRESS LINE 1 if different than indicated on the Application Turnaround. See the Mailing Address Appendix to determine the correct abbreviations.

REISSUED 03/01/10 – CHANGE NO. 03-10

IV. F. (CONT’D)

        k. Enter ADDRESS LINE 2 if different than indicated on the Application Turnaround. See the Mailing Address Appendix to determine the correct abbreviations.

          NOTE: Do NOT use a “#” sign in the address for NC Health Choice cases. Any data following this sign is deleted.

        l. Enter the CITY, STATE, and ZIP CODE if different than indicated on the Application Turnaround. See the Mailing Address Appendix to determine the correct abbreviations.

          NOTE: A NC Health Choice case MUST have a North Carolina address. If any other State is entered, an error message displays.

        m. Enter the casehead/payee's three-digit area code and seven-digit PHONE NUMBER if applicable.
        n. Enter a VERIFICATION INDICATOR to indicate if all eligibility factors have been verified.

          “Y” = YES “N” = NO

        o. Enter SUBSTITUTE PAYEE CODE and NAME if a substitute payee has been appointed to the case. See the Codes Appendix in EIS 4000 to determine the appropriate substitute payee code.
        p. Enter the number of individuals in the NEEDS UNIT. This field is used as an edit to assure the correct maintenance allowance has been entered based on the number of persons in the budget unit and that their income does not exceed the maintenance amount.
        q. Do not enter a CHANGE CODE.

    G. Application Data

      1. Enter the APPLICATION NUMBER from the Application Turnaround.
      2. Enter the ONGOING DISPOSITION REASON and DATE. RETRO disposition is not valid for NC Health Choice. See EIS 4300, Part Six, to determine the appropriate disposition reason code. It is very important to enter the correct disposition code as the automated notice is produced based on the reason entered on the DSS-8125. The disposition reason code determines the text of the notice.

REISSUED 03/01/10 – CHANGE NO. 03-10

IV. H. (CONT’D)

    H. Case Termination Data

      If approving the case in terminated status (Open/Shut), enter the CASE TERMINATION REASON and DATE. The date must be the last day of the CERTIFICATION THRU month. See EIS 4300, Part Six, to determine the appropriate termination reason code.

    I. DO NOT ENTER PAYMENT DATA.

    J. Medicaid Data

      1. Enter MEDICAID STATUS “A”.
      2. Enter MEDICAID EFFECTIVE DATE. BCBS will calculate the enrollment period based upon the MEDICAID EFFECTIVE DATE of the add-on approval and the thru date of the existing case.
        a. This date must be the first month of NC Health Choice eligibility for each individual being added.
        b. This date must not be before 10/1/98.
        c. This date must be before or the same as CASE TERMINATION DATE if CASE TERMINATION DATE is entered.
      3. Do not enter the CERTIFICATION PERIOD FROM and THRU dates.
      4. Enter MEDICAID CLASS. The Medicaid class MUST match the classification on the current case.
      5. Do not enter DEDUCTIBLE BALANCE/PATIENT MONTHLY LIABILITY (DB/PML) Type or DB/PML AMOUNT.
      6. Do not enter RETRO MA 1 or RETRO MA 2.

    K. Earned Income

    Do not enter earned income.

    L. Unearned Income

      Do not enter unearned income.

    M. Needs

      1. Enter the MAINTENANCE AMOUNT. The amount must be a whole dollar amount. The amount must be more than or the same as the TOTAL COUNTABLE MONTHLY INCOME.

REISSUED 02/01/02 – CHANGE NO. 07-02

IV. M. (CONT’D)

      2. Do not enter AMBULATION CAPACITY.
      3. Do not enter DOMICILIARY RATE.
      4. Do not enter TOTAL COUNTABLE MONTHLY INCOME.

    N. Special Data

      1. Do not enter the FOOD STAMP NUMBER.
      2. Mark “YES” or “NO” for VA PAYMENT.
      3. Enter SPECIAL REVIEW TYPE and DATE if needed.
        a. If entered, the DATE must be after the ongoing month.
        b. Not allowed for Open/Shut approvals.
        c. See the Codes Appendix to determine the appropriate special review code and date.
      4. Do not enter JOBS/WORK REGISTRATION/EXEMPTION data.
      5. Enter SPECIAL USE CODE and DATA if needed. This is not allowed for Open/Shut approvals. See the Codes Appendix for codes and date information.

    O. Do not enter Special Coverage Group Data.

    P. Individual Data

      The casehead name and the individual data for the individual(s) included on the case is 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 corrections.

      EIS requires all children in the household who are eligible for NC Health Choice to be on the same case in EIS even if they are budgeted separately.

REISSUED 3/01/10 – CHANGE NO. 03-10

IV. P. 1. (CONT’D)

      Enter the following data:

      1. Enter the INDIVIDUAL TERMINATION DATE if an individual is not eligible in the ongoing case.
        a. Do not enter if there is only one individual on the application.
        b. This date must be the last day of the month of eligibility.
        c. This date may be the date of application. This should only be entered if an individual is on the application but should not be included on the case.
        d. This date must be before or the same as the current calendar month.
        e. If DATE OF DEATH is entered, do not enter.
      2. Do not enter CASE STATUS. EIS automatically enters “C”.
      3. Enter the RSDI CLAIM NUMBER if the individual has Social Security benefits.
      4. Enter “N” in MEDICARE A & B fields.
      5. Do not enter FAMILY STATUS. EIS generates.
      6. Enter a LIVING ARRANGEMENT CODE. This code must be the same for all individuals on the case. See the Codes Appendix in EIS 4000 to determine the appropriate living arrangement code.
      7. Do not enter SPECIAL REPORT CODE.
      8. Do not enter JOBS/WORK REGISTRATION/EXEMPTION.

REVISED 03/01/10 – CHANGE NO. 03-10

IV. P. 9. (CONT’D)

      9. Enter SPECIAL USE DATA CODE and DATA if needed. Do not enter if the approval is Open/Shut. See the Codes Appendix in EIS 4000 to determine the appropriate special use code and dates.
      10. Do not enter REFUGEE STATUS CODE and U.S. ENTRY DATE.
      11. Enter DATE OF DEATH, if applicable.
        a. If the deceased is the only individual in the application, CASE TERMINATION REASON 52 is required if the date of death is entered.
        b. The DATE OF DEATH must be before or the same as the CASE TERMINATION DATE.
        c. The DATE OF DEATH must be less than or equal to the current date.
      12. Enter CITIZEN/ID code and date.
      13. Do not enter JOBS/WORK REGISTRATION/EXEMPTION data.
      14. Do not enter WORK EXPERIENCE.
      15. Do not enter GROSS EARNED INCOME.
      16. Do not enter WORK EXPENSES.
      17. Do not enter CHILD/ADULT CARE.
      18. Do not enter NET EARNED INCOME.
      19. Do not enter EDUCATIONAL LEVEL.

      NOTE: WHEN THERE IS MORE THAN ONE INDIVIDUAL, USE A DSS-8126 AS A CONTINUATION OF THE DSS-8125 TO ENTER INDIVIDUAL DATA. If there are three or more individuals, use a second DSS-8126.

    Q. Signatures and Date

      1. Enter DATE COMPLETED and WORKER’S SIGNATURE field if using a paper form.
      2. The county director or his designee must sign the form in the DIRECTOR'S SIGNATURE field if using a paper form.

REVISED 10/01/12 – CHANGE NO. 01-13

IV. (CONT’D)

    R. Key the DSS-8125 and DSS-8126's.

    S. Output

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

      1. Benefits Issued

        a. The Division of Medical Assistance (DMA) issues a NC Health Choice identification card at approval for all children with any benefits of October 1, 2011 or later.

        b. A separate identification card will be issued for each individual on the case.

      2. Case Profile

        EIS produces a Case Profile the night the approval processes. The profile is mailed to the county the following workday.

    T. Caseworker Supervisor Report

      The add-on approval is reported on the Caseworker Supervisor Report. The number of approvals completed is determined from the WORKER NUMBER. Cases approved for NC Health Choice appear as M-IC on the Caseworker Supervisor Report.

    U. Automated Notices

      1. EIS produces an automated notice (DSS-8108A) for each NC Health Choice approval the night the DSS-8125 processes in the system.
      2. The DISPOSITION REASON CODE entered on the DSS-8125 determines the text of the notice.
      3. EIS calculates the 60th calendar day for the notice.
      4. The date of the automated notice is the next county workday after the DSS-8125 processes. This is the date the notice is mailed to the recipient. A copy of the notice is not mailed to the county.

REISSUED 10/01/12 – CHANGE NO. 01-13

IV. (CONT’D)

      5. A Notice Register Report is produced each night and is mailed to the county the following workday. NC Health Choice cases appear as M-IC on the Notice Register Report. 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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