Family and Children's Medicaid MA-3330 – ALIEN REQUIREMENTS

X. COVERAGE FOR EMERGENCY MEDICAL SERVICES

A. Principle

1. Non-qualified aliens are eligible for Medicaid for emergency medical services only. Also, qualified aliens during the 5-year disqualification period are eligible for Medicaid for emergency medical services only.

2. Evaluate the applicant who does not have citizenship and identity documentation after the 6 month pending period for emergency medical services if he states he has had an emergency.

3. This means the applicant who does not provide citizenship/identity documentation, the qualified alien who is not eligible for full coverage during the 5 year period from date of entry, and the non-qualified alien can only be authorized for Medicaid for the actual days he received an emergency medical service. An emergency medical service is defined in B.

4. The county departments of social services (DSS) determine the dates of coverage when the emergency service is labor and regular delivery or Caesarean delivery. The medical review staff determines for the Division of Medical Assistance (DMA) the dates of coverage for all other emergency services, including miscarriages and other pregnancy terminations.

Medicaid may not be authorized until after the emergency service has occurred. Follow procedures in this section to determine whether a non-qualified alien or qualified alien with a 5-year disqualification period is authorized for Medicaid and the dates of coverage.

B. Definition of Emergency Services

1. Labor and delivery, including delivery by Caesarean section, or

NOTE: For miscarriages and pregnancy terminations, follow procedures in D. to determine if and when an emergency existed.

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(X.B.)

2. Treatment after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in:

a. Placing the patient's health in serious jeopardy, or

b. Serious impairment to bodily functions, or

c. Serious dysfunction of any bodily organ or part.

NOTE: Once the medical condition is stabilized, even if it remains serious or results in death, it is no longer an emergency.

C. Procedures to Establish Authorization Dates for Labor and Delivery, including Delivery by Caesarean Section

1. When the IMC is notified that labor and delivery or a Caesarean section has occurred:

a. Contact the hospital and obtain information regarding the day of admission and delivery, and

b. Document the record with the information obtained from the hospital.

2. Vaginal Deliveries

a. Authorize one day if the day of admission and the day of delivery are the same day. Authorize one postpartum day. (2 total days)

b. Authorize two days if the day of admission and the day of delivery are consecutive days. Authorize one postpartum day. (3 total days)

Authorize one day if the day of admission and the day of delivery are not the same day and are not consecutive, authorize the day of delivery. Authorize one postpartum day. (2 total days)

3. Caesarean Section --Authorize a Caesarean section delivery for a maximum of 5 days beginning with the day the section is performed, i.e. day of Caesarean section plus 4 days maximum.

4. Determine other eligibility factors, including state residence. When all other eligibility requirements have been met, process the case as open/shut M-PW using the appropriate classification code according to EIS instructions.

NOTE: Regular delivery and Caesarean section do not include prenatal care, postpartum care, or the 60 days continuation period.

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(X. C.)

5. If the pregnant woman alleges other emergency medical services relating to her pregnancy, the days must be approved by DMA through a medical review. Follow instructions below.

6. If the due date is not within the 45 day processing period or the pregnant woman has not delivered by the 45th day, deny the application.

D. Procedures to Establish Authorization Dates for Other Emergency Medical Services

IT IS VERY IMPORTANT TO FOLLOW THESE PROCEDURES TO ASSURE THAT THE MEDICAL REVIEW STAFF HAS THE MEDICAL INFORMATION REQUIRED TO DETERMINE EMERGENCY STATUS OF A NON QUALIFIED ALIEN

1. If the applicant does not allege an emergency service, deny the application.

2. For an applicant eligible only under the Medicaid for the Disabled Program and disability is not established, follow instructions in MA-2525, Disability, in the Aged, Blind, and Disabled Medicaid Manual, to determine disability. The determination of emergency medical treatment by the medical review staff is a separate determination from the disability determination made by Disability Determination Services (DDS). Continue to process the application while awaiting a disability decision or approval of emergency dates from the medical review staff.

3. Approval or denial of date(s) of emergency medical services is made by the medical review staff for the Division of Medical Assistance (DMA), and is based on medical evidence submitted by the IMC.

4. When the request is for approval of an inpatient hospital admission, the following medical evidence is required:

a. Physician's order sheets,

b. Physician's progress notes,

c. Admitting history and physical,

d. Death summary, discharge summary, or interim summary:

However, if a discharge summary or interim summary is not readily available, send information in. The reviewer will determine if it is needed.

If the applicant has been hospitalized more than 60 days, the attending physician may submit an "interim summary" in lieu of the official discharge summary.

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(X.D.4.d)

(1) It must be clearly marked as "interim."

(2) The decision rendered will cover only the admission date through the interim summary cut-off date.

5. When the request is for approval for an emergency room, clinic, or doctor's office visit (there is no inpatient hospitalization), the following medical evidence is required:

a. Entire medical record for the date requested, and

b. Statement indicating "Emergency Room [or Clinic/Doctor's Office] Record Only - No Other Documentation."

6. Request the required evidence from the appropriate provider using the DMA-5133, Emergency Medical Services Request For Information.

7. The county must review information submitted by the hospital, clinic, and doctor. Ensure that the information received includes all required information for the dates requested. Check to see if the copies are legible. Faxed copies may not be clear. Ensure that the medical records received from the provider belong to the applicant. Do not send to the medical review contractor unless all necessary information is included for all dates requested.

8. When it is verified that all the necessary information has been received, attach it to the completed DMA-5135, Date (s) Of Emergency Services Requested For An Alien, and forward the medical records by CD, DVD, paper, or fax for the medical review:

MAXIMUS

Attn: Michele M. Kraynik RN, Esq.
Project Director, State Appeals
50 Square Drive, Suite 120
Victor, NY 14564

Fax number: 585-869-3355.

When completing the DMA-5135, Date (s) Of Emergency Services Requested For An Alien;

• Please type or print legibly.
• Fill form out completely with specific dates requested.
• Include the Medicaid Identification Number (MID) for the applicant the review is for (patient). This may be different from the case head. (e.g. A child is the patient but the mother is the case head. Use the child’s MID number.)

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(X. D.8)

• Include a county contact person, contact phone, fax number and e-mail address.
• Provide complete review dates. If it is for a period of time, provide a beginning date and an ending date to be reviewed.
• Do not request a review for dates that have previously been reviewed unless a hearing decision requires the re-submittal for a new decision.
• Do not request a review for labor and delivery unless the days exceed the number allowed per X. C. above.
• Submit medical records for each day being requested. Bills are not needed. Do not send medical records for dates you did not list on DMA-5135, Date (s) Of Emergency Services Requested For An Alien.

9. Information Submitted to The Medical Review Staff:

a. If during the initial review, the medical review staff determines that the information attached to DMA-5135, Date (s) Of Emergency Services Requested For An Alien, is incomplete or inaccurate, the entire package will be returned to the county DSS indicating what is missing or inaccurate on the DMA-5134, Emergency Medical Services Request For Missing Information.

(1) Request the missing, or correct information from the provider. Write on the DMA-5133, Emergency Medical Services Request For Information, "Additional Request for Information" and note items that are needed.

(2) Upon receipt of the missing, or correct information, re-submit the entire package to the medical review staff as soon as possible.

b. If during the medical review, the medical review staff determines that additional information is needed the DMA-5133, noting what is needed, will be faxed to the county.

(1) Request the additional information from the provider. Write on the DMA-5133, "Additional Request for Information" and note items that are needed.

(2) Upon receipt of the additional information, send the information and the DMA-5133, to the medical review staff as soon as possible.

10. When the provider states on the request that there is no additional information in the record, write on the DMA-5135, Date (s) Of Emergency Services Requested For An Alien, or on the DMA-5133, Emergency Medical Services Request For Information, "No additional information can be obtained," and re-submit to the medical review staff. This applies to this additional request only

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(X D.)

11. When the county DSS forwards the information to the medical review staff for a decision regarding a request for emergency services, the county DSS will receive from the medical review staff an acknowledgement of receipt. If acknowledgement is not received within 14 calendar days, call the medical review staff.

12. Do NOT have the hospital or other medical provider send the information directly to the medical review staff. Submission of all information goes through the county dss.

13. When sending information requested by the medical review staff, do not send a new DMA-5135, Date (s) Of Emergency Services Requested For An Alien. When a second one is completed and returned with the requested information, it appears to be a new request and can slow the review process.

14. When the required medical evidence has not been received from the provider or you have not received a decision from the medical review staff by the 45th day, deny the application for missing information following procedures in MA-3215, Processing the Application. However, if it is a MAD-90 application and disability is not established, continue to pend the application until you receive the disability determination or 6 months, whichever comes first.

15. If you receive notification from the medical review staff that date(s) have been approved as an emergency after you have denied the application, reopen following instructions in MA-3215, Processing the Application. Ensure the applicant meets all other eligibility requirements.

E. Approval and Authorization in EIS

1. The medical review staff will transmit the determination for emergency coverage with the dates of approval/denial indicated to the appropriate county DSS as a password protected attachment to an e-mail or via secure fax, depending on the capabilities and preferences of each county DSS office. Upon receipt, take appropriate action immediately.

2. The completed and signed DMA-5135, Date (s) Of Emergency Services Requested For An Alien, is mailed to the appropriate DSS within a week of the medical review staff’s faxed decision. The medical records are NOT returned.

3. Determine other eligibility factors, including establishing disability and/or state residence. When all other eligibility requirements have been met, process the case as open/shut in the appropriate aid program/category and the appropriate classification code. Refer to EIS instructions.

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(X. E.)

4. Authorize only the dates approved by the medical review staff. If multiple dates in a month are approved, but they are not consecutive, contact the EIS unit for assistance in keying.

NOTE: Inappropriate Medicaid authorization for this group of aliens will result in claims being charged to the county DSS.

5. If no days are approved by the medical review staff, deny the application.

F. Procedures to Establish Authorization Dates for Ongoing Hemodialysis

1. Follow procedures in D. and E. for the initial determination of emergency services for hemodialysis.

2. Once it is determined that the individual is eligible for hemodialysis, the medical review staff issues a blanket approval by stating “…all on-going hemodialysis …” on the faxed decision and on the DMA-5135, Date (s) Of Emergency Services Requested For An Alien, that you receive. For future applications for this individual, do not submit medical information for hemodialysis. The individual meets the emergency service’s criteria for each hemodialysis treatment. The approval of emergency services for hemodialysis is indefinite

3. Verify with the provider of hemodialysis the dates that the applicant received dialysis in the retroactive months and in the month of application.

4. Include in the approval letter the dates approved. Remind the individual when he needs to apply again by giving the month in which he next needs to apply.

5. Notify the applicant to reapply at least every four months. Each application is for the month of application and three months of retroactive coverage. After the initial application, further applications are administrative.

6. Do not issue Medicaid cards. Inform the client that NO Medicaid cards will be issued.

7. Because there are so many dates that a patient with renal disease must have dialysis, and because MMIS can accommodate only so much data before it begins to “drop” eligible dates, be conscientious to handle these cases timely.

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(X.F)

8. To authorize multiple dates in months that are not consecutive, contact the EIS Unit at 919-855-4000 for assistance.

NOTE: Inappropriate Medicaid authorization for this group of aliens will result in claims being charged to the county DSS.

Emergencies other than hemodialysis must be handled as any other request for emergency services, including a situation connected with the dialysis that results in a hospitalization or other need for emergency services.

NOTE: This procedure does not apply to peritoneal dialysis. Follow instructions in D. and E. for each application that includes peritoneal dialysis.