NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 3101

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CHANGES TO MEDICAID CASES

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EIS 3101 – CHANGES TO MEDICAID CASES

I. COMPLETING THE DSS-8125

II. SIGNATURES AND DATE

III. KEY THE DSS-8125.

IV. OUTPUTS

V. FOR ANY CHANGE NOT LISTED, SEE ”OTHER CHANGED DATA”

EIS 3101 – CHANGES TO MEDICAID CASES

CHANGE OF ADDRESS

REISSUED 02/01/11 - CHANGE NO. 03-11

I. COMPLETING THE DSS-8125

A. Use the following instructions to change the address of any active Medicaid case. If a numeric field requires less digits than spaces available, precede with zeroes.

1. Enter the CASEHEAD/PAYEE's name at the top of the form for filing purposes.

2. Enter the COUNTY NAME.

3. Enter the CASE ID from the current Case Profile.

4. Enter your assigned WORKER NUMBER.

5. Enter the COUNTY NUMBER from the current Case Profile.

6. Ensure the DISTRICT NUMBER on the Case Profile is correct.

If incorrect, enter the appropriate DISTRICT NUMBER.

7. Enter the AID PROGRAM/CATEGORY.

8. Enter ADDRESS LINE 1. See the Mailing Address Appendix, EIS-4050, for correct abbreviations. Do not enter punctuation or symbols in an address. For I-AS and H-SF, enter in care of (c/o) the adoptive parent, foster parent, or county director's name on ADDRESS LINE 1 . Always enter the apartment number or lot number on ADDRESS LINE 1 when the address is too long for one line.

9. Enter ADDRESS LINE 2 if an additional line of address is needed. Do not enter just Rd or St if there is not room on ADDRESS LINE 1. Do not enter this field if ADDRESS LINE 1 has not been completed. Use ADDRESS LINE 2 to enter the location where the Postal Service must deliver the mail. For long-term care cases, enter the name of the facility on Address Line 1.

Examples:

Line 1 Shady MHP Lt 39

Line 2 900 Stuckey Road

Line 1 c/o John Jones

Line 2 Rt 6 Box 46A

Line 1 Britthaven

Line 2 3409 Bond St

Line 1 Apt 10

Line 2 1187 W Johnston St

Actual Address ~ 287 Colonial Village Drive

Line 1 287 Colonial Vlg

Line 2 Blank

REVISED 02/01/11 - CHANGE NO. 03-11

I. A. (CONT’D) (CHANGE OF ADDRESS)

10. If the recipient is in the custody of the North Carolina Department of Corrections, enter the address as:

Medicaid Coordinator

Division of Prisons

831 W Morgan St

Raleigh NC 27603

11. Enter the FACILITY code if you want the automated DMA-5016 mailed to an address other than the case address. (FACILITY code is not required if same facility as case address.) If facility code is present, update or delete the code, if appropriate. Case must be LTC for FACILITY code to be entered. See EIS 1063, Automated DMA-5016.

12. Enter the CITY, STATE, and ZIP CODE. See the Mailing Address Appendix for correct abbreviations.

B. DO NOT ENTER the following data fields on the DSS-8125:

1. Verification Indicator

2. Change Code

3. Notice Override

4. Application Data

5. Case Termination Data

6. All Payment Data

7. Medicaid Effective Date

8. Retro MA 1 and 2

9. Work Experience

10. Educational Level

11. Issue CRD

NOTE: ALL OTHER FIELDS ARE OPTIONAL. A DETAILED EXPLANATION OF EACH FIELD IS INCLUDED IN ”OTHER CHANGED DATA”.

II. SIGNATURES AND DATE

A. Enter the DATE COMPLETED.

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

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

III. KEY THE DSS-8125.

REISSUED 02/01/11 - CHANGE NO. 03-11

IV. (CONT’D) (CHANGE OF ADDRESS)

IV. OUTPUTS

When the DSS-8125 processes successfully, the following are received:

A. Case Profile

An updated Case Profile is produced the night the change processes and is mailed to the county the following workday.

B. Automated DMA-5016-If the case is long term care, an automated DMA-5016 is produced the night the change processes and is mailed to the facility the next workday.

C. Caseworker Supervisor Report

All changes completed by an IMC are reported on the Caseworker Supervisor Report. The number of actions completed is determined from the WORKER NUMBER.