NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 4000

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CODES APPENDIX

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EIS 4000 CODES APPENDIX TABLE OF CONTENTS

I. DSS-8124/8125/8126 CODES

II. DMA-2041 CODES

III. DMA-5022 CODES

I. DSS-8124/8125/8126 CODES

II. DMA-2041 CODES

III. DMA-5022 CODES

EIS 4000 CODES APPENDIX TABLE OF CONTENTS

REVISED 02/01/11 – CHANGE NO. 03-11

I. DSS-8124/8125/8126 CODES

	PAGE
AID PROGRAM/CATEGORY/BENEFITS	1
ALIEN ID	1
AMBULATION CAPACITY	1
APPLICATION TYPE	1
AUTHORIZED REPRESENTATIVE RELATIONSHIP HIERARCHY	2
CASE STATUS	2
CITIZEN/ID	2
COUNTY NAME/NUMBER	5
DEDUCTIBLE BALANCE	5
EDUCATION HISTORY	5
EDUCATIONAL LEVEL	5
EPICS INDICATORS	5
ETHNICITY	6
FAMILY STATUS	6
FEDERAL POVERTY LEVEL	7
GRANDFATHERED STATUS	7
GRANT RECOUPMENT	8
HOW APPLICATION RECEIVED	8
JOBS/WORK PARTICIPATION/EXEMPTION	8
JOBS/WORK REQUIREMENT SAVINGS	8
LANGUAGE PREFERENCE	8
LIVING ARRANGEMENT	8
MEDICAID CLASSIFICATION	9
NC HEALTH CHOICE CLASSIFICATION	10
BREAST AND CERVICAL CANCER CLASSIFICATION	11
MEDICAID STATUS	11
PATIENT MONTHLY LIABILITY	11
PAYMENT TYPE	11
PROVIDER CODES	12
RACE	12
REFUGEE	13
RELATIONSHIP TO PAYEE	13
SEX	14
SPECIAL COVERAGE GROUP	14
SPECIAL NEEDS	15
SPECIAL REPORTING	15
SPECIAL REVIEW	16
SPECIAL USE DATA	18
SPOUSE INDICATOR	22
STEPPARENT INDICATOR	22
SUB PROGRAM	22
SUBSTITUTE PAYEE	23
VETERAN ASSISTANCE PAYMENT STATUS	23
WORK EXPERIENCE	23
WORK FIRST CHILD ONLY CASE	23

REISSUED 02/01/11 – CHANGE NO. 03-11

Table Of Contents (Cont’d)

II. DMA-2041 CODES

	PAGE
INSURANCE TYPE	23
RELATIONSHIP	24
THIRD PARTY INSURANCE COMPANIES	24

III. DMA-5022 CODES


SECTION B
Deductible Balance Amount	24
Patient Monthly Liability Amount	24
Pay Type	24
SECTION C
AMBULATION CAPACITY	25
CATEGORY OF ASSISTANCE	25
CODE	25
LEVEL OF CARE	25
TYPE	26

*** The following appendices contain Change, Disposition, Termination, and Transfer Codes for all aid program/categories.

Codes Appendix A – Work First Codes

Codes Appendix B - Medicaid Codes

Codes Appendix C - Refugee Assistance Codes

Codes Appendix D - Special Assistance Codes

Codes Appendix E – Transitional Codes

REVISED 02/01/11 – CHANGE NO. 03-11

EIS 4000 – CODES APPENDIX

I. DSS-8124/8125/8126 CODES

AID PROGRAM/CATEGORY/BENEFITS


AID PROGRAM	AID CATEGORY	DESCRIPTION	BENEFITS
A AF	Work First Assistance		B
H SF	Foster Care - Non Title IV-E Foster Care		M
I AS	Title IV-E Adoption Subsidy/Foster Care		M
M AA	Medicaid-Aid to the Aged		M
M AB	Medicaid-Aid to the Blind		M
M AD	Medicaid-Aid to the Disabled		M
M AF	Medicaid-Aid to Families with Dependent Children		M
M IC	Medicaid-Infants and Children		M
M PW	Medicaid-Pregnant Woman		M
M QB	Medicaid-Qualified Beneficiary		M
M RF	Medicaid-Refugees		M
M SB	Medicaid-Special Assistance to the Blind –obsolete effective 9/1/2010		M
R RF	Refugee Assistance		B
S AA	Special Assistance-Aid to the Aged		B
S AD	Special Assistance-Aid to the Disabled		B
S CD	Special Assistance-Certain Disabled		C

B=Both Cash and Medicaid C=Cash Only M=Medicaid Only

ALIEN ID

This code reflects a unique identification/file number assigned by USCIS (US Citizenship & Immigration Services-formally INS) to every alien who is admitted to the U.S. or who otherwise comes into contact with the agency. Key only the numeric part of the Alien ID. Most current Alien numbers are 8 or 9 digits, often with leading zeros.

AMBULATION CAPACITY


CODE	VALUE

A	Ambulatory (1995 Disenfranchised)
S	Semi-ambulatory (1995 Disenfranchised)
B	Basic SA (Non-Disenfranchised)
H	In Home Program
C	SA/ACH Special Care Unit
E	Basic SA (Exempt)

APPLICATION TYPE


CODE	VALUE

1	New Application
2	Reapplication
3	Administrative Add-An-Individual Application
4	New Application with Retroactive Benefits - Medicaid Only
5	Reapplication with Retroactive Benefits - Medicaid Only
6	Add-An-Individual Application
7	Administrative New Application (MAF and MIC Only)

REVISED 02/01/11 – CHANGE NO. 03-11

AUTHORIZED REPRESENTATIVE RELATIONSHIP HIERARCHY

Hierarchy	Relationship Type	EIS Code
First	Legal Guardian (includes DSS with custody or guardianship)	A
Second	Power of Attorney	B
Third	Health Care Power of Attorney	C
Fourth	Department of Social Services (placement responsibility only)	D
Fifth	Spouse (Not separated)	E
Sixth	Parent (for children under 21, a parent who is not the casehead but who lives in the home).	F
Seventh	Authorized Representative (An individual designated in writing by the applicant/recipient to assist with eligibility issues and who can have access to the information in the case file.)	G
Eighth	Authorized Representative as designated by SSA on SDX	H

CASE STATUS

CODE	VALUE

R	Recipient (See WF700 CODES for additional codes)

CITIZEN/ID

Individual Data (ID) Codes

CODE	DESCRIPTION	DATE – Required (MMCCDDYY)
10	A document from chart 1 was used to document citizenship and identity.	Date documentation was received
11	Citizenship and identity was verified by Social Security Administration.	EIS will automatically enter date SSA response was received
12	Citizenship and identity was verified but Social Security states there is an indication of death.	Date SSA response was received
25	A document from chart 2 was used to document citizenship and a document from chart 5 was used to document identity.	Date documentation was received

REISSUED 02/01/11 – CHANGE NO. 03-11

CITIZEN/ID CONT’D

35	A document from chart 3 was used to document citizenship and a document from chart 5 was used to document identity.	Date documentation was received
45	A document from chart 4 was used to document citizenship and a document from chart 5 was used to document identity.	Date documentation was received
50	Medicare, SSI, individuals receiving Social Security benefits on the basis of a disability (SSDI), Lawful Permanent Resident (LPR) recipient, or Title IV-B (HSF) child eligible under MIC. These individuals are excluded from documentation of citizenship and identity.	Date code entered in EIS
97	The applicant has indicated Y-Yes for citizenship but the SSA response does NOT indicate citizenship.	Date the first request for information is sent to the recipient for documentation of citizenship and identity.
98	Individual declares citizenship but there is no documentation in the record.	Date the record was checked (Ongoing NCHC cases prior to January 1, 2010 only)
99	Exparte situations where the individual is not required to provide citizenship and identity documentation until the next redetermination.	Date code entered in EIS.
51	Documentation of Lawful Permanent Resident status and identity.	Date documentation was received.
60	Documentation of REFUGEE status and identity.	Date documentation was received.
61	Documentation of ASYLEE status and identity.	Date documentation was received.
62	Documentation of CUBAN/HAITIAN status and identity.	Date documentation was received.
63	Documentation of AMERASIAN status and identity.	Date documentation was received.
64	Documentation of TRAFFICKING VICTIM status and identity.	Date documentation was received.
65	Documentation of “SI” (Special Immigrant) status and identity.	Date documentation was received.
66	Documentation of “SQ” (Special Immigrant) status and identity.	Date documentation was received.

REISSUED 02/01/11 – CHANGE NO. 03-11

CITIZEN/ID CONT’D

DSS-8124 Application SSA Response Codes

A	SSN is verified, there is no indication of death, and the allegation of citizenship is consisistent with SSA data.
B	SSN is verified, there is no indication of death, and the allegation of citizenship is NOT consistent with SSA data.
C	SSN is verified, there is indication of death, and the allegation of citizenship is consistent with SSA data.
D	SSN is verified, there is indication of death, and the allegation of citizenship is NOT consistent with SSA data.
E	Name, Date of Birth, or SSN not matching with SSA data.
V	Citizenshp and Identity was previously verified.

Refer to MA-3330, Citizen/Alien Requirements, to reference the documentation charts.

EXCEPTION: The following recipients do not require a code, but you may enter a code for the individual.

* SCD

* MPW presumptive

* HSF and IAS

* Automatic newborn

Administrative applications are exempt from citizenship entry. So are appeal reversals when the original date of application on the date screen is prior to 9/1/06.

You may enter a code for any individual that is active in EIS, including SSI Medicaid recipients. An individual only has one CITIZEN/ID code and date at a time. If a new code is entered, EIS uses the following hierarchy list to determine if the prior code is overlayed or does not change.

HIERARCHY: 10 overlays 25, 35, 45, 50, or 99

11 overlays anything except 10 or 25

12 overlays anything except 10, 11 or 25

25 overlays 35, 45, or 99

35 overlays 45 or 99

45 overlays 99

50 overlays 35, 45, or 99

97 can be overlaid by anything except 98 and 99

98 can be overlaid by anything except 99

99 can be overlaid by anything

51 and 60-66 can be overlaid by any code

50 can be overlaid by 51 and 60-66

NOTE: 10,11,12,25 can not be overlaid by any code.

If the wrong code is entered and it is not an overlay based in this list, your must delete the code. If the code is deleted, the date is deleted automatically. See EIS 3100 for how to delete data.) Key the correct code and date the next workday.

If the code is overlayed, the date is not changed unless you entered a new date when entering the new code.

REISSUED 02/01/11 – CHANGE NO. 03-11

COUNTY NAME/NUMBER

01 Alamance	26 Cumberland	51 Johnston	76 Randolph
02 Alexander	27 Currituck	52 Jones	77 Richmond
03 Alleghany	28 Dare	53 Lee	78 Robeson
04 Anson	29 Davidson	54 Lenoir	79 Rockingham
05 Ashe	30 Davie	55 Lincoln	80 Rowan
06 Avery	31 Duplin	56 Macon	81 Rutherford
07 Beaufort	32 Durham	57 Madison	82 Sampson
08 Bertie	33 Edgecombe	58 Martin	83 Scotland
09 Bladen	34 Forsyth	59 McDowell	84 Stanly
10 Brunswick	35 Franklin	60 Mecklenburg	85 Stokes
11 Buncombe	36 Gaston	61 Mitchell	86 Surry
12 Burke	37 Gates	62 Montgomery	87 Swain
13 Cabarrus	38 Graham	63 Moore	88 Transylvania
14 Caldwell	39 Granville	64 Nash	89 Tyrrell
15 Camden	40 Greene	65 New Hanover	90 Union
16 Carteret	41 Guilford	66 Northampton	91 Vance
17 Caswell	42 Halifax	67 Onslow	92 Wake
18 Catawba	43 Harnett	68 Orange	93 Warren
19 Chatham	44 Haywood	69 Pamlico	94 Washington
20 Cherokee	45 Henderson	70 Pasquotank	95 Watauga
21 Chowan	46 Hertford	71 Pender	96 Wayne
22 Clay	47 Hoke	72 Perquimans	97 Wilkes
23 Cleveland	48 Hyde	73 Person	98 Wilson
24 Columbus	49 Iredell	74 Pitt	99 Yadkin
25 Craven	50 Jackson	75 Polk	100 Yancey

DEDUCTIBLE BALANCE

CODE	VALUE

D	Deductible Balance

EDUCATION HISTORY

CODE	VALUE

MM	Mail
MF	Face to Face/Individual
MP	Phone
MG	Group

EDUCATIONAL LEVEL (SEE WF700 CODES)

EPICS INDICATORS


CLAIM INDICATOR		DISQUALIFICATION INDICATOR
CODE	VALUE	CODE	VALUE

N	No Claims	N	No Disqualification
Y	One or more claims	W	Work First Only Disqualification
		F	Food Assistance Only Disqualification
		B	Both Work First and Food Assistance

REISSUED 02/01/11 – CHANGE NO. 03-11

ETHNICITY


CODE	VALUE

N	Not Hispanic/Latino
U	Unreported
C	Hispanic Cuban
H	Hispanic Other
M	Hispanic Mexican American
P	Hispanic Puerto Rican

FAMILY STATUS


CODE		VALUE

A	Adult

		Only for Medicaid, Refugee, or Special Assistance/Aged, Blind, Disabled, and Medicaid/Special Assistance for the Blind and Special Assistance/Certain Disabled. Describes the applicant/casehead who is
		1.		Age 19 or over
		2.		Age 18-19 for whom no parental financial responsibility exists.

P	Parent (or expectantParent or expectant parent)
		Only for Medicaid, Medicaid Pregnant Woman, and Refugee Assistance describes:

		1.		The only parent in the case; or
		2.		If both parents are in the case, the parent that is not incapacitated; or
		3.		A stepparent who receives for his children by a previous marriage.
		4.		Both parents if unemployed parent case and no incapacity involved.
		5.		Family Planning (MAF-D) – Use this code if the individual has children.

I	Incapacitated Parent
			Only for Medicaid and Refugee Assistance. Describes an incapacitated parent when the other parent/stepparent is in the case.

REISSUED 02/01/11 – CHANGE NO. 03-11

FAMILY STATUS CONT’D


S	Stepparent
		Only for Medicaid and Refugee Assistance. Describes the stepparent when:
		1.	The parent is incapacitated and both are in the case; or
		2.	The parent is not in the case and the stepparent is acting as the specified relative.



0	Other Specified Relative
		Only for Medicaid and Refugee Assistance. Describes any specified relative other than the parent or stepparent. Family Planning (MAF-D) – Use this code if the individual has no children.

N	Needy/Essential Spouse
		Only for Medicaid.

NOTE: MEDICAID MUST BE CATEGORICALLY NEEDY WITH

GRANDFATHERED PROTECTION


C	Child
		Use in any aid program/category except Special Assistance cases. Describes any individual defined as a child by the policy of the appropriate program.

D	Child Custodial Parent
		Only for AAF. Describes any individual defined as a child by AAF policy who is also a parent.

FEDERAL POVERTY LEVEL


CODE	VALUE

2H	Equal to or less than 100% FPL
3A	101% up through 150% FPL
4A	151% up through 200% FPL

GRANDFATHERED STATUS CODES

MEDICAID ONLY


CODE	VALUE/EFFECTIVE DATE

1	Money payment case in 12-73 with essential spouse/enter 0174
2	Money payment case in 12-73 without essential spouse/enter 0174
3	Medicaid only Categorically Needy - No Money Payment case in 12-73/enter 0174
4	Medicaid Only Medically Needy Case in 12-73/enter 0174
5	Grandfathered State Residence/enter 0980

REVISED 02/01/11 – CHANGE NO. 03-11

SPECIAL ASSISTANCE CASES


CODE	VALUE

6	Money Payment case in 12-73 (Group I)/enter 0174

GRANT RECOUPMENT (See WF700) for additional codes


CODE	VALUE

A	Agency Errors
V	Intentional Program Violation
H	Inadvertent household Errors

HOW APPLICATION RECEIVED


CODE	VALUE

A	Aging Center
D	Department of Social Services
H	Health Departments
L	Low Income Subsidy from Social Security
M	Mail
P	Prison

JOBS/WORK PARTICIPATION/EXEMPTION CODES (See WF 700 CODES)

JOBS/WORK REQUIREMENT SAVINGS CODES (See WF 700 CODES)

LANGUAGE PREFERENCE


CODE	VALUE	CODE	VALUE	CODE	VALUE

EN	English	HI	Hindi	PC	Portuguese Creole
SP	Spanish	HM	Hmong	PG	Portuguese
AR	Arabic	HU	Hungarian	PO	Polich
CA	Cambodian	IT	Italian	RU	Russian
CH	Chinese	JA	Japanese	SC	Serbo-Croatian
FC	French Creole	KO	Korean	TA	Tagalog
FR	French	LA	Laotian	TH	Thai
GE	German	MI	Miao	UR	Urdu
GR	Greek	MK	Mon-Khmer	VI	Vietnamese
GU	Gujarati	PE	Persian	OT	Other

LIVING ARRANGEMENT


CODE	VALUE

10	Private Living Arrangement (not 1/3 reduction)
11	Private Living Arrangement (with 1/3 reduction) (Medicaid Only)
12	Living with Another Work First Family
13	Living with SSI Recipient(s)

REVISED 02/01/11 – CHANGE NO. 03-11

LIVING ARRANGEMENT CONT’D

Long-Term Care (MA)

50	Skilled Nursing Facility
58	Intermediate Care Facility
59	Intermediate Care Facility/Mental Retardation Center
60	Hospital, Over Thirty Days/Psychiatric Residential Treatment Facility (PRTF)

State Mental Hospitals

70	Cherry Hospital
71	Dorothea Dix Hospital
72	Umstead Hospital
73	Broughton Hospital
75	Other Medical Institution
76	Central Regional Hospital

Residential Care (SA or Foster Care)

51	Domiciliary Care, Five or Fewer Beds (SAA, SAD)
52	Domiciliary care, Six or More Beds (SAA, SAD)
53	Foster Care (MAF, MIC, HSF, IAS)
56	Adult Group Home (SAA, SAD, MAF, MRF)
57	Children's Group Home (MAF, MIC, MAF, HSF, IAS)
80	Adoptive Home (MAF, MIC, MRF, HSF, IAS)


CODE	PACE (Program of All Inclusive Care For the Elderly)

14	PACE Private Living Arrangement
15	PACE Living With SSI Recipient(s)
54	PACE Living in Nursing Facility

CODE	MEDICAID SUSPENSION

16	Medicaid suspended – Incarcerated (MAA, MAD, MIC-N, IAS, HSF, MPW, MAB, and MAF - excluding MAFD. NOTE: Exclude these Medicaid classes regardless of aid –program/category: F, H, O, R, U, or V.) program/category)
17	Medicaid suspended – Institution for Mental Diseases (IMD) (MAA, MAD, MIC-N, IAS, HSF, MPW, MAB, and MAF - excluding MAFD. NOTE: Exclude these Medicaid classes regardless of aid program/category: F, H, O, R, U, or V.)

MEDICAID CLASSIFICATION

Categorically Needy - The Medicaid Effective Date must be the first day of the month. (Authorization begins with the first day of the month all eligibility factors are met.)

REISSUED 02/01/11 – CHANGE NO. 03-11

MEDICAID CLASSIFICATION (CONT’D)

Medically Needy – The Medicaid Effective Date can by any day of the month.

(Authorization begins the date all eligibility criteria are met. In cases of excess resources and/or deductible that is the date countable resources are reduced to the resource limit or the date the deductible is met, whichever is later.)

Exception: MPW(P6)Presumptive Eligibility and Undocumented Alien Emergency Services – The Medicaid Effective Date can be any day of the month.

CODE	VALUE
B	Categorically Needy (Used only with MAABD or MQB)
C	Categorically Needy
D	Categorically Needy (Used only as MAF-D – Limited to Family Planning Services)
N	Categorically Needy- No Money Payment
Q	Categorically Needy (Used Only With Dually Eligible Cases or M-QB Cases)
F	Categorically Needy – No Money Payment – Emergency services for non-qualified aliens (includes non-immigrants and illegal and undocumented aliens)
G	Categorically Needy – No Money Payment – Full Medicaid coverage for qualified aliens (after 5 year ban or when five year ban does not apply)
H	Categorically Needy – No Money Payment – Emergency services for qualified aliens (during five year ban)
I	Categorically Needy – No Money Payment – Full Medicaid coverage for pregnant qualified alien
M	Medically Needy
X	Not applicable to the case
O	Medically Needy - Emergency services for non-qualified aliens (includes nonimmigrants and illegal and undocumented aliens)
P	Medically Needy – Full Medicaid coverage for qualified aliens (after 5 year ban or when five year ban does not apply)
R	Medically Needy - Emergency services for qualified aliens (during 5 year ban)
E	Qualifying Individual (Used Only With MQB).
1	Categorically Needy – No Money Payment (Used only as MIC-1-Expanded Medicaid) 185-200% (Under 1) 133-200% (Age 1-5)

NC HEALTH CHOICE CLASSIFICATION

CODE	NC HEALTH CHOICE VALUE

A	No Enrollment Fee (Federally Recognized Native Americans and Alaskan Natives/At or Below 150% FPL)
J	No Enrollment Fee
K	Enrollment Fee
L	Optional Extended Coverage
S	No Enrollment Fee (Federally Recognized Native Americans and Alaskan Natives/Above 150% FPL)

REISSUED 07/01/10 – CHANGE NO. 0111

BREAST AND CERVICAL CANCER MEDICAID CLASSIFICATION

CODE	BCCM VALUE

W	Full Regular Coverage (non-alien)
T	Full Coverage (qualified alien-after 5 year ban or 5 year ban does not apply)
U	Emergency Coverage (qualified alien-during 5 year ban)
V	Emergency Coverage (non-qualified alien; includes non-immigrant, Illegal, and undocumented)

MEDICAID STATUS


CODE	VALUE

A	Authorized
D	Deductible

PATIENT MONTHLY LIABILITY


CODE	VALUE

P	Patient Monthly Liability

PAYMENT TYPE


CODE	VALUE

1	One Payment Monthly
2	Two Payments Monthly (Prior to 04-01-2000)
	Pay-After-Performance (Effective 04-01-2000)
	Work First Benefits (Effective 10-01-2009)
4	Four Months Continued Medicaid (Child or Spousal Support)
5	Transitional Medicaid Only
6	Retention Services Only (Obsolete 11-09-1998)
7	Transitional Medicaid and Retention Services (Obsolete 11-09-1998)
9	Medicaid only
S	Suspended Case (No longer valid 04-01-2000) Work First Sanctioned case (Effective 01-01-2005)

REISSUED 07/01/10 – CHANGE NO. 01-11

PROVIDER CODES

AUTO ASSIGN INDICATOR

Code	Value

Y	Yes, PCP/HMO was assigned to the recipient
N	No, recipient chose PCP/HMO

CHANGE REASON CODES

Code	Value

01	Recipient moved or PCP office moved; transportation impedes access
02	Recipient’s PCP joined CA program recently
03	Third Party Insurance conflict
04	Recipient’s medical needs changed, i.e., another provider type needed
05	Recipient filed complaint against provider and desires to change
06	Recipient is linked to PCP or HMO in error
07	PCP or HMO disenrolls from program
08	Recipient is involuntarily disenrolled by PCP or HMO
09	Other (to be used for waiver tracking purposes and not lock-in)
10	Mass change – going from one PCP number to another PCP number
11	Mass change – PCP number to exempt number
12	Mass change – HMO to HMO

DISTANCE TO PCP L/M INDICATOR

Code	Value

L	Less than 30 miles or 45 minutes
M	More than 30 miles or 45 minutes

RACE


CODE	VALUE

A	Asian
B	Black
I	American Indian
P	Native Hawaiian or Other Pacific Islander
U	Unreported
W	White

REISSUED 11/01/10 – CHANGE NO. 02-11

REFUGEE STATUS CODE

CODE	VALUE (Country of Origin)	CODE	VALUE (Country of Origin)

AF	Afghanistan	LG	Latvia
AL	Albania	LI	Liberia
AO	Angola	MK	Macedonia
AM	Armenia	ML	Mali
AJ	Azerbaijan	MR	Mauritania
BO	Belarus	MX	Mexico
BN	Benin	MD	Moldova
BT	Bhutan	MW	Montenegro
BK	Bosnia & Herzegovina	NP	Nepal
UV	Burkina FASO (Uvolta)	NU	Nicaragua
BM	Burma	NG	Niger
BY	Burundi	NI	Nigeria
CB	Cambodia	MU	Oman
CM	Cameroon	PK	Pakistan
CT	Central African Republic	PN	Palestine
CD	Chad	PL	Poland
CH	China	RE	Reunion
CO	Columbia	RS	Russia
CF	Congo-Brazzaville	RW	Rwanda
HR	Croatia	SG	Senegal
CU	Cuba	SR	Serbia
CG	Democratic Republic of Congo (formerly Zaire)	SL	Sierra Leone
EG	Egypt	SO	Somalia
ER	Eritrea	SU	Sudan
ET	Ethiopia	TH	Thailand
GA	Gambia	TO	Togo
GH	Ghana	TU	Turkey
GV	Guinea	UR	USSR (old)
HA	Haiti	UG	Uganda
HO	Honduras	UP	Ukraine
IR	Iran	VE	Venezuela
IZ	Iraq	VM	Vietnam
IV	Ivory Coast	YM	Yemen
KZ	Kazakhstan	YO	Yugoslavia (old)
KE	Kenya	ZI	Zimbabwe
LA	Laos	OT	Other

RELATIONSHIP TO PAYEE (CASEHEAD)

CODE	VALUE

A	Spouse
B	Son
C	Daughter
D	Step Son
E	Step Daughter
F	Mother
G	Father

REISSUED 11/01/10 – CHANGE NO. 02-11

RELATIONSHIP TO PAYEE (CASEHEAD) (CONT’D)

CODE	VALUE

H	Mother-in-law
I	Father-in-law
J	Grandchild
K	Student
L	Self
M	Brother
N	Sister
O	Nephew
P	Niece
Q	Foster Child
R	Child Under Legal Guardianship/Custody
S	Other

(If SSI Medicaid, S-AA, or S-AD only valid code = L; If M-RF only valid codes = A or L)

SEX


CODE	VALUE

F	Female
M	Male

SPECIAL COVERAGE GROUP

CODE VALUE/DATE

NOTE: The “UP” code is no longer valid for MAF effective 08/01/1999, or for AAF effective 10/01/2005.

Case-Applicable to S-AA and S-AD Cases

LT Special Assistance Cases Awaiting a Higher Level of Care: Enter the six digit begin date that the FL-2/MR-2 is received recommending the higher level of care. Enter the six digit end date when an Fl-2/MR-2 is received indicating the recipient's condition has improved, and domiciliary care remains the appropriate level of care.

Community Alternative Program

AI-CAP/AIDS ICF-Obsolete 12/31/06	HC-CAP/Children Hospital-eff.11/01/95
AS-CAP/AIDS SNF-Obsolete 12/31/06	SC-CAP/Children SNF-effective 11/01/95
CI-CAP/DA ICF level of care	IC-CAP/Children ICF-Obsolete 08/01/10
CS-CAP/DA SNF level of care	CC-CAP/Children-prior to 11/01/95
CM-CAP-MR/DD ICF MR level of care (Comprehensive Waiver)	C2-CAP-MR/DD ICF MR level of care (Supports Waiver) effective 11/01/08

REVISED 02/01/11 – CHANGE NO. 03-11

SPECIAL COVERAGE GROUP (CONT’D)

ID-CAP CHOICE ICF level of care-in Duplin and Cabarrus counties – eff. 01/01/2005; in Forsyth and Surry counties – eff. 08/01/2007. Statewide eff. 01/01/2011

SD-CAP CHOICE SNF level of care-in Duplin and Cabarrus counties – eff. 01/01/2005; in Forsyth and Surry counties eff. 08/01/2007. Statewide eff. 01/01/2011

SPECIAL NEEDS

Code	Definition	Aid progam/category
1	SSI children and other disabled children who are not SSI eligible	MAD MAB SAD	EIS inserts special needs code 1
2	In foster care or other out-of-home placement	HSF	EIS inserts special needs code 2
2	In foster care or other out-of-home placement	MIC/MAF	Worker entry
3	Receiving foster care or adoption assistance	IAS	EIS inserts special needs code 3
3	Receiving adoption assistance	MIC/MAF	Worker entry
4	Self-identified	All except MAA and MQB	Worker entry

SPECIAL REPORTING


CODE	VALUE

U	Principal Wage Earner (No longer valid for MAF effective 08/01/1999, or for AAF effective 10/01/2005)
M	Minor Mother
I	Indian on Reservation
P	Passalong (Obsolete as of 12/02/2002)
L	Legally Designated Unearned Income
E	Employed
D	Disabled individual
C	Caretaker of deprived, dependent child (parent is only person in the case; child receives SSI)

REVISED 02/01/11 – CHANGE NO. 03-11

SPECIAL REVIEW

CODE	VALUE	DATE TO ENTER
1	Delete 1/3 disregard	Month and year disregard is to end
2	Income to begin	Month and year income to begin
3	Income to change (include receipt of seasonal income)	Month and year income to change
4	Income to end	Month and year income to end
5	Medical review	Month and year review is due
6	Reserve to increase	Month and year reserve to increase
7	Social Security/SSI (follow-up to application)	Month and year 90 days following application for Social Security/SSI
8	Follow-up to temporary age determination
9	Follow-up to projected date of final order of adoption	Month and year review is due
A	Adoptive child reaches age 18	Month and year case is to be terminated
B	Baby Due	Month and year baby is due
C	Review for contributions	Month and year review is due
D	Delete $30 disregard	Month and year disregard is to end
E	Earned income, disregard ends	Month and year the earned income disregard ends (Obsolete as of 08/16/03)
F	Disregard of full-time student's income ends	Month and year 6 months exclusions of earned income ends
G	Grant Recoupment Ends	Month and year Grant Recoupment Ends
H	Hardship Exemption Ends	Month and Year Hardship Exemption Ends (See WF700)
I	IV-E Foster Care child reaches age 19	Month and year case is to be terminated (Obsolete as of 11/22/2010)
J	Job Bonus Ends	Month and year that Job Bonus Ends Obsolete as of 11/6/00)(See WF700)
K	Work Exemption To End MMCCYY	Month and year work exemption is to end
L	Review for Living With	Month and year review is due
M	Review for Sale of Property	Month and year review is due
P	Evaluate Work First Benefits	Month and year to be evaluated
Q	Eval for sanction ending MMCCYY	Month and year to be evaluated
R	Real Prop Exclusion Ends	Month and year Real Property Exclusion from Reserve Ends

REVISED 02/01/11 – CHANGE NO. 03-11

SPECIAL REVIEW (CONT’D)

S	FL-2/MR-2 due	Month and year level of care review is due
T	Transitional to Terminate	Month and year transition period ends
U	Medicare Eligible	Month and year Medicare begins
V	Verify Current Alien Status	Month and year verification is due
W	Review for Work Registration	Month and year review is due
X	Rev Disqualification	Month and year review is due
Y	Review of Countable Resource	Month and year review is due
Z	Citizenship/Identity Due	Month and year documentation is due
DR	Delete Authorized Representative (Applicable to SAA/SAD and Medicaid cases only)	Month and year review is due

SPECIAL REVIEW CODES APPLICABLE TO SAA/SAD CASES WITH SSI INCOME AND THE TOTAL COUNTABLE MONTHLY INCOME (TCMI) IS LESS THAN THE FEDERAL BENEFIT RATE(FBR)

CODE	VALUE	DATE TO ENTER
E	SSI 1/3 reduced ending (Effective 11/22/2010)	Month and year review is due
I	SSI In-Kind support/maint ending(Effective 11/22/2010)	Month and year review is due
N	SSI Couple deeming (Valid only with Ambulation Capacity Code ‘H’)	Month and year review is due
RS	SSI/SS recoupment	Month and year review is due
LI	Life Insurance cash accruing face value greater than $1500.	Month and year review is due
VA	VA only or SSI/VA only	Month and year review is due

SPECIAL REVIEW CODES (APPLICABLE TO SAA/SAD CASES WITH COMBINATION OF INCOME (RSDI, SSI, VA, etc)AND THE TOTAL COUNTABLE MONTHLY INCOME IS LESS THAN THE FEDERAL BENEFIT RATE:

CODE	VALUE	DATE TO ENTER
E	SSI 1/3 reduced ending	Month and year review is due
I	SSI In-Kind support/maint ending	Month and year review is due
N	SSI Couple deeming (Valid only with Ambulation Capacity Code ‘H’)	Month and year review is due
RS	SSI/SS recoupment	Month and year review is due
LI	Life Insurance cash accruing face value greater than $1500.	Month and year review is due
VA	VA only or SSI/VA only	Month and year review is due

REISSUED 02/01/11 – CHANGE NO. 03-11

SPECIAL USE DATA


CODE	VALUE/DATE

	Case - Applicable to H-SF only.

*HS	Prior to conversion 3/1/90, this case was in aid program/category H-SF. Child in foster care.

*PS	Prior to conversion 3/1/90, this case was in aid program/category P-SF. Child in adoptive placement.

*MR	Prior to conversion 3/1/90, this case was in aid program/category M-RC. Child in county custody.

*PR	Prior to conversion 3/1/90, this case was in aid program/category P-RC. Child in adoptive placement.

	Case - Applicable to I-AS and H-SF only.

FC	Enter for out-of-state foster care children along with the two digit alpha code for the state from which a child was placed in North Carolina. Refer to EIS 4050, III.

AS	Enter for out-of-state adoption assistance children along with the two digit alpha code for the state from which a child was placed in North Carolina. Refer to EIS 4050, III.

	Case - Applicable to I-AS only.

IF	Child in foster care. Enter the six digit date Medicaid eligibility begins.

	Case – Applicable to SAA and SAD only.

LI	Life Insurance Face Value Over $1500

REISSUED 02/01/11 – CHANGE NO. 03-11

SPECIAL USE DATA (CONT’D)



		Case - Applicable to M-AF only.

*MR		Prior to conversion 3/1/90, this case was in aid program/category M-RC or P-RC. Child in long-term care.

*THIS IS A SYSTEM CODE GENERATED AT 3/1/90 CONVERSION. DO NOT ENTER.

	Case - Applicable to M-PW only cases dispositioned with codes “P1”, “P2”, “P3”, “P4”, or “P6”.

PT	Provider Referred Timely: Enter the seven digit provider number preceded with zeroes.
PL	Provider Referred Late: Enter the seven digit number preceded with zeroes.

	Individual

SN	No longer valid. Effective 6/4/2001 Special Needs information is entered in the Individual Special Needs field.

	Individual - Aliens

CH	Qualified alien under age 19 for whom the 5 year ban of Medicaid eligibility does not apply. Enter the code “CH” along with the six digit month and year (MMCCYY) that eligibility begins and the six digit month and year (MMCCYY) that the child turns 19. The end date includes the month of the 19^th birthday.

P1	^1st pregnancy – Qualified alien who is pregnant for whom the 5 year ban of Medicaid eligibility does not apply. Enter the code “P1” along with the six digit month and year (MMCCYY) that eligibility begins and the six digit month and year (MMCCYY) that the postpartum period ends for the individual’s first pregnancy authorized under Medicaid.

P2	^2nd pregnancy – Qualified alien who is pregnant for whom the 5 year ban of Medicaid eligibility does not apply. Enter the code “P2” along with the six digit month and year (MMCCYY) that eligibility begins and the six digit month and year (MMCCYY) that the postpartum period ends for the individual’s second pregnancy authorized under Medicaid.

REISSUED 02/01/11 – CHANGE NO. 03-11

SPECIAL USE DATA (CONT’D)


P3	^3rd pregnancy – Qualified alien who is pregnant for whom the 5 year ban of Medicaid eligibility does not apply. Enter the code “P3” along with the six digit month and year (MMCCYY) that eligibility begins and the six digit month and year (MMCCYY) that the postpartum period ends for the individual’s third pregnancy authorized under Medicaid.
P4	^4th pregnancy – Qualified alien who is pregnant for whom the 5 year ban of Medicaid eligibility does not apply. Enter the code “P4” along with the six digit month and year (MMCCYY) that eligibility begins and the six digit month and year (MMCCYY)that the postpartum period ends for the individual’s fourth pregnancy authorized under Medicaid.

P5	^5th pregnancy – Qualified alien who is pregnant for whom the 5 year ban of Medicaid eligibility does not apply. Enter the code “P5” along with the six digit month and year (MMCCYY) that eligibility begins and the six digit month and year (MMCCYY) that the postpartum period ends for the individual’s fifth pregnancy authorized under Medicaid.

P6	^6th pregnancy – Qualified alien who is pregnant for whom the 5 year ban of Medicaid eligibility does not apply. Enter the code “P6” along with the six digit month and year (MMCCYY) that eligibility begins and the six digit month and year (MMCCYY) that the postpartum period ends.

	Individual – Hurricane Certification Period Extensions

AL	Hurricane Katrina (DMA Administrative Letter No. 11-05)
F1	Hurricane Frances (DMA Administrative Letter No. 03-05)
FL	Hurricane Floyd (DMA Administrative Letter No. 12-00, Addendum 2)
I1	Hurricane Isabel-1^st extension(DMA Administrative Letter No. 04-04)
I2	Hurricane Isabel-2nd extension(DMA Administrative Letter No. 04-04, Addendum 1)
LA	Hurricane Katrina (DMA Administrative Letter No. 11-05)
LR	Hurricane Rita (DMA Administrative Letter No. 11-05)
MS	Hurricane Katrina (DMA Administrative Letter No. 11-05)
TX	Hurricane Rita (DMA Administrative Letter No. 11-05)

	Individual - IEVS

CR	Enter the code “CR” along with the six digit date you are completing the data entry form. The code “CR” is used when an applicant/recipient has presented his social security card as verification of his number.

SS	Enter the code “SS” along with the six digit date the SS-5 or the DSS-8174 is submitted.

REISSUED 02/01/11 – CHANGE NO. 03-11

SPECIAL USE DATA (CONT'D)



VM	Enter the code “VM” along with the six digit date of the Enumeration Data Sheet or the date you resolve any discrepancy due to an invalid welfare ID on the Enumeration Error Report or a discrepancy in name, date of birth and/or sex from the report of social security numbers sent for revalidation.

VB	Enter the code “VB” along with the six digit date you are completing the data entry form. The code “VB” indicates a social security number verified by BENDEX or Third Party Query.

VC		Enter the code “VC” along with the six digit date you are completing the data entry form. The code “VC” indicates a social security number verified by MCI when a “V” is present on the validation screen.

VS		Enter the code “VS” along with the six digit date your are completing the data entry form. The code “VS” indicates a social security number verified by SDX.

		Individual - Medical Coverage Groups

NB		Newborn: Enter the six digit date coverage under this group begins and the last day of the month the child becomes one year old or the date coverage ends.

B1		(HCWD) Health Coverage for Workers with Disabilities-Basic Coverage Group – Equal to or less than 150% Federal Poverty Level. Effective May 1, 2009, B1 is obsolete as an individual Special Use indicator and was converted in EIS to a Sub Program indicator on the Medicaid Eligibility (IE) segment.

M5		(HCWD) Health Coverage for Workers with Disabilities-Medically Improved Coverage Group – Equal to or less than 150% Federal Poverty Level. Effective May 1, 2009, M5 is obsolete as an individual Special Use indicator and was converted in EIS to a Sub Program indicator on the Medicaid Eligibility (IE) segment.

		Individual – Passalong (Dates Not Required)

PC		Passalong Cola
PD		Passalong Disabled Adult Child (DAC)
PW		Passalong Widow(er)

REISSUED 02/01/11 – CHANGE NO. 03-11

SPOUSE INDICATOR (Valid Only For MAA, MAB, MAD and MQB)


CODE	VALUE

Y	Yes (There is a spouse in the home or community spouse for LTC)
N	No (There is not a spouse in the home or community spouse for LTC)

STEPPARENT INDICATOR

(Financially Responsible Adults)

The following codes apply only to RRF, MAF, MIC, and MRF.


CODE	VALUE

0	No financially responsible adult other than those included in the case
1	Stepparent with earned income
2	Stepparent with no earned income
3	Parent or legal guardian of a minor parent with earned income
4	Parent or legal guardian of a minor parent with no earned income
5	Other financially responsible adult with earned income
6	Other financially responsible adult with no earned income

SUB PROGRAM


CODE	VALUE

B1	(HCWD) Health Coverage for Workers with Disabilities–Basic Coverage Group-Equal to or less than 150% Federal Poverty Level
M5	(HCWD) Health Coverage for Workers with Disabilities-Medically Improved Group-Equal to or less than 150% Federal Poverty Level
B2	(HCWD) Health Coverage for Workers with Disabilities-Basic Coverage Group-151% through 200% Federal Poverty Level. (Suspended Effective 12/1/09).
M6	(HCWD) Health Coverage for Workers with Disabilities-Medically Improved Group-151% through 200% Federal Poverty Level. (Suspended Effective 12/1/09).
MF	Money Follows the Person for CAPMR, CAPDA, CAP Choice, PACE individuals transitioning from institutional care into a qualified residence in the community

REISSUED 02/01/11 – CHANGE NO. 03-11

SUBSTITUTE PAYEE


CODE	VALUE

10	Legal Guardian
11	Personal Representative
12	Payee for Protective Payment
13	Trustee
14	Clerk of Superior Court (Name of Clerk)

NOTE: WHEN A SUBSTITUTE PAYEE IS ENTERED ON THE DSS-8125, THE SUBSTITUTE PAYEE NAME AS WELL AS THE CASEHEAD/PAYEE NAME IS PRINTED ON THE CHECK.

VETERAN ASSISTANCE PAYMENT STATUS


CODE	VALUE

Y	Yes (receiving VA benefits)
N	No (not receiving VA benefits)

WORK EXPERIENCE (See WF 700 CODES)

WORK FIRST CHILD ONLY CASE REASON CODES (See WF 700 CODES)

II. DMA-2041 CODES

INSURANCE TYPE


CODE	VALUE

00	Major Medical
01	Basic Hospital Surgical
02	Basic Hospital
03	Dental
04	Cancer
05	Accident
06	Indemnity
07	Nursing Home
08	Medicare Supplement
10	Major Medical and Dental
11	Major Medical and Nursing Home Coverage
12	Intensive Care Coverage
13	Hospital Outpatient Only Coverage
14	Physician Only Coverage
15	Heart Attack Only Coverage
16	Prescription Drugs Only Coverage
17	Vision Care Coverage

REISSUED 02/01/11 – CHANGE NO. 03-11

RELATIONSHIP


CODE	VALUE

A	Spouse
B	Son
C	Daughter
D	Step Son
E	Step Daughter
F	Mother
G	Father
H	Mother-in-law
I	Father-in-law
J	Grandchild
K	Student
L	Self
M	Brother
N	Sister
O	Nephew
P	Niece
Q	Foster Child

THIRD PARTY INSURANCE COMPANIES ADDRESSES AND CODES

A listing of insurance company names, addresses, and codes is available online. For inquiry procedures, refer to Third Party Recovery Inquiry,
EIS 1055. If you have any questions regarding a specific company or code that is not listed, contact TPR at the Division of Medical Assistance. Refer to
EIS 1200 for State Office contact information.

III. DMA-5022 CODES

SECTION B


CODE	VALUE

DB	Deductible Balance Amount
PML	Patient Monthly Liability Amount
Pay Type	Payment type on the case for the period of time for which Medicaid is authorized

REISSUED 02/01/11 – CHANGE NO. 03-11

SECTION C

AMBULATION CAPACITY (AMB.CAP.)


CODE	VALUE

A	Ambulatory (1995 Disenfranchised)
S B H D C	Semi-Ambulatory (1995 Disenfranchised) Basic SA (Non-Disenfranchised) In Home Program 2003 Disenfranchised SA/ACH Special Care Unit
E	Basic SA (Exempt)

CATEGORY OF ASSISTANCE (CAT OF ASST)


CODE	VALUE

A	Regular Work First Child Care
B	Work First UP Child Care (Effective 10/01/2005, the UP code is no longer valid for AAF)
C	Regular Work First JOBS Child Care
D	Work First UP JOBS Child Care (Effective 10/01/2005, the UP code is no longer valid for AAF)
E	Transitional Child Care
F	Regular Work First
G	Work First UP (Effective 10/01/2005, the UP code is no longer valid for AAF)

CODE


CODE	VALUE

I	Indian On A Reservation
R	Refugee

LEVEL OF CARE (LVL OF CARE)

CODE	VALUE

1	Center
2	Family Day Care Home
3	Care provided by a relative - in child's home
4	Care provided by a non-relative - inside child's home
5	Care provided by a relative - outside child's home

ISSUED 02/01/11 – CHANGE NO. 03-11

TYPE

STATE ISSUED CHECKS


CODE	VALUE

2	Adjusted Payment
3	Prior Month Request
5	SA Partial Payment Request
8	State Alexander V. Hill Penalty (Obsolete as of 05/02)
9	County Alexander V. Hill Penalty (Obsolete as of 05/02)

COUNTY ISSUED CHECKS


CODE	VALUE

6	Adjusted Payment
7	Regular Issue Request