NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 2259

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APPROVING H-SF (NON TITLE IV-E FOSTER CARE) NEW APPLICATIONS OR REAPPLICATIONS

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EIS 2259 – APPROVING H-SF (NON TITLE IV-E FOSTER CARE) NEW APPLICATIONS OR REAPPLICATIONS

I. GENERAL INFORMATION

II. COMPLETING THE DSS-8125

III. KEY THE DSS-8125.

IV. OUTPUTS

V. AUTOMATED NOTICES

EIS 2259 – APPROVING H-SF (NON TITLE IV-E FOSTER CARE) NEW APPLICATIONS OR REAPPLICATIONS

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

I. GENERAL INFORMATION

A. Use the instructions in this section to complete the DSS-8125 Eligibility Information System Data Sheet. A sample of the DSS-8125 is located at the end of this volume. For keying instructions, see EIS 4900.

B. Use the most current DSS-8124I Application Turnaround to determine what information has previously been entered for the applicant. This information is retained by the system and brought forward at application approval. For this reason, most of the information entered on the DSS-8124 need not be re-entered when the application is approved.

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

1. Name

2. Social Security Number

3. Date of Birth

4. Sex

5. Race/Ethnicity/Language

D. Use the Application Turnaround to correct the following items before keying the DSS-8125 for approval.

1. County Number

2. Aid Program/Category - See the Aid Program/Category Chart.

3. Application Type

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. After the approval processes overnight, use the DB/PML function when:

1. Authorizing Medicaid benefits under a different aid program/ category from the month of application through the month of disposition.

2. Authorization for all retroactive months cannot be entered on the DSS-8125.

Refer to EIS 3105, Deductible Balance/Patient Monthly Liability Transaction.

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

I. (CONT’D)

F. There are two types of applications, one part and two part. A one part application can be for retroactive coverage only or ongoing coverage only. A two part application is for retroactive and ongoing coverage.

G. Each piece of a two part Medicaid application may be dispositioned (approved/denied/withdrawn) regardless of whether the other part is being dispositioned.

H. New applications and reapplications are dispositioned exactly the same way.

I. A DMA-2041 is required when an applicant/recipient has health and/or accident insurance.

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

II. COMPLETING THE DSS-8125

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

A. CASE IDENTIFYING INFORMATION

1. Enter the CASEHEAD/PAYEE NAME for filing purposes.

2. Enter the COUNTY NAME.

3. Do not enter the CASE ID. The CASE ID is brought forward from the application and may not be changed.

4. Enter your WORKER NUMBER.

5. Enter your COUNTY NUMBER.

6. Enter the COUNTY CASE NUMBER.

7. Enter the DISTRICT NUMBER.

8. Do not enter COUNTY REASSIGNMENT NEW COUNTY.

9. Do not enter COUNTY REASSIGNMENT EFFECTIVE DATE.

10. Enter AID PROGRAM/CATEGORY. If a change is needed, it must be re-entered on the Application Turnaround before approval is keyed.

11. Do not enter CASEHEAD/PAYEE NAME. All casehead/payee name changes must be entered on the NAME CHANGE screen before approval is keyed.

REVISED 09/01/03 - CHANGE NO. 02-04

II. A. (CONT’D)

12. If the applicant is not in long term care, enter:

ADDRESS – Refer to EIS 4050, Mailing Address Appendix, for complete instructions to enter address correctly, if different than indicated on the Application Turnaround. Failure to enter the address properly can result in delay of delivery of notices and cards to the recipient.

NOTE: LINE 1 SHOULD BE C/O COUNTY DEPARTMENT OR FOSTER PARENT.

13. If the applicant is in long term care, enter

a. ADDRESS - For a long term care application, refer to EIS 4050, Mailing Address Appendix, for complete instructions to enter the facility address correctly, if different than indicated on the Application Turnaround.

b. If you want the DMA-5016 mailed to a different address than the case address, enter the facility code. (See EIS 1063 for instructions on determining the facility code.)

EIS mails the Medicaid card and DMA-5016 to the case address if a facility code is not entered.

EIS mails the Medicaid card to the case address and the DMA-5016 to a different address if a facility code is also entered.

14. Enter CITY, STATE, and ZIP Code if different than indicated on the Application Turnaround. See EIS 4050, Mailing Address Appendix, to determine the correct abbreviations.

15. Enter the casehead/payee's three-digit area code and
seven-digit PHONE NUMBER if applicable.

16. Enter a VERIFICATION INDICATOR to indicate if all eligibility factors have been verified.

“Y” = YES “N” = NO

17. Enter SUBSTITUTE PAYEE CODE and NAME if a substitute payee has been appointed to the case, such as county director or foster parent. See the Codes Appendix to determine the appropriate substitute payee code.

18. Do not enter a CHANGE CODE.

REISSUED 09/01/03 - CHANGE NO. 02-04

II. A. (CONT’D)

19. Enter “Y” in NOTICE OVERRIDE if you wish to override the notice.

Always override the automated notice when you use the DB/PML function to issue any benefits or when Medicaid status is “D”.

B. APPLICATION DATA

1. Enter the APPLICATION NUMBER from the Application Turnaround.

2. If approving ongoing coverage, enter the ONGOING DISPOSITION REASON and DATE. See the Codes Appendix to determine the appropriate disposition reason code; and/or

3. If approving retroactive coverage, enter the RETRO DISPOSITION REASON AND DATE.

It is very important to enter the correct disposition code. Unless overridden, an automated notice is produced based on the reason entered on the DSS-8125. The disposition code determines the text of the notice. See AUTOMATED NOTICES at the end of this section for more information regarding the automated notices.

If the notice is overridden, the disposition date must be the same date the approval notice is mailed to the recipient.

C. CASE TERMINATION DATA

1. If approving and terminating a case on the same DSS-8125 (Open/Shut), enter a CASE TERMINATION REASON and DATE. The date must be the last day of the certification through month. See the Codes Appendix to determine the appropriate termination reason code.

OR

If approving retroactive coverage only (if 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.

2. If MEDICAID CLASS is “F” or “O”, enter CASE TERMINATION REASON and DATE.

3. Do enter OLD CASE TERMINATION REASON and DATE.

D. DO NOT ENTER PAYMENT DATA

REISSUED 10/01/96 - CHANGE NO. 2-96

II. (CONT'D)

E. MEDICAID DATA

For approving ongoing only or retroactive and ongoing at the same time.

1. Enter MEDICAID STATUS “A”.

If the case being approved has CAP coverage:

a. Enter “A” for authorized and Y in the NOTICE OVERRIDE field and send a manual notice, or enter APPROVAL CODE “A1” and use the Supplemental Notice Text.

b. Enter “D” for Deductible and Y in Notice Override field and complete a manual notice. If the Notice Override field is blank, an error message will be displayed.

2. Enter MEDICAID EFFECTIVE DATE.

a. If approving ongoing coverage, the MEDICAID EFFECTIVE DATE:

(1) Must not be before the application month.

(2) Must fall within the certification period and may be any day of the month.

(3) Must be before or the same as the ongoing processing month.

(4) Must be before or the same as the CASE TERMINATION DATE if completing an Open/Shut.

b. If approving retroactive coverage with ongoing, the MEDICAID EFFECTIVE DATE:

(1) May be up to three months before the month of application if there is continuous coverage (no break). If there is a break in coverage, use the RETRO MA 1 and RETRO MA 2.

(2) Must be before or the same as the CERTIFICATION THRU date.

REISSUED 10/01/96 - CHANGE NO. 2-96

II. E. 2. b. (CONT'D)

(3) Must be before or the same as the ongoing processing month.

(4) May be any day of the month if the MEDICAID EFFECTIVE DATE falls within the certification period.

(5) Must be before the month of application and any day of the month if the MEDICAID EFFECTIVE DATE does not fall within the certification period.

(6) Must be before or the same as the CASE TERMINATION DATE if you are approving and terminating a case on the same DSS-8125.

3. Enter MEDICAID CERTIFICATION FROM DATE.

a. If approving ongoing coverage, the CERTIFICATION FROM DATE:

(1) Must be the first day of the month.

(2) Must be the application month or the application month plus one to six months.

(3) Must be before or the same as the MEDICAID EFFECTIVE DATE.

(4) Must be before the CERTIFICATION THRU DATE.

b. If approving ongoing and retroactive coverage, the CERTIFICATION FROM DATE:

(1) Must be the first day of the month.

(2) Must be the application month or the application month plus one to six months.

(3) Must be the month of application if MEDICAID EFFECTIVE DATE is before the month of application.

(4) Must be before the MEDICAID CERTIFICATION THRU DATE.

4. Enter the MEDICAID CERTIFICATION THRU DATE.

a. If approving ongoing coverage, the MEDICAID CERTIFICATION THRU DATE:

(1) Must be the last day of the month, and must be the same as the TERMINATION DATE if you are approving and terminating a case on the same DSS-8125.

REVISED 10/01/07 - CHANGE NO. 02-08

II. E. 4. a. (CONT'D)

(2) May be any day of the month if MEDICAID CLASS is “F” or “O”. The month and year must be the same as the TERMINATION DATE if you are approving and terminating a case on the same DSS-8125.

(3) Must not exceed six months from the FROM DATE.

(4) Must be the same as the MEDICAID EFFECTIVE DATE or later.

b. If approving ongoing and retroactive coverage, the MEDICAID CERTIFICATION THRU DATE:

(1) Must be the last day of the month, and must be the same as the TERMINATION DATE if you are approving and terminating a case on the same DSS-8125.

(2) May be any day of the month if MEDICAID CLASS is “F” or “O”. The month and year must be the same as the TERMINATION DATE if you are approving and terminating a case on the same DSS-8125.

(3) Must not exceed six months from the FROM DATE.

(4) Must be the same as the MEDICAID EFFECTIVE DATE or later.

F. RETRO MA 1 AND 2

Complete RETRO MA 1 and 2 to authorize Medicaid before the month of application if the MEDICAID EFFECTIVE DATE does not cover all retroactive months to be authorized. 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 04/90 and 06/90, 04/90 must be entered in RETRO MA 1. No retroactive coverage will be permitted prior to October 1, 2007 for the Expanded Foster Care Program.

1. RETRO MA 1

a. Enter “H” “SF” in AID PROGRAM/CATEGORY.

b. Enter AUTHORIZATION FROM and AUTHORIZATION THRU dates.

REISSUED 10/01/07 - CHANGE NO. 02-08

II. F. 1. b. (CONT'D)

(1) AUTH FROM DATE:

(a) Must be before the application month and before the MEDICAID EFFECTIVE DATE if MEDICAID EFFECTIVE DATE is entered.

(b) May be up to three months before the month of application and any day of the month.

(2) AUTH THRU DATE:

(a) May be up to three months before the application month and must be before the MEDICAID EFFECTIVE DATE if MEDICAID EFFECTIVE DATE is entered.

(b) Must be the last day of the month if MEDICAID CLASS is not “F” or “O”, and must be the same as the TERMINATION DATE if you are approving and terminating a case on the same DSS-8125.

(c) May be any day of the month if MEDICAID CLASS is “F” or “O”. The date must be the same as the TERMINATION DATE if you are approving and terminating a case on the same DSS-8125.

(d) This date must not be before RETRO MA FROM 1.

c. Enter MEDICAID CLASS for the retroactive period.

d. Enter DB/PML if applicable for the retroactive period.

e. Enter DB/PML AMOUNT if DB/PML AMOUNT type is entered. “D” must be entered if the RETRO MA AUTH FROM 1 is not the first day of the month and MEDICAID CLASS is not “F” or “O”.

f. If a PML is entered and you need the DMA-5016 to go to a different facility than the facility 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.)

2. RETRO MA 2

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

a. Enter “H” “SF” in AID PROGRAM/CATEGORY.

REISSUED 07/01/10 - CHANGE NO. 01-11

II. F. 2. (CONT'D)

b. Enter AUTHORIZATION FROM and AUTHORIZATION THRU dates. The RETRO MA 2 FROM and THRU DATES must be after the RETRO MA 1 THRU DATE.

(1) AUTH FROM DATE:

(a) Must be before the application month and before the MEDICAID EFFECTIVE DATE if MEDICAID EFFECTIVE DATE is entered.

(b) May be up to three months before the month of application and any day of the month.

(2) AUTH THRU DATE:

(a) May be up to three months before the application month and before the MEDICAID EFFECTIVE DATE if MEDICAID EFFECTIVE DATE is entered.

(b) Must be the last day of the month, and must be the same as the TERMINATION DATE if you are approving and terminating a case on the same DSS-8125.

(c) May be any day of the month if MEDICAID CLASS is “F” or “O”. The month and year must be the same as the TERMINATION DATE if you are approving and terminating a case on the same DSS-8125.

c. Enter MEDICAID CLASS for the retroactive period.

d. Enter the DB/PML if applicable for the retroactive period.

e. Enter DB/PML AMOUNT if DB/PML type is entered. “D” must be entered if the RETRO MA AUTH FROM 2 is not the first day of the month and the MEDICAID CLASS is not “F” or “O”.

f. If a PML is entered and you need the DMA-5016 to go to a different facility than the facility 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 2 period. (See EIS 1063 for instructions on determining the facility code.)

REVISED 07/01/10 - CHANGE NO. 01-11

II. (CONT'D)

G. EARNED INCOME (IF ZERO, LEAVE BLANK)

All fields must be in dollars and cents.

1. Enter the amount of GROSS EARNED INCOME. The amount must be entered if WORK EXPENSES, CHILD/ADULT CARE, DISREGARD, or NET EARNED INCOME is entered.

2. Enter the amount of WORK EXPENSES.

3. Enter CHILD/ADULT CARE if applicable.

4. ENTER THE AMOUNT OF DISREGARD.

5. ENTER THE AMOUNT OF THE NET EARNED INCOME.

6. Do not enter GRANT RECOUPMENT CODE, AMOUNT, or END DATE.

H. UNEARNED INCOME (IF ZERO, LEAVE BLANK)

All fields must be in dollar and cents amounts.

1. Enter SSI AMOUNT for long term care cases only.

2. Enter the RSDI AMOUNT. If entered, RSDI CLAIM NUMBER is required.

3. Enter the TOTAL NET UNEARNED INCOME. The amount must be more than or the same as RSDI AMOUNT if RSDI entered; and/or more than or the same as SSI AMOUNT if SSI entered.

I. Enter the OTHER UNEARNED INCOME.

1. The amount must be dollars and cents.

2. The amount must be included in the TOTAL NET UNEARNED INCOME.

J. Enter the TOTAL NET UNEARNED INCOME.

1. The amount must be dollars and cents.

2. The amount must be the same as the RSDI AMOUNT plus OTHER UNEARNED, if RSDI and OTHER UNEARNED INCOME is entered.

3. TOTAL COUNTABLE MONTHLY INCOME must also be entered.

REISSUED 07/01/10 - CHANGE NO. 01-11

K. 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 the TOTAL COUNTABLE MONTHLY INCOME. The amount must be in dollars and cents. If entered, TOTAL NET UNEARNED INCOME must be entered.

L. 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. If entered, the date must be before the ongoing month. Do not enter if CASE TERMINATION REASON and DATE are entered.

6. Do not enter JOBS/WORK REQUIREMENT SAVINGS REASON and AMOUNT.

7. Enter SPECIAL USE CODE and DATA if applicable.

M. SPECIAL COVERAGE GROUP DATA

1. Enter SPECIAL COVERAGE CODE, BEGIN DATE, or END DATE, if case is a CAP case. Do not enter end date unless CAP coverage ends. (Refer to EIS 3101. CHANGES TO MEDICAID CASES-SPECIAL COVERAGE GROUPS.)

2. Do not enter SPECIAL NEEDS INDIVIDUAL ID, SPECIAL NEEDS CODE, SPECIAL NEEDS FROM DATE, OR SPECIAL NEEDS THRU DATE.

N. 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 FIELDS

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 a notice to the authorized representative in addition to the applicant.

REISSUED 07/01/10 - CHANGE NO. 01-11

II. N. (CONT'D)

If an applicant is a CAP recipient, the CAP Case Manager’s name and address must be entered for the purpose of mailing an automated notice to the CAP Case Manager 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. This includes information about CAP services for automated notices.

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.

O. INDIVIDUAL DATA

The casehead name and 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).

1. Do not enter INDIVIDUAL TERMINATION DATE.

2. Do not enter CASE STATUS. EIS generates CASE STATUS CODE “R”.

3. Enter the RSDI CLAIM NUMBER if the individual receives Social Security benefits or Medicare coverage.

a. A “Z” suffix is not allowed for an individual under age 65.

b. The RSDI CLAIM NUMBER must be the individual’s Social Security Number if the suffix is A, M, or T.

4. Enter a “Y” or “N” in MEDICARE A to indicate whether or not the individual has Medicaid A. If yes, you must enter an RSDI claim number.

REISSUED 07/01/10 - CHANGE NO. 01-11

II. O. (CONT'D)

5. Enter a “Y” or “N” in MEDICARE B to indicate whether or not the individual has Medicaid B. If yes, you must enter an RSDI claim number.

6. Enter “A” or “C” in FAMILY STATUS CODE as defined by policy.

7. Enter a LIVING ARRANGEMENT CODE. See the Codes Appendix to determine the appropriate living arrangement code.

8. Enter a 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 DATA CODE and DATE(s) if applicable. See the Codes Appendix to determine the appropriate special use data code and date(s).

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.

d. Date of Death cannot be more than three (3) months before the month of application.

13. HSF is exempt from documentation of Citizenship/Identity Code in EIS. Enter Citizenship Identity Code if policy requires a CITIZEN/ID Code. See the Codes Appendix to determine the appropriate Citizen/ID code and date.

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.

REISSUED 07/01/10 - CHANGE NO. 01-11

II. O. (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. 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. Enter COMMUNITY CARE OF NORTH CAROLINA (CCNC) provider or exempt number. Refer to EIS 4100, Community Care of North Carolina, for more information.

P. SIGNATURES and DATE

1. Enter the DATE COMPLETED.

2. Sign the DSS-8125 in the WORKER'S SIGNATURE field.

3. The county director or his designee must sign the form in the DIRECTOR'S SIGNATURE field.

III. KEY THE DSS-8125.

IV. OUTPUTS

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

A. CASE PROFILE

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

B. 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.

REISSUED 07/01/10 - CHANGE NO. 01-11

C. DMA-5016 (Patient Liability Information)

The automated DMA-5016 is created after the action processes in EIS and is mailed the next workday for the current and retro periods, if applicable, to the appropriate facility indicated by the code(s) or address entered.

D. CASEWORKER SUPERVISOR REPORT

The application approval is reported on the Caseworker Supervisor Report. The number of approvals completed is determined from the WORKER NUMBER.

V. AUTOMATED NOTICES

A. An automated notice (DSS-8108A) is produced for each HSF 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 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.

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.