DOCUMENTATION REQUIREMENTS

Transcription

1 DOCUMENTATION REQUIREMENTS INTRODUCTION Preface The primary purpose of basic documentation is to substantiate eligibility. A thorough interview is the cornerstone of accurate casework. The SUCCESS fields do not always capture all the aspects of an effective interview. Additional documentation may be required to address questionable or unclear information of each case. General Rules When a SUCCESS field alone fully and clearly documents a situation, additional documentation is not required. It is not necessary to do negative documentation. There are multiple codes to document types of verification. CS for client statement, is usually a clear enough documentation of the source of verification. TC for telephone call would never, alone, be adequate for documentation. LE for letter is sufficient documentation as long as letter is in case record or available for review. Examples: TC (telephone call) - requires documentation of the phone number called, the name of the person spoken to, the date of the contact and any other parts of the conversation that are relevant to the case. OT (other) - requires documentation of the source of verification. Include additional documentation as needed for clarification. Identification All documentation should start with the date of the action and include the case manager s last name and first initial and Worker ID. Customer Contact Center(s) should indicate the unit you work for (South GA, Metro, etc.). A blank line should separate the documentation for each date. VOLUME II/MA, MT 49 05/15 APPENDIX D-1

2 Documentation Requirements for //Family Medicaid Press F21 (Shift + F9) to access NARR //Family Medicaid All case actions Application, Change or Review Date and type of contact FTF (Face to Face), Alt (Alternate) or Telephone Who was interviewed HIPPA form mailed to AR or Authorized Representative if not in case record (not required for COMPASS applications) HIPAA form mailed to other adult AU/BG members including full name and date mailed ADDR If residential and mailing addresses are different For Supervisory Reviews Supervisor s name, date reviewed and accuracy of AU information. Indicate either No corrections needed or Corrections due by mm/dd/yy Verification checklist; verification requested and due date Fair Hearings Voter Registration: Valid value is sufficient with Y indicating client registered, N indicating client declined to register, and U indicating client did not return or provided no response on the Declaration Statement / Document date and attempt to contact applicant for interview For Claims thoroughly indicate all under-issuances, over-issuances, PIC referrals (Form 5667), claims actions and IPV disqualifications. Reminder: Always access the NARR screen from the ADDR screen to VOLUME II/MA, MT 49 05/15 APPENDIX D-2

3 ensure that the documentation is attached to the correct person. TCOS explained Cooperation with Quality Control explained Simplified Reporting Requirement explained Transitional Hardship extension Family Medicaid Request for three months prior coverage and verification requested Actions taken and any pertinent information regarding information entered on SDME screen for Medically Needy cases VOLUME II/MA, MT 49 05/15 APPENDIX D-3

4 Identity verification of Authorized Representative AREP If an AU member is living in a Drug/Alcohol Treatment Center and the name of the center Need for Protective Payee Subsidized Employment subsidy period VOLUME II/MA, MT 49 05/15 APPENDIX D-4

5 //Family Medicaid Name, age, and relationship of non-au/bg members and why they are not included in the AU/BG Denials, closures, and reductions entered by the CM (500 level codes) Changes in AU/BG composition (additions and deletions) Fair Hearings At application and review, if non-au members purchase and prepare meals separately and the criteria for separate AU status When a manual NOMI is sent for missed interviews (applications and reviews) /Family Medicaid Unusual relationships or financial responsibilities Receipt of GRG MSP and/or GRG CRISP, EIS, TSS, or WSP STAT Trace degrees of relationship of adult to child(ren) including paternity verification for paternal relatives, GRG AUs and source of verification Circumstances under which GRG MSP/CRISP or both were approved or terminated Family Medicaid Tax Filer/Non Tax Filer status, name of other person if filing jointly, and dependents claimed. Unusual relationships or financial responsibilities Dual Eligibility Final determination of three months prior request If another AU ID number is used to process request for Prior Months coverage, cross reference this AU ID For Newborn cases in which the child no longer resides with the mother and is now living with a female caretaker: This child is Newborn eligible. This child is the (grandchild, niece, nephew, etc.) of the head of household. Due to system limitations, it is not possible to code the relationship correctly. For Newborn cases in which the child no longer resides with the mother and is now living with a male caretaker: The child in this case is Newborn eligible. Due to system limitations, it is not possible for this VOLUME II/MA, MT 49 05/15 APPENDIX D-5

6 child to be in an F15 case because he/she lives with a male caretaker. This child is eligible through the month in which he/she turns 1. The 6 month review will be completed as a dummy review. VOLUME II/MA, MT 49 05/15 APPENDIX D-6

7 //Family Medicaid SSN/Client ID match discrepancies / Receipt/termination of out-of-state benefits and source of verification /Family Medicaid Date letter of non-cooperation received and any subsequent cooperation with DCSS Good Cause for failure to cooperate, if applicable Changes and discrepancies in AP information DEM1 Explanation if AP is unknown Any changes for APAD, APDE, APEM and APCO screens Minor parent living arrangements Any changes in deprivation Date 713 sent to DCSS for any other reason Family Medicaid If AP has health insurance for child(ren), why CSS referral was not made, including AP s name(s) If pregnancy terminated for any reason other than a live birth //Family Medicaid Resolution of Death Matches DEM2 Type of evidence used to verify citizenship if not fully explained by the valid value (CAPS program will use this information for documentation) / The reason and period for granting citizenship Good Cause Lawbreaker status date of offense and conviction; if conviction meets the lawbreaker criteria and how it was verified Circumstances resulting in penalty/disqualification for any fleeing felons or probation/parole violators Identity verification for Head of Household/AR (CAPS program will use this information for documentation) VOLUME II/MA, MT 49 05/15 APPENDIX D-7

8 Identity verification sources with no corresponding valid value will be coded as TR AU s statement of 1 st Offender status Verification of immunization and Good Cause Child s name and circumstances for non-custodial minor parents Reason for extension being granted for alienage verification VOLUME II/MA, MT 49 05/15 APPENDIX D-8

9 DEM2 (continued) Family Medicaid Start date if Reasonable Opportunity Period is allowed for citizenship/id Availability of TPL for all AU members on DEM2 01 (do not use TPL1 screen) Date DMA Form 285/COMPASS TPL page sent to Health Management Systems, Inc. if AR has TPL, or if there has been a change, on DEM2 01 for all AU members Details of non-cooperation for TPL, if applicable Documentation of Deemed Newborn status If HIPP referral was completed. //Family Medicaid Eligibility/ineligibility for each alien and how verified ALAS Clarify student status Verification of school attendance for 18 year old Unsatisfactory school attendance for minor parent; Good Cause if appropriate Each 12 month TFSP review and any change(s) PRCO DEM3 Any requirements that are coded No that should be coded as Yes (example service not available) Anytime that a requirement changes (example AR had CPS and now CPS has been closed) Failure to cooperate with a requirement, conciliation, and Good Cause Sanction information tracking of sanctions, including date and type of current sanction and date/findings of 12 month sanction panel review 44/47/Extension staffings VOLUME II/MA, MT 49 05/15 APPENDIX D-9

10 DEM4 FSME State-required ADTs for DV and ADA must be completed in full at each application and review Reason deductions were not given for potentially eligible AU members (such as current expenses or non-reimbursed expenses not verified) If Medicaid application is pending and if Medicare premium was not allowed as a deduction AU s statement of medical transportation expenses such as mileage to and from the doctor/pharmacy and total miles for transportation Computation or explanation of expenses given, if needed VOLUME II/MA, MT 49 05/15 APPENDIX D-10

11 RES1 RES2 RES3 TRAN //Family Medicaid Questionable situations including joint ownership Disposition of resources //Family Medicaid Inclusion or exclusion if valid value is not self-explanatory Disposition of resources //Family Medicaid Details of any resources if valid value is not sufficient Disposition of resources / Specifics of any transfers of resources //Family Medicaid Reason for termination of employment, end date and how verified ERN1 Copy and paste DOL information to REMA for AU members 16 years and older; if unable to copy and paste, document details Discrepancies in Clearinghouse information Results of any Work Number matches //Family Medicaid Hourly rate of pay ERN2 Tips, if not included in gross pay on pay stubs Reason any pay period is not considered representative pay Calculation of representative pay EVNC DEAL //Family Medicaid All documentation should be on ERN2 //Family Medicaid VOLUME II/MA, MT 49 05/15 APPENDIX D-11

12 Alien sponsor s name and address Child Support paid outside the home, to whom it is paid, and how the monthly amount is calculated /Family Medicaid For Deemor budgets: Names of person counted as IRS dependents For Allocation: to whom income can be allocated VOLUME II/MA, MT 49 05/15 APPENDIX D-12

13 //Family Medicaid If subsidized care is being provided CARE If contact is made with the AR, document dependent care arrangement if AU is eligible for dependent care deduction and none is allowed AU s statement of childcare transportation expenses such as mileage to and from the day care provider and total miles for transportation //Family Medicaid Date payments will begin or terminate Source and expected duration of any contributions Calculation of income amount UINC Results of UCB/SDX/BENDEX/$TARS matches and resolution of any discrepancies Amount and source of last third party verification if PH valid value entered at periodic review / Reason net, instead of gross, is used (i.e. UCB, SSA, SSI) /Family Medicaid Details of application for other benefits if not entered on screen; explanation for not requiring application when potentially eligible Circumstances of Voluntary Quit and work sanctions WORK SHEL Date Form 830 mailed for AB and MP Good Cause for not participating in applicant services If the shelter expenses are paid by anyone outside the home How this arrangement affects the household s eligibility for shelter VOLUME II/MA, MT 49 05/15 APPENDIX D-13

14 deductions and how the situation was verified, if questionable If the household shares expenses and their eligibility for the amounts that are paid Whether the insurance and taxes are included in the mortgage payment How the monthly shelter costs (rent, taxes, insurance) were calculated if paid more often/less often than on monthly basis If utilities are included in the rent Basis of Limited SUA Calculations of shelter proration of ineligible alien(s) VOLUME II/MA, MT 49 05/15 APPENDIX D-14

15 /Family Medicaid The reason the case is over the SOP The reason Expedited indicator changed MISC The reason for manual issuance, date of manual issuance, and the month and amount of manual issuance Financial management or questionable and unclear information regarding household circumstances Family Medicaid How first month of TMA was established VOLUME II/MA, MT 49 05/15 APPENDIX D-15

16 Employment Services All contacts regarding participation (Applicants and Recipients) Brief notes regarding all appointments (Applicants and Recipients) ESPR Job readiness level brief documentation to support determination of job readiness level and changes in job readiness level, i.e. work history, criminal background, etc. (Applicants only) Assigned applicant job search period (Applicants only) All referrals to providers for other services/resources (Applicants and Recipients) Initial TFSP and TFSP changes, including changes in job readiness level, with information supporting reason NOTE Actual screen is no longer consistent with current practice, so document following information: Date of TFSP (Reference form on file) ESWP Phase, long and short term goals along with supporting activities along with job readiness level FLSA calculation for Work Experience and Community Service (initial calculation and each review and update of this calculation) Completion of Agency will... ; Participant will... ; and Support Services provided fields from actual ESWP screen if there was not enough room to document this on the ESWP screen ESAC Contacts related to participant s progress in activity Application of deemed meeting or FLSA policy VOLUME II/MA, MT 49 05/15 APPENDIX D-16

17 If activity temporarily delayed or interrupted for Good Cause, document dates and reason participation is excused Negotiation/monitoring of sponsor agreements Explanation when hours entered does not reflect actual hours of participation due to deemed meeting criteria or other reasons (i.e. school breaks, site closures, excused absences), and if Good Cause granted VOLUME II/MA, MT 49 05/15 APPENDIX D-17

18 ESDC ESSS SUCCESS screen should capture all information When expenditure exhausted for a support service for the participation period Verification method for payment of SS Tracking of EIS, TSS and WSP Failure to meet a program requirement ESNO If conciliation appointment kept; closure date if not kept Result of conciliation Social Services notified Date of panel review for 12 month closure sanction ESWH ESAD SUCCESS screen should capture all information SUCCESS screen should capture all information VOLUME II/MA, MT 49 05/15 APPENDIX D-18

19 Documentation Requirements for ABD Medicaid/ Press F21 (Shift + F9) to access NARR ABD Medicaid/ All case actions Application, Change or Review Date and type of contact FTF (Face to Face), Alt (Alternate) or Telephone Who was interviewed HIPPA form mailed to AR or Authorized Representative if not in case record (not required for COMPASS applications) HIPAA form mailed to other adult AU/BG members including full name and date mailed ADDR For Supervisory Reviews Supervisor s name, date reviewed and accuracy of AU information. Indicate either No corrections needed or Corrections due by mm/dd/yy Fair Hearings Verification Checklist; verification requested and due date Voter Registration: Valid value is sufficient with Y indicating client registered, N indicating client declined, and U indicating client did not return or provided no response on the Declaration Statement ABD Medicaid Date Form 315 was given or mailed for all L01 cases and W01 cases over age 55 if form is not in case record Request for three months prior coverage and verification requested For Medically Needy, document actions taken and any pertinent information entered on SDME screen VOLUME II/MA, MT 49 05/15 APPENDIX D-19

20 If residential and mailing addresses are different Date and attempt to contact applicant for interview For Claims thoroughly indicate all under-issuances, over-issuances, PIC referrals (Form 5667), claims actions and IPV disqualifications. Reminder: Always access the NARR screen from the ADDR screen to ensure that the documentation is attached to the correct person. TCOS explained Transitional VOLUME II/MA, MT 49 05/15 APPENDIX D-20

21 AREP Identity verification of Authorized Representative If AU member is living in a Drug/Alcohol Treatment Center and the name of the center ABD Medicaid/ Name, age, and relationship of non-au/bg members and why they are not included in the AU/BG Reason for denials/closures entered by the ES (500 level codes) Changes in AU/BG composition (additions and deletions) STAT ABD Medicaid Unusual and/or financial responsibilities (example: Q-track couple split) Final determination of three months prior request If another AU ID number was used to process Prior Months, cross reference this AU ID At application and review, if non-au members purchase and prepare meals separately and the criteria for separate AU status When a manual NOMI is sent for missed interviews (applications or reviews) ABD Medicaid SSI ineligibility for Katie Beckett or unusual circumstances DEM1 SSN/Client ID match discrepancies Receipt/termination of out-of-state benefits and source of verification DEM2 ABD Medicaid/ Resolution of Death Matches Type of evidence used to verify citizenship if not fully explained by VOLUME II/MA, MT 49 05/15 APPENDIX D-21

22 the valid value ABD Medicaid Start date if Reasonable Opportunity Period is allowed for Citizenship/Identity Availability of TPL for all AU members on DEM2 01 (do not use TPL1 screen) Date DMA Form 285/COMPASS TPL page sent to Health Management Systems, Inc. if A/R has TPL, or if there has been a change, on DEM2 01 for all AU members Details of non-cooperation for TPL, if applicable Date DMA Form 327 sent to DCH upon death of recipient in L01 or W01 VOLUME II/MA, MT 49 05/15 APPENDIX D-22

23 Reason and period for granting Citizenship Good Cause Lawbreaker status date of offense and conviction; if conviction meets the lawbreaker criteria and how it was verified DEM2 (continued) Circumstances resulting in penalty/disqualification for any fleeing felons or probation/parole violators Identity verification for Head of Household/AR Identity verification sources with no corresponding valid value will be coded as TR AU s statement of 1 st Offender status ALAS ABD Medicaid/ Eligibility/ineligibility for each alien and how verified ABD Medicaid Katie Beckett: Date packet sent to GMCF Residence prior to admission and upon discharge for protection of income determinations Type of IME INST Reason for use of Diversion field; explain how the amount entered was obtained Reason for reconciliation and months affected Reason for use of Pat Liab Amount field; explain how the amount entered was obtained Hospital stays and how verified FSME Reason deductions were not given for potentially eligible AU members (such as current expenses or non-reimbursed expenses not verified) VOLUME II/MA, MT 49 05/15 APPENDIX D-23

24 If Medicaid application is pending and if Medicare premium was not allowed as a deduction AU s statement of medical transportation expenses such as mileage to and from the doctor/pharmacy and total miles for transportation Computation or explanation of expenses given, if needed ABD Medicaid/ Questionable situations including joint ownership Disposition of resources RES1 Inheritances ABD Medicaid Burial fund exclusions (life insurance, burial contracts, burial funds) For Promissory Notes, Loans and Property Agreements explain how the resource amount was determined VOLUME II/MA, MT 49 05/15 APPENDIX D-24

25 ABD Medicaid/ Inclusion or exclusion if valid value is not self-explanatory Disposition of resources RES2 ABD Medicaid Liens and rebuttal process and how equity value was determined (if applicable) Property search discrepancies Disposition of previously owned property Details of any excluded real property other than homeplace ABD Medicaid/ Details of any resource if valid value is not sufficient RES3 Disposition of resources ABD Medicaid Details of any amount entered as OC due to burial exclusion ABD Medicaid/ Details of any transfer and verification used TRAN ABD Medicaid Details of any recalculation of penalty and verification used Results of any Undue Hardship requests ABD Medicaid/ Reason for termination of employment, end date, and how verified ERN1 Copy and paste DOL information to REMA for AU members 16 years and older; if unable to copy and paste, document details Discrepancies in Clearinghouse information Results of any Work Number matches VOLUME II/MA, MT 49 05/15 APPENDIX D-25

26 ABD Medicaid/ Hourly rate of pay ERN2 Tips, if not included in gross pay on pay stubs Reason any pay period is not considered representative pay Calculation of representative pay EVNC ABD Medicaid/ All documentation should be on ERN2 ABD Medicaid/ Alien sponsor s name and address DEAL Child Support paid outside the home, to whom it is paid, and how the monthly amount is calculated VOLUME II/MA, MT 49 05/15 APPENDIX D-26

27 If subsidized care is being provided CARE If contact is made with the A/R, document dependent care arrangement if AU is eligible for dependent care deduction and none is allowed AU s statement of childcare transportation expenses such as mileage to and from the day care provider and total miles for transportation ABD Medicaid/ Date payments begin or terminate Source and expected duration of any contributions Calculation of income amount Results of UCB/SDX/BENDEX/$TARS matches and resolution of any discrepancies UINC Amount and source of last third party verification if PH valid value entered at periodic review ABD Medicaid Details of application for any other benefits if not entered on screen; explanation for not requiring application when potentially eligible Effective date of QIT and any pertinent details (non-compliance, funded date, deviant) Date that Pooled Trusts, SNTs and deviant QITs are sent to DCH and results Reason net, instead of gross, is used (i.e. UCB, SSA, SSI) PLAW ABD Medicaid How determination was made and why person is eligible Yearly COLA VOLUME II/MA, MT 49 05/15 APPENDIX D-27

28 WORK Circumstances of Voluntary Quit and work sanctions If the shelter expenses are paid by anyone outside the home SHEL How this arrangement affects the household s eligibility for shelter deductions and how the situation was verified, if questionable If the household shares expenses and their eligibility for the amounts that are paid Whether the insurance and taxes are included in the mortgage payment VOLUME II/MA, MT 49 05/15 APPENDIX D-28

29 How the monthly shelter costs (rent, taxes, insurance) were calculated if paid more/less often than on monthly basis SHEL (continued) If utilities are included in the rent Basis of Limited SUA Calculations of shelter proration of ineligible alien(s) ISM1 ABD Medicaid Details of determination of ISM, including manual budget or see Form 969 in case record ABD Medicaid Reason the case is over the SOP QMB override reason MISC Reason Expedited indicator changed Reason for manual issuance, date of manual issuance, and the month and amount of manual issuance VOLUME II/MA, MT 49 05/15 APPENDIX D-29