NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 2264

-----------------------------------------------------------------------------

APPROVING AN S-AA OR S-AD NEW APPLICATION OR REAPPLICATION

-----------------------------------------------------------------------------

EIS 2264 – APPROVING AN S-AA OR S-AD NEW APPLICATION OR REAPPLICATION

I. GENERAL INFORMATION

II. COMPLETING THE DSS-8125

III. SUBMIT THE DSS-8125 AND SUPPLEMENTAL NOTICE INFORMATION FORM TO DATA ENTRY FOR KEYING.

IV. OUTPUTS

V. AUTOMATED NOTICES

EIS 2264 – APPROVING AN S-AA OR S-AD NEW APPLICATION OR REAPPLICATION

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

I. GENERAL INFORMATION

A. Use the following instructions to complete the DSS-8125, Eligibility Information System Data Sheet. A sample of the
DSS-8125 is located at the end of this volume.

NOTE: FOR KEYING INSTRUCTIONS, SEE EIS 4900.

B. Use the current DSS-8124I Application Turnaround to determine what information has previously been entered for the applicants. 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 does not need to be re-entered when the application is approved. These fields are noted below.

C. You may use the Application Turnaround to make allowable corrections before keying the DSS-8125 for approval or you may make the corrections on the DSS-8125 at approval.

If there is a change of payee, see EIS 2052, Making Changes to
SA Applications.

D. A DMA-5022 is required when authorization is for more than two prior month payments.

E. Use the DB/PML screen to authorize any Medicaid eligibility before the determination of dual eligibility not including the three months before the application month. See EIS 3105 for instructions to authorize Medicaid for these individuals.

F. New applications and reapplications are dispositioned exactly the same way unless you are approving a reapplication against an ongoing case. If this is true, old case termination data is required.

G. When an individual re-applies for both MAABD and SAA/SAD against the same closed case ID and the SAA/SAD application is approved first, the MAABD application must be administratively denied. If the applicant is eligible for MAABD prior to the SAA/SAD eligibility, complete an administrative DSS-8124 application as “NEW” under MAABD and approve by completing the DSS-8125.

If these procedures are not followed, the system will require old case termination date. If entered, the ongoing SAA/SAD case will be closed.

H. 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.

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

II. (CONT'D)

A. CASE IDENTIFYING INFORMATION

1. Enter the CASEHEAD/PAYEE NAME at the top of the form 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 or EFFECTIVE DATE.

9. Enter “S” “AA” or “S” “AD” for AID PROGRAM/CATEGORY.

10. Do not enter CASEHEAD/PAYEE NAME. Make all changes to the casehead/payee name on the Name Change screen.

11. 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.

12. ADDRESS - For an SAA or SAD 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.

Enter the facility code in the last three spaces of ADDRESS LINE 2. Refer to EIS 1063 to determine the appropriate
3-digit facility code.

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

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

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

“Y” = YES “N” = NO

REVISED 04/1/93 - CHANGE NO. 2-93

II. A. (CONT'D)

16. Enter a SUBSTITUTE PAYEE CODE and NAME if a substitute payee has been appointed to the case. See the Codes Appendix to determine the appropriate substitute payee code.

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

Always override the automated notice when:

a. You approve an application and authorize benefits on the DMA-5022. If all benefits are authorized on the DSS-8125, an automated notice can be produced.

b. You approve an application but the assistance unit is not eligible for one or more month's benefits. If the assistance unit is elgible for benefits beginning the month after application, but ineligible for the month of application an automated notice can be produced.

c. You approve an application and the assistance unit is eligible for the Community Alternatives Program (CAP).

d. You approve an application with an approval code created for “other”.

B. APPLICATION DATA

1. Enter the APPLICATION NUMBER from the Application Turnaround.

2. Enter the ONGOING DISPOSITION REASON and DATE. See the Codes Appendix to determine the appropriate disposition reason code.

a. The ONGOING DISPOSITION DATE must be the application date or later.

b. THE ONGOING DISPOSITION DATE must be the application date or later.

3. Do not enter RETRO DISPOSITION REASON and DATE.

C. CASE TERMINATION DATA

1. Enter the CASE TERMINATION REASON and DATE if the application is to be approved and terminated on the same DSS-8125

(Open/Shut). See the Codes Appendix to determine the appropriate termination reason code.

a. The CASE TERMINATION DATE must be the last day of the month.

REISSUED 04/1/93 - CHANGE NO. 2-93

II. C. 1. (CONT'D)

b. The CASE TERMINATION DATE must be before the ongoing month but not before the month of application.

c. If the application is disposed of in terminated status, retroactive checks are produced from the MONTHLY PAYMENT EFFECTIVE DATE through the CASE TERMINATION DATE.

NOTE: DO NOT ENTER A PAYMENT REVIEW FROM AND THRU DATE IF YOU ARE APPROVING AN APPLICATION IN TERMINATED STATUS.

2. If you are approving a reapplication against an active case, enter the OLD CASE TERMINATION REASON and DATE to terminate the case against which you are approving an application. See the Codes Appendix to determine the appropriate termination reason code.

D. PAYMENT DATA

1. Enter the PAYMENT REVIEW PERIOD FROM and THRU dates for all cases except those approved in terminated status.

a. The PAYMENT REVIEW PERIOD must be 12 months.

b. The FROM date must not be before the month of application.

c. The THRU date must not be before the FROM date.

2. Enter the MONTHLY PAYMENT AMOUNT as a whole dollar amount.

a. The AMOUNT must be the MAINTENANCE AMOUNT, minus the TOTAL COUNTABLE INCOME, minus GRANT RECOUPMENT.

b. The system does not check the calculation when the application is approved in terminated status (open/shut.)

If the applicant is eligible for only one month, enter the check amount in the MONTHLY PAYMENT AMOUNT field.

3. Do not enter MONTHLY PAYMENT TYPE. The system enters a “1”.

4. Enter the MONTHLY PAYMENT EFFECTIVE DATE. This date must not be before the month of application or after the ongoing month.

5. PRIOR MONTH PAYMENT 1 AMOUNT and DATE and PRIOR MONTH PAYMENT 2 AMOUNT and DATE.

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

II.5 (CONT'D)

If you are approving an application which requires a check for a different amount than the ongoing monthly payment amount, you must use the prior month payment block(s). The DSS-8125 has room for two prior month payments. If more than two prior months payments are needed, use a DMA-5022. See EIS 2268 for instructions on completing the DMA-5022.

It is important that these fields are completed in date order (oldest first). Enter the first two prior month checks on the DSS-8125 and any additional months on the DMA-5022.

a. Prior month payments must be before the PAYMENT EFFECTIVE DATE and cannot be before the month of application.

b. PRIOR MONTH PAYMENT 2 PAYMENT DATE and AMOUNT cannot be entered unless PRIOR MONTH PAYMENT 1 is entered.

c. PRIOR MONTH PAYMENT 2 must be after the PRIOR MONTH PAYMENT 1 date.

NOTE: IF THE FIRST MONTH'S CHECK FOR AN ONGOING CASE IS PRORATED, IT MUST BE ENTERED IN THE PRIOR MONTH PAYMENT FIELD.

E. MEDICAID DATA

1. Do not enter MEDICAID STATUS. The system enters “A” for authorized.

2. Enter the EFFECTIVE DATE of Medicaid eligibility.

a. The EFFECTIVE DATE must not be more than three months before the month of application or after the ongoing month.

b. The EFFECTIVE DATE may be 1, 2, or 3 months before the application month if Medicaid coverage is continuous.

3. Do not enter the CERTIFICATION PERIOD FROM and THRU dates.

4. Enter a “C” in MEDICAID CLASS. If this is a DUALLY ELIGIBLE CASE, complete an 8125 the day after the approval is keyed and accepted into the system. You must:

a. Enter “Q” in MEDICAID CLASS;

b. Enter “Y” in MEDICARE A at the individual level; if not already entered.

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

II. E. 4. (CONT'D)

NOTE: IF THIS IS A REAPPLICATION AGAINST AN SSI MAABD CASE, DO NOT ENTER A MEDICAID CLASS. THIS IS CONTROLLED BY THE SDX.

5. Do not enter DEDUCTIBLE BALANCE/PATIENT MONTHLY LIABILITY (DB/PML).

6. Do not enter DB/PML AMOUNT.

7. Enter RETRO MA 1 to authorize Medicaid before the month of application if the case is eligible for only the first and/or second month(s) of the three month retroactive period. Enter the following:

a. “S” “AA” or “S” “AD” in RETRO MA 1 AID PROGRAM/CATEGORY.

b. RETRO MA 1 AUTHORIZATION FROM and THRU dates. This must include the first and/or second months of the three month period prior to the month of application.

For example: The month of application is May. The three months prior are February (1st month), March (2nd month), and April (3rd month).

c. “C” in RETRO MA 1 MEDICAID CLASS.

d. Do not enter DB/PML and DB/PML AMOUNT.

8. Do not enter RETRO MA 2.

F. EARNED INCOME (IF ZERO, LEAVE BLANK)

1. Enter the GROSS EARNED INCOME. The amount must be dollars and cents.

2. Enter the WORK EXPENSES. The amount must be dollars and cents.

3. Do not enter CHILD/ADULT CARE.

4. Enter the DISREGARD. The amount must be dollars and cents.

5. Enter the NET EARNED INCOME. The amount must be dollars and cents. If entered, GROSS EARNED INCOME must be greater than zeroes and the amount entered must not be greater than the GROSS EARNED INCOME amount entered.

)

6. Enter GRANT RECOUPMENT if a reduction in the assistance check is made to repay an overpayment.

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

II. F. (CONT'D)

a. Enter the CODE. See the Codes Appendix to determine the appropriate grant recoupment code.

b. Enter the AMOUNT in whole dollars.

c. Enter the END DATE. The END DATE must not be before the ongoing month. A special message is printed on the Case Management Report one month before the month the grant recoupment amount must be changed or removed from the case.

G. UNEARNED INCOME (IF ZERO, LEAVE BLANK)

1. Enter the SSI AMOUNT.

a. The amount must be dollars and cents.

b. The amount may be zero.

2. Enter the RSDI AMOUNT.

a. The amount must be a whole dollar amount. Zeroes must be entered in the cents column.

b. This amount must be less than or same as the TOTAL NET UNEARNED INCOME.

c. If entered, an RSDI CLAIM NUMBER is required.

3. Enter the OTHER UNEARNED INCOME

a. The amount must be in dollars and cents.

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

4. Enter the TOTAL NET UNEARNED INCOME. The amount must be dollars and cents.

H. Needs

1. Enter the MAINTENANCE AMOUNT. The amount must be a whole dollar amount. Zeroes must be entered in the cents column.

2. Enter the AMBULATION CAPACITY. See the Codes Appendix for the appropriate ambulation capacity code.

3. Enter the DOMICILIARY RATE. The amount must be a whole dollar amount.

4. Enter the TOTAL COUNTABLE MONTHLY INCOME. The amount must be dollar and cents and must be the sum of TOTAL NET UNEARNED INCOME plus NET EARNED INCOME minus (-) $20.

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

II. I.

I. SPECIAL DATA

1. Enter a FOOD STAMP NUMBER for each case receiving Food Stamps if not previously entered on the DSS-8124 or the Application Turnaround.

2. Do not enter STEPPARENT INDICATOR.

3. Enter GRANDFATHER STATUS CODE and DATE to reinstate a Group I case terminated due to administrative error. See the Codes Appendix for the appropriate grandfather status code. This must be a reapplication.

4. Do not enter the SSI STATUS. The system enters “N” or “Y”.

5. Mark “YES” or “NO” for VA PAYMENT.

6. Enter SPECIAL REVIEW TYPE and DATE if needed. Not allowed if CASE TERMINATION REASON and DATE are entered.

a. See the Codes Appendix to determine the appropriate special review code and date.

b. The DATE must not be before the ongoing month.

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

8. Enter the two digit SPECIAL USE CODE and DATA if applicable. If entered, enter the six digit BEGIN DATE (MMDDYY)and six digit END DATE (MMDDYY). The END DATE can be 999999.

J. SPECIAL COVERAGE GROUP DATA (INCLUDING SPECIAL NEEDS)

1. Complete the following fields if the individual's condition requires a higher level of care.

a. Enter “LT” in CODE 1.

b. Enter the six digit BEGIN DATE. The BEGIN DATE must be the date the FL-2/MR-2 is received recommending the higher level of care.

c. Do not enter the six digit END DATE at approval.

2. Complete the following fields if the individual is determined eligible for CAP coverage.

a. Enter the appropriate CAP code in SPECIAL COVERAGE CODE 1. Refer to the Codes Appendix to determine the appropriate code.

REISSUED 03/01/08 - CHANGE NO. 05-08

II. J. 2. (CONT'D)

b. Enter the six digit BEGIN DATE. This date cannot be prior to the date of application.

c. If the CAP eligibility is for a limited period of time, you may also enter the END DATE.

If the case is approved in terminated status, (OPEN/SHUT) and there is a CAP BEGIN DATE but there is not a CAP END DATE, EIS will close the CAP coverage using the Case Termination Date on the case.

3. Do not enter SPECIAL NEEDS.

K. SUPPLEMENTAL NOTICE INFORMATION

The following three data elements have been added to the DSS-8125 Data Entry screen. Only one is applicable to S-AA and S-AD. 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 Entray for keying.

1. Enter the AUTHORIZED REPRESENTATIVE'S NAME and ADDRESS if an authorized representative has been appointed to the case. An automated notice will be produced for both the payee and the authorized representative.

2. Do not enter SECONDARY NOTICE CODE.

3. Do not enter NOTICE TEXT.

L. INDIVIDUAL DATA

NOTE: IF THIS IS A REAPPLICATION AGAINST AN SSI MAABD CASE, INDIVIDUAL DATA IS CONTROLLED BY THE SDX.

1. The INDIVIDUAL ID is brought forward from the 8124I.

2. If the individual's FIRST, MI, and LAST NAME are different than indicated, they must be corrected on the Name Change Screen.

3. The SOCIAL SECURITY NUMBER is brought forward from the 8124I.

The Name Change Screen must be used if:

a. It must be added, OR

b. It must be corrected.

4. Do not enter INDIVIDUAL TERMINATION DATE.

5. Do not enter CASE STATUS. The system enters “R” for recipient.

REVISED 03/01/08 – CHANGE NO. 05-08

II. L. (CONT’D)

6. DATE OF BIRTH must be corrected on the Name Change screen if different than indicated on the Application Turnaround.

a. For S-AA, the individual must be age 65 or older.

b. For S-AD, the individual must be age 18 through 64.

c. When changing the date of birth on the Name Change Screen, and there is a DSS-8125 pending for an action other than a termination, you must first delete the pending DSS-8125 before the date of birth can be changed.  If you attempt to change the date of birth before deleting the DSS-8125, EIS displays the error message:  031:  TO MAKE CHANGE ON DOB, YOU MUST DELETE 8125 FORM. Keying the DSS-8125 after the date of birth change ensures the action processes through the appropriate age edits in EIS.

7. RACE/ETHNICITY/LANGUAGE must be corrected on the Name Change screen.

8. SEX must be corrected on the Name Change screen if different than indicated on the Application Turnaround. The appropriate responses are “M” (MALE) or “F” (FEMALE).

9. Enter the RSDI Claim Number if the individual receives Social Security benefits or has Medicare coverage.

a. A “Z” suffix is not allowed if:

(1) The Medicaid Classification is Q.

(2) The individual is under 65 years of age in the ongoing month.

b. The RSDI CLAIM NUMBER:

(1) Can not be blank or zeroes if the Medicaid Classification code is Q.

(2) Must be the individual’s own Social Security Number if the suffix is A, M, or T.

(3) Is the individual’s Social Security Number with a suffix of “Z” for an alien who does not qualify for Medicare due to not having five years of residency in the U.S. and who is age 65 or over in the ongoing month. This will allow claims for the alien to bypass Medicare editing.

10. Enter a “Y” or “N” in MEDICARE A to indicate whether or not the individual has Medicare A. If “Y” is entered, the RSDI CLAIM NUMBER must also be entered. Enter “Y” if the MEDICAID CLASS is “Q”.

REVISED 10/01/09 – CHANGE NO. 01-10

II. L. (CONT'D)

11. Enter a “Y” or “N” in MEDICARE B to indicate whether or not the individual has Medicare B. If “Y” is entered, the RSDI CLAIM NUMBER must also be entered.

12. Do not enter FAMILY STATUS. The system enters “A” for adult.

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

14. Enter a SPECIAL REPORT CODE if needed. See the Codes Appendix to determine the appropriate special report code.

15. Do not enter a WORK REGISTRATION CODE.

16. Enter SPECIAL USE CODE and DATA if needed. See the Codes Appendix to determine the appropriate special use code and dates.

17. Do not enter a REFUGEE STATUS CODE or U. S. ENTRY DATE.

18. Enter DATE OF DEATH if the individual is deceased.

a. If DATE OF DEATH is entered, CASE TERMINATION REASON and DATE must also be entered.

b. The DATE OF DEATH must be:

(1) Before or the same as the CASE TERMINATION DATE;

(2) Before or the same as the current date; and

(3) The date of application or later.

19. Enter the two digit CITIZEN/ID code and the date (mmddccyy format). If the date of application is prior to September 1, 2006, the code is not required, but allowed. This date cannot be a future date. See the Codes Appendix to determine the appropriate CITIZEN/ID code and date.

20. Enter the RELATIONSHIP TO PAYEE code. See Codes Appendix to determine the appropriate code.

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

22. Do not enter WORK EXPERIENCE.

23. Do not enter GROSS EARNED INCOME.

24. Do not enter WORK EXPENSES.

25. Do not enter CHILD/ADULT CARE.

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

II. L. (CONT'D)

26. Do not enter NET EARNED INCOME.

27. Do not enter EDUCATIONAL LEVEL.

28. Enter type and date of EDUCATION provided. Refer to EIS 4100, Community Care of North Carolina, for more information.

29. 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.

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

M. SIGNATURES AND DATE

1. Enter the DATE COMPLETED.

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

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

III. SUBMIT THE DSS-8125 AND SUPPLEMENTAL NOTICE INFORMATION FORM TO DATA ENTRY FOR KEYING.

IV. OUTPUTS

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

A. BENEFITS ISSUED

1. Money

a. PRIOR MONTH checks are produced for the months and amounts indicated in the PRIOR MONTH PAYMENT fields on the DSS-8125. These checks are produced the night the approval form processes and are mailed to the recipient the next workday.

b. Checks are also produced for the period of time beginning with the MONTHLY PAYMENT EFFECTIVE DATE through the current calendar month. These checks are produced the night the approval form processes and are mailed to the recipient the next workday.

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

IV. A. (CONT’D)

c. For approvals processed between the fourth worknight from the end of the month and the end of the month, a separate check is produced for the next calendar month. This check is mailed the last working day of the month.

NOTE: DO NOT ISSUE COUNTY CHECKS FOR SPECIAL ASSISTANCE. ALL CHECKS MUST BE STATE ISSUED.

2. Medicaid

An annual Medicaid identification card for each individual on the case is produced the night the approval processes and mailed to the recipient the following workday.

B. CASE PROFILE

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

C. 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 S-AA or S-AD approval the night the DSS-8125 processes in the system unless “Y” is entered for “NOTICE OVERRIDE”.

B. The DISPOSTION REASON CODE 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 state 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.