NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL
ELIGIBILITY INFORMATION SYSTEM EIS 4300
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NC HEALTH CHOICE APPLICATION DISPOSITIONS - PART FOUR
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EIS 4300 - NC HEALTH CHOICE APPLICATION DISPOSITIONS – PART FOUR
I. DENYING AN APPLICATION
II. WITHDRAWING AN APPLICATION
III. APPROVING THE APPLICATION
IV. ADD-ON APPLICATION APPROVALS
EIS 4300 - NC HEALTH CHOICE APPLICATION DISPOSITIONS – PART FOUR
REVISED 07/01/06 – CHANGE NO. 01-07
I. DENYING AN APPLICATION
A. Deny all applications in EIS using the DSS-8124 screen. Ensure the fields HOW APP RECEIVED and HLTH CH? are completed before denying the application.
B. Use the following instructions to deny a NC Health Choice application.
1. Enter data only in the PROSPECTIVE DISPOSITION fields. Retro benefits are not allowed for NC Health Choice.
2. Enter a denial code in the TYPE field.
3. Enter a DISPOSITION DATE. This is the date all factors have been verified that the applicant is ineligible. This cannot be a future date.
4. Enter the appropriate denial code in the REASON field. If the appropriate denial code is not used, you will be given an error message, “DENIAL CODE NOT VALID FOR NCHC”. See EIS 4300, Part Six, for denial codes.
5. Do not enter the notice override.
C. Signature and Date.
1. Sign in the CASEWORKER'S SIGNATURE field and enter the DATE if using a paper form.
2. The county director or his designee must sign and date the form in the DIRECTOR'S SIGNATURE and DATE field if using a paper form.
D. Key the DSS-8124.
E. Output
EIS produces a DSS-8124I Application Turnaround and the form is mailed to the county the next workday. It shows the denial information for the application.
F. Caseworker Supervisor Report
The denial is reported on the Caseworker Supervisor Report. The number of denials completed is determined from the WORKER NUMBER. NC Health Choice cases appear as M-IC on the Caseworker Supervisor Report.
G. General Information for Automated Denial Notices
1. The DSS-8109A, Notice of Denial or Withdrawal of Public Assistance, is a system generated notice.
REISSUED 07/01/06 – CHANGE NO. 01-07
I. G. (CONT’D)
2. The DENIAL REASON CODE entered on the DSS-8124 determines the text of the notice.
3. EIS calculates the 60th calendar day for the notice.
4. The date of the automated notice is the next state workday after the DSS-8124 processes. This is the date the notice is mailed to the recipient. A copy of the notice is not mailed to the county.
5. A Notice Register Report is produced each night and is mailed to the county the following workday. NC Health Choice cases appear as M-IC on the Notice Register Report. 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.
H. System generated DSS-8109A
1. The format is designed for a two-window envelope. The applicant's address is printed on the right with the county DSS's address printed in the upper left corner of the notice.
2. EIS prints the information for the DSS-8109A based on the data entered in EIS. The printed information includes:
a. Date Mailed
b. Worker Number
c. County DSS's Phone Number
d. County Case Number
e. Case ID
f. Date of Application
g. NC Health Choice
h. Applicant Name and Address
3. EIS indicates the application is denied and prints the reason for denial. The reason text printed on the notice is the same as the text in the denial codes table. Refer to EIS 4300, Part Six, for the denial codes. The appropriate policy manual reference is also indicated, as well as the 60th day from the date of the notice.
ISSUED 10/01/98 – CHANGE NO. 7-99
II. WITHDRAWING AN APPLICATION
A. Withdraw all applications using the DSS-8124 screen. Ensure the fields HOW APP RECEIVED and HLTH CH? are completed before withdrawing the application.
B. Use the following instructions to withdraw the NC Health Choice application.
1. Enter data only in the PROSPECTIVE DISPOSITION fields.
2. Enter a withdrawal code in the TYPE field.
3. Enter the DISPOSITION DATE. This is the date the applicant requests withdrawal of the application. This cannot be a future date.
4. Enter the appropriate withdrawal code in the REASON field. See EIS 4300, Part Six, for the withdrawal codes.
5. Do not enter the notice override.
C. Signature and Date.
1. Enter Caseworker Signature and date if using a paper form.
2. The county director or his designee must sign and date the form in the DIRECTOR'S SIGNATURE and DATE field if using a paper form.
D. Key the DSS-8124.
E. Outputs
A DSS-8124I Application Turnaround is produced and is mailed to the county the following day showing the application withdrawn.
F. Caseworker Supervisor Report
The withdrawal is reported on the Caseworker Supervisor Report. The number of withdrawals completed is determined from the WORKER NUMBER. NC Health Choice withdrawals appear on the Caseworker Supervisor Report as M-IC.
G. General information for Automated Notices
1. The DSS-8109A, Notice of Denial or Withdrawal of Public assistance, is preprinted to accommodate system issuance for NC Health Choice.
2. An automated notice (DSS-8109A) is produced for each NC Health Choice withdrawal the night the DSS-8124 processes in EIS.
ISSUED 10/01/98 – CHANGE NO. 7-99
II. G. (CONT’D)
3. The WITHDRAWAL REASON CODE entered on the DSS-8124 determines the text of the notice.
4. EIS calculates the 60th calendar day for the notice.
5. The date of the automated notice is the next state workday after the DSS-8124 processes. This is the date the notice is mailed to the recipient. A copy of the notice is not mailed to the county.
6. A Notice Register Report is produced each night and is mailed to the county the following workday. NC Health Choice cases appear on the Notice Register Report as M-IC. 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.
H. System generated DSS-8109A
1. The format is designed for a two-window envelope. The applicant's address is printed on the right with the county DSS's address printed in the upper left corner of the notice.
2. EIS prints the information for the DSS-8109 based on the data entered in EIS. The information entered includes:
a. Date Mailed
b. Worker Number
c. County DSS Phone Number
d. County Case Number
e. Case ID
f. Date of Application
g. NC Health Choice
h. Applicant Name and Address
3. EIS indicates the application is withdrawn and prints the reason for withdrawal. The reason text printed on the notice is the same as the text in the withdrawal codes table. Refer to EIS 4300, Part Six, for the withdrawal codes. The appropriate manual reference is also indicated, as well as the 60th day.
I. To ensure the applicant is notified in a timely manner, it is imperative that the DSS-8124 is keyed promptly. If not, the notice issuance is delayed.
REVISED 03/01/10 – CHANGE NO. 03-10
III. APPROVING THE APPLICATION
A. General Information
Use these instructions to complete the DSS-8125 screen. Ensure the fields HOW APP RECEIVED and HLTH CH? are completed on the DSS-8124 before approving the application.
NOTE: For keying instructions, see EIS 4900, Appendix B.
B. EIS retains data previously entered on the DSS-8124 screen. This information is brought forward on the DSS-8125 at application approval. For this reason, most of the information entered on the DSS-8124 screen need not be re-entered when the application is approved.
C. Use the NAME CHANGE screen to change or correct the following data before keying the DSS-8125 for approval:
1. Name
2. Social Security Number
3. Date of Birth
4. Sex
5. Race
D. Use the DSS-8124 screen to correct the following items before keying the DSS-8125 for approval.
1. County Number
2. Aid Program/Category
3. Individual ID Number
4. How App Received
5. Health Choice indicator
6. The “Z” (Citizenship) Code
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. New applications and reapplications are dispositioned exactly the same way.
REISSUED 03/01/10 – CHANGE NO. 03-10
III. (CONT’D)
F. A DMA-2041 is required when an applicant/recipient has health and/or accident insurance other than comprehensive health insurance. For example, a child is covered with dental insurance. This insurance must be reported to TPR.
Refer to EIS 3350, Instructions for Third Party Health and Accident Resources Information (DMA-2041).
G. Completing the DSS-8125 screen
If a numeric field requires less digits than spaces available, precede with zeroes.
1. CASE IDENTIFYING INFORMATION
REVISED 04/01/06 – CHANGE NO. 04-06
III. G. 1. (CONT’D)
H. Application Data
I. Case Termination Data
1. If approving the case in terminated status (Open/Shut), enter the CASE TERMINATION REASON and DATE. The date must be the last day of the CERTIFICATION THRU month. See EIS 4300, Part Six, to determine the appropriate termination reason code.
REISSUED 04/01/06 – CHANGE NO. 04-06
III. (CONT’D)
2. If approving a NC Health Choice reapplication and there is an ongoing MIC case, enter the OLD CASE TERMINATION REASON and DATE if all the individuals on the M-IC case are being approved for NC Health Choice.
J. DO NOT ENTER PAYMENT DATA.
K. Medicaid Data
1. Enter MEDICAID STATUS “A”.
2. Enter MEDICAID EFFECTIVE DATE.
a. This date must be the first day of the month.
b. This date must be equal to the CERTIFICATION FROM DATE.
c. This date must not be before 10/1/98.
NOTE: If the case is not eligible for NC Health Choice in the month of application, then the MEDICAID EFFECTIVE DATE and the CERT FROM DATE should equal the first day of the month of eligibility.
3. Enter the CERTIFICATION FROM DATE. BCBS calculates the
12-month enrollment period based upon the CERTIFICATION FROM DATE.
a. This date must be equal to or later than the month of application.
b. This date must be the first day of the month.
c. This date must be before the CERTIFICATION THRU DATE.
4. Enter the CERTIFICATION THRU DATE.
a. This date must be the last day of the month.
b. This date should always be 12 months from the CERTIFICATION FROM DATE.
NOTE: NC Health Choice cases should ALWAYS be given a
12-month CERTIFICATION PERIOD. There is no need to monitor the recipient’s age since individuals automatically terminate at age 19 and most other changes are not reacted to during the 12-month CERTIFICATION PERIOD.
c. If the CASE TERMINATION DATE is entered, the CERTIFICATION THRU DATE must be the same as the termination date.
REVISED 12/01/03 – CHANGE NO. 04-04
III. K. (CONT’D)
REISSUED 12/01/03 – CHANGE NO. 04-04
III. (CONT’D)
REISSUED 03/01/10 – CHANGE NO. 03-10
III. (CONT’D)
Q. Individual Data
The casehead name and the individual data for the individual(s) included on the case is 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 corrections.
BCBS requires all children in the household who are eligible for NC Health Choice to be on the same case in EIS even if they are budgeted separately. This does not apply to individuals eligible for Optional Extended Coverage (L class).
Enter the following data:
1. Enter the INDIVIDUAL TERMINATION DATE if an individual is not eligible in the ongoing case.
a. Do not enter if there is only one individual on the case.
b. This date must be the last day of the month of eligibility.
c. This date may be the date of application. This should only be entered if an individual is on the application but should not be included on the case.
d. This date must be before or the same as the current calendar month.
e. If DATE OF DEATH is entered, do not enter.
2. Do not enter CASE STATUS. EIS automatically enters “C”.
3. Enter the RSDI CLAIM NUMBER if the individual has Social Security benefits.
4. Enter “N” in MEDICARE A & B fields.
5. Do not enter FAMILY STATUS. EIS generates.
6. Enter a LIVING ARRANGEMENT CODE. This code must be the same for all individuals on the case. See the Codes Appendix in EIS 4000 to determine the appropriate living arrangement code.
7. Do not enter SPECIAL REPORT CODE.
REVISED 03/01/10 – CHANGE NO. 03-10
III. Q. (CONT’D)
REVISED 02/01/11 – CHANGE NO. 03-11
III. (CONT’D)
Blue Cross Blue Shield (BCBS) issues an identification card for the approval for the period beginning with the CERTIFICATION FROM DATE through the end of the twelve-month certification period. The card is mailed to the recipient the 2nd workday following the night the approval processes in EIS.
REISSUED 02/01/11 – CHANGE NO. 03-11
III. V. (CONT’D)
3. EIS calculates the 60th calendar day for the notice.
4. 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.
5. A Notice Register Report is produced each night and is mailed to the county the following workday. NC Health Choice cases appear as M-IC on the Notice Register Report. 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.
IV. ADD-ON APPLICATION APPROVALS
A. General Information
Use these instructions to complete the DSS-8125 screen. Ensure the fields HOW APP RECEIVED and HLTH CH? are completed on the DSS-8124 before approving the application.
NOTE: For keying instructions, see EIS 4900, Appendix B.
B. EIS retains data previously entered on the DSS-8124 screen. This information is brought forward on the DSS-8125 at application approval. For this reason, most of the information entered on the DSS-8124 screen need not be re-entered when the application is approved.
C. Use the NAME CHANGE screen to change or correct the following data before keying the DSS-8125 for approval:
1. Name
2. Social Security Number
3. Date of Birth
4. Sex
5. Race
D. Use the DSS-8124 screen to correct the following items before keying the DSS-8125 for approval.
1. County Number
2. Aid Program/Category
3. Individual ID Number
4. How App Received
5. Health Choice indicator
REVISED 03/01/10 – CHANGE NO. 03-10
IV. D. (CONT’D)
E. A DMA-2041 is required when an applicant/recipient has health and/or accident insurance other than comprehensive health insurance. For example, a child is covered with dental insurance. This insurance must be reported to TPR.
Refer to EIS 3350, Instructions for Third Party Health and Accident Resources Information (DMA-2041).
F. Completing the DSS-8125 screen
If a numeric field requires less digits than spaces available, precede with zeroes.
1. CASE IDENTIFYING INFORMATION
REISSUED 03/01/10 – CHANGE NO. 03-10
IV. F. 1. (CONT’D)
G. Application Data
1. Enter the APPLICATION NUMBER from the Application Turnaround.
2. Enter the ONGOING DISPOSITION REASON and DATE. RETRO disposition is not valid for NC Health Choice. See EIS 4300, Part Six, to determine the appropriate disposition reason code. It is very important to enter the correct disposition code as the automated notice is produced based on the reason entered on the DSS-8125. The disposition reason code determines the text of the notice.
H. Case Termination Data
If approving the case in terminated status (Open/Shut), enter the CASE TERMINATION REASON and DATE. The date must be the last day of the CERTIFICATION THRU month. See EIS 4300, Part Six, to determine the appropriate termination reason code.
I. DO NOT ENTER PAYMENT DATA.
REVISED 02/01/02 – CHANGE NO. 07-02
IV. (CONT’D)
J. Medicaid Data
1. Enter MEDICAID STATUS “A”.
2. Enter MEDICAID EFFECTIVE DATE. BCBS will calculate the enrollment period based upon the MEDICAID EFFECTIVE DATE of the add-on approval and the thru date of the existing case.
a. This date must be the first month of NC Health Choice eligibility for each individual being added.
b. This date must not be before 10/1/98.
c. This date must be before or the same as CASE TERMINATION DATE if CASE TERMINATION DATE is entered.
3. Do not enter the CERTIFICATION PERIOD FROM and THRU dates.
4. Enter MEDICAID CLASS. The Medicaid class MUST match the classification on the current case.
5. Do not enter DEDUCTIBLE BALANCE/PATIENT MONTHLY LIABILITY (DB/PML) Type or DB/PML AMOUNT.
6. Do not enter RETRO MA 1 or RETRO MA 2.
K. Earned Income
Do not enter earned income.
L. Unearned Income
M. Needs
1. Enter the MAINTENANCE AMOUNT. The amount must be a whole dollar amount. The amount must be more than or the same as the TOTAL COUNTABLE MONTHLY INCOME.
REISSUED 02/01/02 – CHANGE NO. 07-02
IV. M. (CONT’D)
2. Do not enter AMBULATION CAPACITY.
3. Do not enter DOMICILIARY RATE.
4. Do not enter TOTAL COUNTABLE MONTHLY INCOME.
N. Special Data
1. Do not enter the FOOD STAMP NUMBER.
2. Mark “YES” or “NO” for VA PAYMENT.
3. Enter SPECIAL REVIEW TYPE and DATE if needed.
a. If entered, the DATE must be after the ongoing month.
REISSUED 3/01/10 – CHANGE NO. 03-10
IV. N. 3. (CONT’D)
b. Not allowed for Open/Shut approvals.
c. See the Codes Appendix to determine the appropriate special review code and date.
4. Do not enter JOBS/WORK REGISTRATION/EXEMPTION data.
5. Enter SPECIAL USE CODE and DATA if needed. This is not allowed for Open/Shut approvals. See the Codes Appendix for codes and date information.
O. Do not enter Special Coverage Group Data.
P. Individual Data
The casehead name and the individual data for the individual(s) included on the case is 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 corrections.
EIS requires all children in the household who are eligible for NC Health Choice to be on the same case in EIS even if they are budgeted separately.
Enter the following data:
1. Enter the INDIVIDUAL TERMINATION DATE if an individual is not eligible in the ongoing case.
a. Do not enter if there is only one individual on the application.
b. This date must be the last day of the month of eligibility.
c. This date may be the date of application. This should only be entered if an individual is on the application but should not be included on the case.
d. This date must be before or the same as the current calendar month.
e. If DATE OF DEATH is entered, do not enter.
REVISED 03/01/10 – CHANGE NO. 03-10
IV. P. (CONT’D)
2. Do not enter CASE STATUS. EIS automatically enters “C”.
3. Enter the RSDI CLAIM NUMBER if the individual has Social Security benefits.
4. Enter “N” in MEDICARE A & B fields.
5. Do not enter FAMILY STATUS. EIS generates.
6. Enter a LIVING ARRANGEMENT CODE. This code must be the same for all individuals on the case. See the Codes Appendix in EIS 4000 to determine the appropriate living arrangement code.
7. Do not enter SPECIAL REPORT CODE.
8. Do not enter JOBS/WORK REGISTRATION/EXEMPTION.
9. Enter SPECIAL USE DATA CODE and DATA if needed. Do not enter if the approval is Open/Shut. See the Codes Appendix in EIS 4000 to determine the appropriate special use code and dates.
10. Do not enter REFUGEE STATUS CODE and U.S. ENTRY DATE.
11. Enter DATE OF DEATH, if applicable.
a. If the deceased is the only individual in the application, CASE TERMINATION REASON 52 is required if the date of death is entered.
b. The DATE OF DEATH must be before or the same as the CASE TERMINATION DATE.
c. The DATE OF DEATH must be less than or equal to the current date.
12. Enter CITIZEN/ID code and date.
13. Do not enter JOBS/WORK REGISTRATION/EXEMPTION data.
14. Do not enter WORK EXPERIENCE.
15. Do not enter GROSS EARNED INCOME.
16. Do not enter WORK EXPENSES.
17. Do not enter CHILD/ADULT CARE.
18. Do not enter NET EARNED INCOME.
REVISED 02/01/11 – CHANGE NO. 03-11
IV. P. (CONT’D)
19. Do not enter EDUCATIONAL LEVEL.
NOTE: WHEN THERE IS MORE THAN ONE INDIVIDUAL, USE A DSS-8126 AS A CONTINUATION OF THE DSS-8125 TO ENTER INDIVIDUAL DATA. If there are three or more individuals, use a second DSS-8126.
Q. Signatures and Date
1. Enter DATE COMPLETED and WORKER’S SIGNATURE field if using a paper form.
2. The county director or his designee must sign the form in the DIRECTOR'S SIGNATURE field if using a paper form.
R. Key the DSS-8125 and DSS-8126's.
S. Output
When the DSS-8125 has processed successfully, the following are received:
1. Benefits Issued
Blue Cross Blue Shield (BCBS) issues an identification card for the approval for the period beginning with the MEDICAID EFFECTIVE DATE through the end of the twelve-month certification period. The card is mailed to the recipient the 2nd workday following the night the approval processes in EIS.
EXAMPLE:
NC Health Choice approval processes in EIS on Monday night. Blue Cross Blue Shield receives the transaction on Tuesday and processes the approval Tuesday night. BCBS mails the identification card to the recipient on Wednesday.
If an approval processes in EIS on Friday night and Monday is a holiday, BCBS processes the approval on Tuesday night. BCBS mails the identification card to the recipient on Wednesday.
Blue Cross Blue Shield (BCBS) produces a separate identification card for each individual on the case.
2. Case Profile
EIS produces a Case Profile the night the approval processes. The profile is mailed to the county the following workday.
REISSUED 02/01/11 – CHANGE NO. 03-11
IV. (CONT’D)
