NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 4300

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NC HEALTH CHOICE - NOTICES AND CODES

PART SIX

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NC HEALTH CHOICE - NOTICES AND CODES


I. NC HEALTH CHOICE DISPOSITION CODES

II. NC HEALTH CHOICE CHANGE CODES

III. NC HEALTH CHOICE TRANSFER CODES

IV. NC HEALTH CHOICE TERMINATION CODES

V. APPLICATION DISPOSITION CODES

VI. REDETERMINATION

Vii. CHANGE CODES

ViII. TRANSFER CHANGE CODES

IX. CASE TERMINATION CODES

IX. TERMINATION CODES (CONT’D)

IX. TERMINATION CODES (CONT’D)


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EIS 4300 – NC HEALTH CHOICE – NOTICES AND CODES
PART SIX

REISSUED 04/01/05 – CHANGE NO. 05-05

          CODES FOR NC HEALTH CHOICE

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I. NC HEALTH CHOICE DISPOSITION CODES

    A. NC Health Choice Approval Codes

      Based on the approval code entered on the DSS-8125 screen, EIS produces a notice to say:

      1. “This is to notify you that your NC Health Choice has been approved.”
      2. Followed by:

        “The following individuals are approved on this application:

        Name

      3. “You are eligible for the following months:”

        MMDDCCYY thru MMDDCCYY

      4. EIS prints the text associated with the disposition reason code entered.
      5. “State rules supporting this action are found in Section 3255 of the Family and Children’s Manual.”

    B. For Open/Shut Approvals, the following text is printed in addition to the text indicated above:

      1. “All NC Health Choice benefits will stop.”
      2. EIS prints the text associated with the termination code entered. Refer to the Termination Codes.

    C. NC Health Choice Denial Codes

      The reason code entered as the application disposition reason determines the text printed on the automated DSS-8109.

      1. The text will be:

        “This is to notify you that your application for NC Health Choice has been denied.”

REVISED 04/01/05 – CHANGE NO. 05-05

I.C. (CONT’D)

      2. Followed by:

        “The reason for this action is:

        ________________________________________________

      3. The state regulations applied to make this decision are found in Section 3255 of the Family and Children’s Medicaid Manual.

    D. NC Health Choice Withdrawal Codes

      The reason code entered as the application disposition reason determines the text printed on the automated
      DSS-8109.

      1. For NC Health Choice applications, the text will be:

        “This is to notify you that your application for NC Health Choice has been withdrawn.

      2. Followed by:

        “The reason for this action is:

        ____________________________________________________

      3. The state regulations applied to make this decision are found in Section 3255 of the Family and Children’s Medicaid Manual.

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II. NC HEALTH CHOICE CHANGE CODES

    A. NC Health Choice Change Codes

      Based on the “Adequate” or “Timely” change code entered on the DSS-8125 screen, EIS produces a notice to say:

      1. “Adequate” or “Timely” is indicated at the top of the notice.
      2. “The Change Which Will Take Place:”
        a. “Effective MMDDCCYY” (This date will be the Medicaid Effective Date, Individual Termination Date or Individual Date of Death).
        b. When an individual termination date or date of death is present:

          (Name of individual) This individual(s) is being terminated from your case” or “This individual(s) was deleted because of death.”

REVISED 04/01/05 – CHANGE NO. 05-05

II.A.2.(CONT’D)

        c. The following statement will print:

          “You are eligible for the following months:”

          “MMDDCCYY thru MMDDCCYY.”

      3. “Why the Change Will Be Made:”

        EIS prints the reason that corresponds to the Change code entered, then the sentence:

        “State rules supporting this action are found in Section 3255 of the Family and Children’s Manual.”

      4. “When the Change Will Be Made:”
        a. If the change code entered is an “ADEQUATE” code, the notice will state;

          “The change will be effective on MM/DD/CCYY.” However, you have until MMDDCCYY which is 10 days from the date of this letter to request a hearing

        b. If the change code entered is a “TIMELY” code, the notice will state;

          “The change will be effective on MM/DD/CCYY which is 10 workdays from the date of this letter, unless you ask for a hearing on or before that date.”

    B. NC Health Choice Redetermination Notice with no change in benefits.

      Based on the redetermination code entered on the DSS-8125 screen, EIS produces a notice to say:

      1. “NC Health Choice has been continued.”
      2. The following statement prints:

        “You are eligible for the following months:”

        “MMDDCCYY thru MMDDCCYY”

      3. “State rules supporting this action are found in Section 3255 of the Family and Children’s Medicaid Manual.”

REVISED 04/01/05 – CHANGE NO. 05-05

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III. NC HEALTH CHOICE TRANSFER CODES

    NC Health Choice to M-IC-N and M-AF are the only allowable adequate transfers.

    Based on the adequate transfer code entered on the DSS-8125 screen, EIS produces a notice to say:

    A. “Adequate”

    B. “The Change Which will Take Place”

      “Effective MMDDCCYY”

      “Your Medicaid continues under another category.”

    C. EIS prints the text associated with the Adequate Transfer code entered.

    D. “State rules supporting this action are found in Section 3255 of the Family and Children’s Manual.”

    E. “When the Change Will Be Made:”

      “The change is effective on MMDDCCYY. However, you have until MMDDCCYY which is 10 days from the date of this letter to request a hearing.”

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IV. NC HEALTH CHOICE TERMINATION CODES

    Based on the “Adequate” or “Timely” termination code entered on the DSS-8125 screen, EIS produces a notice to say:

    A. “Adequate” or “Timely” is indicated at the top of the notice.

    B. “The Change Which Will Take Place:”

      “Effective MMDDCCYY

      All NC Health Choice Benefits Will Stop.”

    C. “Why the Change Will Be Made:”

      EIS prints the reason that corresponds to the Termination code entered. Then the sentence:

      “State rules supporting this action are found in Section 3255 of the Family and Children’s Manual.”

REVISED 10/01/12 - CHANGE NO. 01-13

IV. (CONT’D)

    D. “When the Change Will Be Made:”

      1. If the termination code entered is an “ADEQUATE” code, the notice will state;

        “The change will be effective on MM/DD/CCYY.” However, you have until MMDDCCYY which is 10 days from the date of this letter to request a hearing

      2. If the termination code entered is a “TIMELY” code, the notice will state;

        “The change will be effective on MM/DD/CCYY which is 10 workdays from the date of this letter, unless you ask for a hearing on or before that date.”

        NOTE: TERMINATION NOTICES ARE GENERATED FOR AUTOMATED TERMINATIONS OF OPTIONAL EXTENDED COVERAGE(“L” CLASS).

REVISED 10/01/12 - CHANGE NO. 01-13

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V. APPLICATION DISPOSITION CODES

    APPROVAL

    Use when insurance was NOT dropped to qualify for NC Health Choice

    CODE

    REASON

       

    A1

    The child(ren) for whom you applied is eligible for NC Health Choice. You will receive a benefit booklet and ID card from the Division of Medical Assistance (DMA).

    (F & C 3255)

       

    A2

    The child(ren) for whom you applied is eligible for NC Health Choice. Medicaid benefits for all others have been approved in another case. You will receive a benefit booklet and ID card from the Division of Medical Assistance (DMA). (F & C 3255)

       

    A4

    The child(ren) for whom you applied is eligible for NC Health Choice. NC Health Choice benefits for all others have been denied. You will receive a benefit booklet and ID card from the Division of Medical Assistance (DMA).

    (F & C 3255)

       

    A6

    The child(ren) for whom you applied is eligible for NC Health Choice. You will receive a benefit booklet and ID card from the Division of Medical Assistance (DMA).

    (This code is for adds.) (F & C 3255)

       

    B8

    The following individual(s) is approved for NCHC for the months of ____thru____. You must provide verification of citizenship and/or identity to continue to receive NCHC. If documentation is not received, your NCHC will be terminated. (F & C 3331)

    Use when insurance WAS dropped to qualify for NC Health Choice

    CODE

    REASON

       

    B1

    The child(ren) for whom you applied is eligible for NC Health Choice. You will receive a benefit booklet and ID card from the Division of Medical Assistance (DMA).

    (F & C 3255)

       

    B2

    The child(ren) for whom you applied is eligible for NC Health Choice. Medicaid benefits for all others have been approved in another case. You will receive a benefit booklet and ID card the Division of Medical Assistance (DMA). (F & C 3255)

REVISED 10/01/12 - CHANGE NO. 01-13

V. APPLICATION DISPOSITION CODES (CONT’D)

    APPROVAL

    Use when insurance WAS dropped to qualify for NC Health Choice

    CODE

    REASON

       

    B3

    The children(ren) for whom you applied is eligible for NC Health Choice. NC Health Choice benefits for all others have been denied. You will receive a benefit booklet and ID card from the Division of Medical Assistance (DMA).

    (F & C 3255)

       

    B4

    The child(ren) for whom you applied is eligible for NC Health Choice. You will receive a benefit booklet and ID card from the Division of Medical Assistance (DMA).

    (This code is for adds.) (F & C 3255)

       

    B8

    The following individual(s) is approved for NCHC for the month of ___thru___. You must provide verification of citizenship and/or identity to continue to receive NCHC. If documentation is not received, your NCHC will be terminated. (F & C 3331)

    Use when reopening a case into “L” class

    CODE

    REASON

       

    B5

    The child(ren) for whom you are applying is eligible for NC Optional Extended Coverage. Within 10 days you will receive additional information from the Division of Medical Assistance (DMA). (F&C 3255)

REISSUED 10/01/12 - CHANGE NO. 01-13

V. APPLICATION DISPOSITION CODES (CONT’D)

    DENIAL

    CODE

    REASON

       

    A2

    The child(ren) has comprehensive health insurance or Medicare. (F & C 3255)

       

    A3

    You did not pay the NC Health Choice enrollment fee.

    (F & C 3255)

       

    B3

    Your income exceeds the income level for your family size. (F & C 3255)

       

    B6

    You failed to cooperate with child support enforcement in enforcing the court order for your child(ren)’s non-custodial parent to provide health insurance. (F & C 3255)

    C1

    The child(ren) for whom you applied did not meet the state residence requirements. (F & C 3255)

REISSUED 10/01/12 - CHANGE NO. 01-12

V. APPLICATION DISPOSITION CODES (CONT’D)

    DENIAL

    CODE

    REASON

       

    C2

    The child(ren) for whom you applied is not a U.S. Citizen, Refugee, or Qualified Alien. (F & C 3255)

       

    C3

    The child(ren) for whom you applied does not meet the age requirement. (F & C 3255)

       

    C4

    Your child is eligible for NC Health Choice but the program is not funded to cover more children at this time. If more funds are made available, you will be contacted about enrolling your child in NCHC. (F & C 3255)

       

    C5

    The child(ren) for whom you applied is living in a public non-medical institution. (F & C 3255)

       

    D6

    The child applicant is not living with a person who meets the definition of a parent/caretaker. (F & C 3255)

       

    F1

    Eligibility could not be established because we have been unable to locate you by letter or by phone. (F & C 3255)

    F2

    The child(ren) for whom you applied is already receiving assistance in another case. (F & C 3255)

       

    F3

    You have refused to allow us to match your Social Security number against other agencies’ records. (F & C 3255)

       

    F5

    The child(ren) for whom you applied has been approved to receive benefits in another aid program category.

    (F & C 3255)

       

    F6

    Eligibility does not exist due to the death of the applicant or a child. (F & C 3255)

       

    G1

    You have not provided the information needed to establish eligibility. (F & C 3255)

       

    G2

    You refused to cooperate in the application process.

    (F & C 3255)

       

    G4

    We are unable to document the immigration status of the child(ren) for whom you applied.
    (F & C 3255)

       

    G6

    You did not provide or apply for a social security number. (F & C 3255)

REVISED 10/01/12 - CHANGE NO. 01-13

V. APPLICATION DISPOSITION CODES (CONT’D)

    DENIAL

       

    G8

    Administrative denial (no manual notice required for this code.) (F & C 3255)

       

    K9

    You did not keep your appointments for your interview. (F & C 3255)

       

    N1

    You did not provide documentation of citizenship and/or identity (Individual(s) previously received benefits while trying to resolve citizenship code “97”). (F & C 3331)

    WITHDRAWAL

    CODE

    REASON

       

    W1

    You asked that your application be withdrawn. (F & C 3255)

       

    W5

    You asked that your application be withdrawn rather than allow us to match your social security number against other agencies records. (F & C 3255)

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VI. REDETERMINATION

    CODE

    REASON

       

    01

    NC Health Choice has been continued. (F & C 3255)

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Vii. CHANGE CODES

    REASON

    TIMELY

    ADEQUATE

         

    Your child(ren) no longer qualifies for NCHC due to income limit. You may opt to pay full NCHC premium for 12 months. Within 10 days, you will receive additional info from the Division of Medical Assistance (DMA). (F & C 3255)

    N/A

    53

         

    The state income levels changed. (F & C 3255)

    08

    58

         

    An individual with countable income moved out of your household. (F & C 3255)

    N/A

    63

         

    You now qualify for Medicaid and will receive a yearly Medicaid card. (When changing from NC Health Choice to MIC-N at reenrollment.)
    (F & C 3230 and 3305)

    N/A

    6I

REISSUED 10/01/12 - CHANGE NO. 01-13

VII. CHANGE CODES (CONT’D)

    INDIVIDUAL DELETION

    REASON

    TIMELY

    ADEQUATE

         

    The individual moved out of state. (F & C 3255)

    02

    62

         

    This child(ren)’s income is more than the income limit. (F & C 3255)

    09

    6H

         

    The child(ren) has comprehensive health insurance or Medicare. (F & C 3255)

    11

    67

         

    The child(ren) was found eligible for Medicaid. (F & C 3255)

    12

    71

         

    The child(ren) is being terminated at your request. (F & C 3255)

    13

    76

         

    The child(ren) is a resident of a public institution. (F & C 3255)

    16

    77

         

    You did not provide a social security number for the child(ren). (F & C 3255)

    18

    6G

         

    The individual is deceased. (F & C 3255)

     

    61

         

    The child no longer lives with you because of placement in foster care or an adoptive home.
    (F & C 3255)

    N/A

    64

         

    The child(ren) in the case has reached age 19.
    (F & C 3255)

    N/A

    70

         

    You did not provide documentation of citizenship and/or identity (Individual(s) previously received benefits while trying to resolve citizenship code “97”). (F & C 3331)

    4W

    9W

         

    The child(ren) is being terminated because premium payment(s) were not receive by deadline given. ENTERED BY DMA STAFF ONLY.(F & C MA 3255)

    N/A

    7P

REISSUED 10/01/12 - CHANGE NO. 01-13

VII. CHANGE CODES (CONT’D)

    SYSTEM GENERATED

    REASON

    TIMELY

    ADEQUATE

         

    System Generated – The child(ren) has reached age 19. (F & C 3255

    06

     
         

    (System Generated). The Health Choice child(ren) has been approved for SSI. (F & C 3255)

     

    90

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ViII. TRANSFER CHANGE CODES

    REASON

    TIMELY

    ADEQUATE

         

    You now qualify for Medicaid and will receive a monthly Medicaid card. (Use to transfer from NC Health Choice to MAF.) (F & C 3255)

    N/A

    6I

         

    The child(ren) entered a long-term care facility or mental health facility. (Use to transfer from NC Health Choice to MAF.) (F & C 3255)

    N/A

    74

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IX. CASE TERMINATION CODES

    REASON

    TIMELY

    ADEQUATE

         

    The child(ren) is a resident of a public institution. (F & C 3255)

    04

    64

         

    The child(ren) has comprehensive health insurance or Medicare. (F & C 3255)

    05

    56

         

    You failed to cooperate with child support enforcement to obtain court ordered health insurance. (F & C 3255)

    1A

    6A

         

    Your income exceeds the income limit for your family size. (F & C 3255

    1B

    74

         

    The child(ren) moved out of North Carolina.
    (F & C 3255)

    1D

    53

         

    You did not provide a social security number for the child(ren). (F & C 3255)

    15

    81

REVISED 10/01/12 - CHANGE NO. 01-13

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IX. TERMINATION CODES (CONT’D)

         

    You did not provide the necessary information to determine your eligibility. (F & C 3255)

    20

    72

         

    We are unable to locate you. (F & C 3255)

    21

    63

         

    The only eligible child(ren) has reached age 19. (F & C 3255)

    22

    77

         

    There are no eligible children living with you. (F & C 3255)

    23

    82

         

    You have not paid the annual NC Health Choice enrollment fee. (F & C 3255)

    24

    71

         

    You asked that NC Health Choice be stopped.
    (F & C 3255)

    29

    55

         

    The child(ren) is deceased. (F & C 3255)

    N/A

    52

         

    The child(ren) was found eligible for Medicaid. (F & C 3255)

    N/A

    54

         

    The child no longer lives with you because of placement in Foster Care or an adoptive home.
    (F & C 3255)

    N/A

    57

         

    There was a change in law or agency policy of which you were previously notified. (F & C 3255)

    N/A

    58

         

    You have failed to provide documentation of citizenship and/or identity (Individual(s) previously received benefits while trying to resolve citizenship code “97”). (F & C 3331)

    2R

    6R

         

    The child(ren) are being terminated because Premium Payment(s) were not received by deadline given. ENTERED BY DMA STAFF ONLY. (F & C 3255)

    N/A

    6P

REVISED 10/01/12 - CHANGE NO. 01-13

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IX. TERMINATION CODES (CONT’D)

    SYSTEM GENERATED

REASON

TIMELY

ADEQUATE

     

(System Generated). You did not provide the necessary information to determine your eligibility. (F & C 3255)

N/A

80

     

System Generated – The child(ren)are being terminated from Optional Extended Coverage because you have exceeded your 12 month certification period. (F & C 3255)

N/A

85

     

System Generated – Children aged 0-5 were moved from NCHC to Expanded Medicaid (MIC-1) effective January 1, 2006. See DMA Administrative Letter 15-05 for a sample of the notice.

N/A

9H

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