NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 4300

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COMPLETING AN APPLICATION FORM FOR NEW APPLICATIONS, REAPPLICATIONS,

AND ADD-AN-INDIVIDUAL APPLICATIONS FOR NC HEALTH CHOICE - PART TWO

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EIS 4300 - COMPLETING AN APPLICATION FORM FOR NEW APPLICATIONS, REAPPLICATIONS, AND ADD-AN-INDIVIDUAL APPLICATIONS FOR NC HEALTH CHOICE – PART TWO

I. GENERAL INFORMATION

II. NAME SEARCH AND INDIVIDUAL ID ASSIGNMENT

III. COMPLETING THE COMPUTER INPUT SCREEN IN EIS

EIS 4300 - COMPLETING AN APPLICATION FORM FOR NEW APPLICATIONS, REAPPLICATIONS, AND ADD-AN-INDIVIDUAL APPLICATIONS FOR NC HEALTH CHOICE – PART TWO

REVISED 12/01/03 - CHANGE NO. 04-04

I. GENERAL INFORMATION

The DSS-8124 screen is used to register a NC Health Choice application into EIS. See III. below and EIS 4900, Appendix B.

II. NAME SEARCH AND INDIVIDUAL ID ASSIGNMENT

Follow the existing procedures in EIS 1056 for completing a name search and individual ID assignment for NC Health Choice applicants. You may use an existing individual ID.

III. COMPLETING THE COMPUTER INPUT SCREEN IN EIS

NOTE: FOR KEYING INSTRUCTIONS, SEE EIS 4900, and APPENDIX B.

A. Use the following instructions to complete the DSS-8124 screen:

1. Form ID is system assigned.

2. Enter the TYPE APP.

a. Enter “1” (New Application); OR

b. Enter “2” (Reapplication); OR

c. Enter “6” (Add-an-Individual)

NOTE: If there is an existing MIC case for an individual and it is determined he becomes eligible for NC Health Choice, register a reapplication against the existing MIC case.

If there is an individual on a multi-person case who becomes eligible for NC Health Choice, delete the individual from the MIC case and register a new application for NC Health Choice for the individual.

If a NCHC case with class A, J, K, or S terminates because the family did not return the reenrollment timely but the family does return the reenrollment within the first 10 days of the following month and you determine the case would now be “L” class, register a reapplication against the closed case. Only individuals on the case at time of termination can be included if case is reopened into “L”.

If a family previously terminated from NCHC reapplies within the 12-month enrollment period established by the terminated case, you must register a new application in order for BCBS to give a new 12-month period. If a reapplication against the closed case is registered, BCBS will only update coverage from the point of reopen through the end of the previously established 12-month period.

Retroactive benefits are not allowed for NC Health Choice. Eligibility for Retro benefits must be evaluated as Medicaid.

REISSUED 12/01/03 – CHANGE NO. 04-04

III. A. (CONT’D) (COMPLETING AN APPLICATION FORM FOR NC HEALTH CHOICE)

3. Enter your assigned WORKER NUMBER.

4 Enter your COUNTY NUMBER.

5. Enter the COUNTY CASE NUMBER.

6. Enter the DISTRICT NUMBER.

7. ADDRESS - Enter the address beginning with ADDRESS LINE 1. Use the correct abbreviations to conserve space if the address is longer than the 18 spaces allowed for addresses. See the Mailing Address Appendix for correct abbreviations. Use ADDRESS LINE 2 if an additional line of address is needed.

If mail is sent in care of another person, enter that person’s name on ADDRESS LINE 1. Use ADDRESS LINE 2 to enter the location where the Postal Service must deliver the mail.

Examples:

Line 1 Albemarle Bldg

Line 2 325 N Salisbury St

Line 1 Strickland Rd

Line 2 Rt 2 Box 108

Line 1 Shady MHP Lt 39

Line 2 900 Stuckey Rd

Line 1 c/o John Jones

Line 2 Rt 6 Box 46A

NOTE: A NC HEALTH CHOICE CASE MUST HAVE A NORTH CAROLINA ADDRESS. If any other State is entered on the 8124, an error message displays when keying the 8125 to approve the case.

NOTE: Do NOT use a “#” sign in the address for NC Health Choice cases. Any data following this sign is deleted.

8. Enter “Y” for ADMIN if the application is administrative.

9. Do not use the TRANSITIONAL field. It does not apply to NC Health Choice (MIC).

10. CASE ID

a. NEW APPLICATION - The CASE ID is assigned by the system for each new application at the time the application is initially entered and accepted into the system.

b. REAPPLICATION - Enter the Case ID from the most recent Case Profile or from Name Search Inquiry.

REISSUED 03/01/10 – CHANGE NO. 03-10

III. A. (10) (CONT’D) (COMPLETING AN APPLICATION FORM FOR NC HEALTH CHOICE)

c. ADD-AN-INDIVIDUAL

(1) Case

Individuals may be added to a case when the application type is "6."

(a) Enter the Case ID of the case to which the individual(s) is being added.

(b) Obtain the Case ID from the current Case Profile or from Name Search Inquiry.

(2) Pending Application

When there is an application pending with application type "1," or "2,” a separate application may be completed as type "6" for additional individuals; however, this application cannot be approved until the first application has been approved to establish the case.

(a) Enter the application number of the pending application to which the individual(s) is being added.

(b) Obtain the application number from the Application Turnaround or from Name Search Inquiry.

(c) Enter the pending application number, including the letter "G," beside "Type 6" on the DSS-8124.

11. INDS ON APP - Enter the total number of individuals on this application.

a. Use an additional DSS-8124 if all individuals on a NC Health Choice (MIC) application cannot be entered on one form.

(1) Renumber the second DSS-8124 so that the line numbers are consecutive to those on the first page.

(2) Key the DSS-8124s or staple the forms together, with line number 01 on top, and submit to Data Entry.

b. The system does not allow more than 19 individuals on a NC Health Choice application. If you have an application with 20 or more individuals:

(1) Create a second (separate) application, and disposition it as a separate case.

(2) Enter the casehead/payee on Line 01 and mark "NO" for INCLUDED IN THE CASE on your second application.

REISSUED 03/01/10 CHANGE NO. 03-10

III. A. (11) (CONT’D) (COMPLETING AN APPLICATION FORM FOR NC HEALTH CHOICE)

(3) Continue with the remainder of individuals on the second application.

12. HOW APP RECEIVED? - Enter one of the following codes to indicate the source from which the NC Health Choice application was received:

a. “D” - County Department of Social Services.

b. “H” - Public Health Department.

c. “M” - By mail.

13. Enter a FOOD STAMP NUMBER for all cases receiving Food Stamps.

14. Enter the CITY, STATE, and ZIP CODE. See the Mailing Address Appendix to determine the appropriate state abbreviations.

15. Enter the AID PGM/CAT as MIC.

16. Do not use the MQB-QI1 field. It does not apply to MIC.

17. Enter a HLTH CH? indicator as follows:

a. Enter a ‘Y’ if the MIC application is for NC Health Choice.

b. Enter a ‘N’ if the MIC application is not for NC Health Choice.

If the aid program/category is entered as MIC, an indicator in this field must be entered on or before application disposition. If a “Y” is entered, the application date cannot be prior to October 1, 1998.

18. Enter C/H INCLUDE as “N” or “Y”.

19. Enter the LINE NUMBER beginning with 01.

20. Enter the INDIV ID for each person to be included on the application.

REVISED 03/01/10 – CHANGE NO. 03-10

III. A. (CONT’D) (COMPLETING AN APPLICATION FORM FOR NC HEALTH CHOICE)

21. Enter the following in the CTZ (Citzenship) field to document citizenship for each individual listed on the DSS-8124. There must be an entry for each individual listed on the DSS-8124.

a. “Y” - Individual is applying for assistance and states he is a U.S. Citizen.

b. “N” - Individual is applying for assistance and states he is not a U.S. Citizen.

c. “X” - Casehead is not applying for benefits or individual who states he is a U.S. Citizen and does not have a social security number.

NOTE: IF THE ID ENTERED IS UNKNOWN TO THE SYSTEM OR IF THE NUMBER DOES NOT MATCH THAT INDIVIDUAL, THE APPLICATION DOES NOT PROCESS.

22. Enter the APPLICATION DATE. This date cannot be before October 1, 1998.

DISPOSITION FIELDS ARE NOT USED IN APPLICATION REGISTRATION. REFER TO EIS 4300, PART FOUR, FOR INSTRUCTIONS ON HOW TO DENY OR WITHDRAW THE APPLICATION AT REGISTRATION.

B. Outputs

An application turnaround is produced overnight when the application is entered and accepted into the system and mailed to the county the next workday.