KAECSES NOTICES

TANF

CI

FA

GP

MA

MK

MP

MS

SI

Universal
Verification/Informational

Collateral
Contact Letters

KsCares NOTICES

Child Care

Work Programs

CC Provider


Notices that have been CHANGED or are NEW are highlighted in this color.

A notice that is listed with both the letter first and the letter last (e.g., F102/102F) means that the notice is available in both English and Spanish. Type the numeric/alpha number on the KAECSES "NORE" screen for the Spanish version.

 

KAECSES NOTICES

TANF and GPCG APPROVAL NOTICEs

A101/101A

TANF/GPCG - Approval for 1 Month Only + Reporting Requirements

A102/102A

TANF/GPCG - Approval for 1st and 2nd Months + Reporting Requirements

A103/103A

TANF/GPCG - Approval for 1st, 2nd and 3rd Months + Reporting Requirements

A104

TANF/GPCG - Denial 1st Month - Approval 2nd Month - CSS Assignment + Reporting Requirements

A105

TANF/GPCG - Denial 1st Month, Approval 2nd and 3rd Months + Reporting Requirements

A106

TANF/GPCG - Review Complete + Reporting Requirements

A107

TANF - Approval 1 Month Only - No CSS Assignment + Reporting Requirements

A108

TANF - Approval 1st and 2nd Months - No CSS Assignment + Reporting Requirements

A109

TANF - Approval 1st, 2nd and 3rd Months - No CSS Assignment + Reporting Req

A110

TANF - Denial 1st Month - Approval for 2nd Month - No CSS Assignment + Reporting Req

A111

TANF - Denial 1st Month - Approval for 2nd and 3rd Months - No CSS Assignment + Reporting Req

A112

TANF Denial - Diversion Payment Approved

A113

TANF Approved, Individual Disqualified, Fraud Non-Coop

A116

Pending TANF Approval-Protective Payee

A117

TANF Approval, Individual Disqualification, Felony Drug Conviction

A121

TANF Review/ Open Work Incentive Payment + Reporting Requirements

A128

TANF/GPCG Approval, no Work Programs + Reporting Requirements

A191

TANF/GPCG and FA - Approval for 1 Month Only + Reporting Requirements

A192

TANF/GPCG and FA - Approval for 1st and 2nd Months + Reporting Requirements

A193

TANF/GPCG and FA - Approval for 1st, 2nd and 3rd Months + Reporting Requirements

A196

TANF/GPCG and FA - Reviews Completed + Reporting Requirements

A197

TANF and FA - Approval for 1 Month Only - No CSS Assignment + Reporting Requirement

A198

TANF and FA - Approval for 1st and 2nd Months - No CSS Assignment + Reporting Req

A199

TANF and FA - Approval for 1st, 2nd and 3rd Months - No CSS Assignment + Reporting Req

   

TANF and GPCG DENIAL NOTICES

A200/200A

TANF/GPCG - Failure to Provide Information

A201

TANF - Failure to Cooperate

A202

TANF/GPCG - Residency Requirement Not Met

A203

TANF/GPCG - Loss of Contact

A204

TANF Denial-No Protective Payee

A206/206A

TANF/GPCG Denial - Excess Income

A207

TANF/GPCG - Resources Exceed Maximum

A208

TANF/GPCG - Denial - Other Reasons

A209/209A

TANF/GPCG - Application Withdrawn

A210

TANF/GPCG - Ineligible Assistance Unit

A211

TANF/GPCG - Citizenship/Alien Status

A212

TANF Denial - Failure to Complete AJS 

A213

TANF - Work Related Requirements Not Met

A214

TANF Denial, Fraud Non-Coop

A216

TANF Denial - CSS Requirements Not Met

A217

TANF Denial, Felony Drug Conviction

A218

TANF/GPCG Denial, No Eligible Child

A219

Withdrawal/Closure, Customer Request/Drug Test

A228

TANF Denial - Permanent Disqualification

A230

TANF Denial - 24 Month Time Limit

A240

TANF - Failure to Apply for Potential Benefits

A244

TANF App Denial- School Enrollment

A290/290A

TANF/GPCG and FA Denial - Failure to Provide Information

A291

TANF and FA Denial - Failure to Cooperate

A292

TANF/GPCG and FA Denial - Residency Requirement Not Met

A293

TANF/GPCG and FA Denial - Loss of Contact

A296

TANF/GPCG and FA Denial - Excess Net Income

A297

TANF/GPCG and FA Denial - Resources Exceed Maximum

A298

TANF/GPCG and FA Denial - Other Reasons

A299

TANF/GPCG and FA Denial - Applications Withdrawn

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TANF and GPCG CLOSURE NOTICES

A400

TANF - Failure to Provide or Verify Information

A401

TANF - Failure to Cooperate

A402

TANF - Residency Requirement Not Met

A403

TANF/GPCG - Loss of Contact

A404

TANF Closure – No Protective Payee

A406/406A

TANF - Closure - Excess Income

A407

TANF/GPCG - Resources Exceed Maximum

A408

TANF/GPCG - Closure - Other Reasons

A409

TANF/GPCG - Closure at Client's Request

A410

TANF/GPCG - Ineligible Assistance Unit

A417

TANF Closure, Felony Drug Conviction

A419

TANF Closure, Fraud Non-Coop

A420

TANF/GPCG - Closure - Excess Earnings

A421

TANF Closure – 1st Work Penalty

A422

TANF Closure –2nd Work Penalty

A423

TANF Closure –3rd Work Penalty

A424

TANF Closure –4th Work Penalty

A428

TANF Closure - No Work Programs

A430

TANF - Closure - 24 Month Time Limit

A431

TANF - Closure and FA Change - 24 Month Time Limit

A433

TANF Closure – 1st CSS Penalty

A434

TANF Closure –2nd CSS Penalty

A435

TANF Closure –3rd CSS Penalty

A436

TANF Closure –4th CSS Penalty TANF/WP

A440

TANF - Failure to Apply for Potential Resources

A443

TANF/GPCG - No Eligible Child

A444

TANF Closure - School Enrollment

A445

TANF Closure/FA Change-School Enrollment

A450

TANF/GPCG - Failure to Complete Review

A451

4 Month Extended Medical Closure

A479

TANF Closure/FA Change-Fraud Non-Coop

A480

TANF Closure/ FA Change- 1st Work Penalty

A481

TANF Closure/ FA Change- 2nd Work Penalty

A482

TANF Closure/ FA Change -3rd Work Penalty

A483

TANF Closure/ FA Change -4th Work Penalty

A485

TANF/GPCG, FA and CC Closure - Excess Income

A490

TANF/GPCG and FA Closure - Failure to Provide Information

A491

TANF and FA Closure - Failure to Cooperate

A492

TANF/GPCG and FA Closure - Residency Requirement Not Met

A493

TANF/GPCG and FA Closure - Loss of Contact

A496

TANF/GPCG and FA Closure - Excess Income

A497

TANF/GPCG and FA Closure - Excess Resources

A498

TANF/GPCG and FA Closure - Other Reasons

A499

TANF/GPCG and FA Closure - Client's Request

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TANF and GPCG REINSTATEMENT NOTICES

A600

TANF - Reinstate After Suspension

A601

TANF/GPCG - Erroneous Discontinuance

A602

TANF - Benefits Paid Pending Hearing Decision

A603

EM - Reinstate After Suspension

A690

TANF/GPCG and FA - Reinstatement Notice

   

TANF and GPCG CHANGE NOTICES

A701

TANF/GPCG - Change in Benefits - Other Reasons

A702/702A

TANF/GPCG - Supplemental Benefits

A703/703A

TANF/GPCG - Change in Household Members - Benefits

A704

TANF - Change in Benefits - Income Change

A705

TANF - Change in Benefits - Work Program Allowance

A706

TANF - Change in Benefits - Living Arrangements

A712

TANF/GPCG - Change to Zero Benefits - Information Pending

A713

TANF/GPCG - Change in Benefits - Recoupment

A715

TANF Change - Fraud Non-Cooperation

A716 Change in benefits/Fraud

A717

TANF Change, Felony Drug Conviction

A718

Suspicion-based Drug Testing Ineligibility Notice

A719

Negative Drug Test

A721

TANF - Change, Work Incentive Eligible

A740

TANF - Change Due to Cooperation With CSS

A741

TANF - Change - CSS Penalty

A744

TANF - Change Due to Cooperation - Work Programs

A745

TANF - Change - 1st Work Penalty

A747

TANF - Change Due to Cooperation - HIPPS

A748

TANF - Change - Non-cooperation With HIPPS

A750/750A

TANF/GPCG and FA Benefits and Income Changes

A751

TANF/GPCG and FA Change in Household Members

A752/752A

TANF/GPCG and FA Change to Zero Benefits - Information Pending

A753

TANF/GPCG and FA Change in Benefits - Recoupment

A754

TANF/FA Change-Fraud Non-Cooperation

A757

TANF Change, FA Change, Felony Drug Conviction

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TANF and GPCG MISCELLANEOUS NOTICES

A800 School Enrollment Verification

A802

Request For Information-Cohabiting Partn

A808

Notice of TANF Months Used

A821

TANF - Successful Families Notice

A822

TANF - Work Readiness Screening

A823

Sample Month Participation

A824

TANF and Work Programs - Important Change

A827

TANF/GPCG - Fraud Disqualification - Nonparticipating Individual

A828

TANF - Fraud Disqualification - Permanent

A831

TANF/GPCG - Repayment Agreement - Fraud - Recipient

A832

TANF/GPCG - Repayment Agreement - Agency/Client Recipient

A834

TANF/GPCG - Repayment Agreement - Non-recipient

   

TANF and GPCG SYSTEM GENERATED NOTICES

X004

Landlord/Residency Verification Request
*Must be manually requested on the ADDR Screen.

X012

TANF Work Incentive Closure

X014

Denial - Failure to Complete Interview Process

X015

Closure - No Review Return

X086

An Important Reminder from DCF

X088

Notice of TANF Months Used

   

TANF and GPCG MASS CHANGE NOTICE

Z046

TANF Mass Change

Z053*

, Z054, Z055, Z056

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CI APPROVAL NOTICES

C100

CI - Approval With or Without Spenddown

C121

CI - Approval LTC - 1 Month

C122

CI - Approval LTC - 2 Months

C123

CI - Approval LTC - 3 Months

C127

CI - Review Complete

C128

CI - Approval - Excess Liability - Spenddown Met

C129

CI - Approval - Excess Liability - Spenddown Unmet

C130

CI - Review - Spenddown Met - Excess Liability

C131

CI - Review - Spenddown Unmet - Excess Liability

 

 

CI DENIAL NOTICE

C208

CI - Denial - General

CI CLOSURE NOTICE

C400

CI - Closure - General

   

CI SUSPEND NOTICE

C504

CI - Suspension of LTC Payment - General

   

CI REINSTATEMENT NOTICE

C600

CI - Reinstate After Suspension

   

CI CHANGE NOTICES

C702

CI - Change in Patient Liability

C756

CI Mass Change/Chge in Obligation

   

CI NOTICES TO FACILITY

C911

CI - Facility Notice - Approval LTC - 1 Month

C912

CI - Facility Notice - Approval LTC - 2 Months

C913

CI - Facility Notice - Approval LTC - 3 Months

C918

Childcare Fraud Non-Cooperation Disqualification

C921

CI - General Denial

C941

CI - General Closure

C961

CI - Reinstate After Suspension

C971

CI - Mass Change

C972

CI - Facility Notice - Change in Patient Liability

C973

CI - Suspension LTC Payment

C974

CI - Review Complete - Remains Eligible

C978

CI - Facility - Excess Liability No Spenddown - Spenddown Met

C979

CI - Facility - Excess Liability - Spenddown Unmet

C980

CI - Review Complete - Excess Liability - Spenddown Met

C981

CI - Review Complete - Excess Liability - Spenddown Unmet

   

CI SYSTEM GENERATED NOTICES

X019

Reporting the Birth of Your Child

X025

Closure for Failure to Return Review

X056

Immunization Notice

X057

Immunization Notice - 12 Months

X086

An Important Reminder from DCF

   

CI MASS CHANGE NOTICE

Z047

CI Mass Change in Patient Liability

   

MEDIKAN APPROVAL NOTICES

D100

MediKan Approval (after 9/1/06)

D101

MediKan GA RN Approval (after 9/1/06)

D110

MediKan Review Complete (after 9/1/06)

 

 

MEDIKAN DENIALS NOTICES

D200

MediKan Denied - Failure to Provide Info

D201

MediKan Denied - Failure to Cooperate

D202

MediKan/Medicaid Denied Residency

D203

MediKan/Medicaid Denied - Loss of Contact

D204

MediKan Denied - Family of the Decreased

D205

MediKan Denied - Income Exceeds Max

D207

MediKan Denied - Resources Exceed Max

D208

MediKan Denied - Other Reasons

D209

MediKan/Medicaid Denied - Application WIthdrawn

D210

MediKan Denied - Application Withdrawn

D211

MediKan/Medicaid Denied - Citizenship

D212

MediKan Denied - Exceeds Lifetime Limit

D214

MediKan Denied - Fail Disability Criteria

D220

MediKan Denied - Failed Interview

 

 

MEDIKAN CLOSURE NOTICES

D400

MediKan - Fail to Provide Information

D402

MediKan Close/MCD Deny Residency

D403

MediKan Close/MCD Deny - Loss of Contact

D405

MediKan Closure - Income Exceeds Max

D407

MediKan Closure - Resources Exceeds Max

D409

MediKan Closure - Client Request

D410

MediKan Close/MCD Deny - Non Coop with PMDT

D411

MediKan Close/MCD Deny - SSA Denied

D412

MediKan Closure - Failure to Cooperate

D413

MediKan Closure - Other Reasons

D440

MediKan Close/MCD Deny - Potential Benefit

D450

MediKan Closure - Fail Complete Review

 

 

MEDIKAN REINSTATEMENT NOTICES

D600

MediKan Reinstatement

D602

MediKan Paid Pending Hearing Decision

 

 

MEDIKAN CHANGE NOTICES

D701

MediKan to Medicaid - SSA Approved

 

 

MEDIKAN MISCELLANEOUS NOTICES

   

D832

Open MediKan - Medicaid Pending

D854

Medikan Time Limit Information

   

FA APPROVAL NOTICES

F107/107F

FA Review complete – IR requirements

F111/111F

FA Approval for one month only + IR requirements 

F112/112F

FA Approval for 1st/2nd months + IR requirements

F113

FA Approval 1st/2nd/3rd months + IR requirements

F114

FA Deny 1st month/approve 2nd month + IR requirements

F115

FA Deny 1st month/approve 2/3 months + IR requirements

F121

Expedited Food Stamps - Postponed Verification

F131

FA Approval for one month only – No IR requirement

F132

FA Approval for 1st/2nd months – No IR requirement

F133

FA Approval 1st/2nd/3rd months – No IR requirement

F134

FA Deny 1st month/approve 2nd month – No IR requirement

F135

FA Deny 1st month/approve 2/3 months – No IR requirement

F137

FA Review Complete – No IR requirement (English and Spanish)

F138

FA approval for 1/2 months 24 month review period

F139 Approval for 1/2 months – no reporting requirement (categorically eligible)
F140 FA Review Complete – 24 mo review
   

FA DENIAL NOTICES

F200

FA - Failure to Provide Information - Reactivate Application (English and Spanish)

F201

FA - Failure to Cooperate

F202

FA - Residency Requirement Not Met

F203

FA - Loss of Contact

F205

FA - Income Exceeds Standard

F207

FA - Resources Exceed Maximum (English and Spanish)

F208

FA - Denial - Other Reasons

F209

FA - Application Withdrawn

F210

FA - Does Not Meet Household Requirement

F211

FA - Citizenship/Alien Status

F212

FA Denial – Potential Employment Violation

F216

FS Denial - ABAWD Requirements Not Met

F221

FA - Student Eligibility Criteria Not Met

F722

Failure to test

F723

Positive Drug test

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FA CLOSURE NOTICES

F400

FA - Failure to Provide or Verify Information

F401

FA - Closure - Failure to Cooperate

F402

FA - Residency Requirement Not Met

F403

FA - Loss of Contact

F405

FA - Income Exceeds Standard (English and Spanish)

F407

FA - Resources Exceed Maximum

F408

FA - General Closure - Other Reasons

F409

FA - Closure at Client Request

F410

FA - No Longer Meets Household Requirement

F416

FS Closure - ABAWD Requirements Not Met

F421

FA - Student Eligibility Criteria Not Met

F422

FA - Residing in an Institution

F424

FA - One Person Household Disqualified for Fraud

F426

FA - Added to Another Active Case

F427

FA Closure – Potential Employment Penalty

F428

FA Closure – Waived Potential Employment Violation

F448 FA - IR Non-Receipt Notice (English and Spanish)
F449 FA - IR Review Complete – Case Closure

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FA SUSPEND NOTICE

   

FA REINSTATEMENT NOTICES

F600

FA - Reinstate after Suspension

F601

FA - Erroneous Discontinuance

F602

FA - Benefits Paid Pending Hearing Decision

F604

FA - Interim Report Reinstatement (English and Spanish)

   

FA CHANGE NOTICES

F701

FA - Change in Benefits - Other Reasons

F702

FA - Supplemental Benefits (English and Spanish)

F703

FA - Change in Household Members(English and Spanish)

F704/704F

FA - Change in Benefits - Income Change

F705

Failed to Verify Deductible Expense

F706

FA - Interim Report Review Complete (English and Spanish)

F707

FA -12 month report review complete (English and Spanish)

F708

FA - Change in Benefits - Change in Household Deductions

F709

FA Comparable Penalty- 3 Months

F711

FA Change-Citizenship/Non-Citizen Status

F712

FA - Change to Zero Benefits - Information Pending

F713

FA - Change in Benefits - Recoupment

F716

FS Change in Benefits - ABAWD Requirements

F719

FA-Comparable Penalty – 6 Months

F720

FA-Comparable Penalty – 1 Year

F721

FA-Comparable Penalty- 10 Years

F722

FA Comparable -TANF Drug Testing

F723

FA Comparable -TANF Drug Positive Test

F726

FA Potential Employment Penalty

F744

Change Due to Coop. /Comparable Penalty

F745/745F

FA - Mass Change - Benefits Change

F746

FA - Change in Benefits - 2 Months

F747

FA-CSS Non-Coop Penalty

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FA MISCELLANEOUS NOTICES

F827

FA - Fraud Disqualification - Nonparticipating Individual

F828

FA - Fraud Disqualification - Permanent

F830

FA - Fraud Disqualification - Participating Individual

F831/831F

FA - Repayment Agreement - Fraud Participating Household

F832/832F

FA - Repayment Agreement - Agency/Client - Participating Household

F833/833F

FA - Repayment Agreement - Agency/Client - Nonparticipating Household

F834/834F

FA - Repayment Agreement - Fraud - Nonparticipating Household

F835/835F

FA - Repayment Agreement

F839

FA - Notice of Lost Benefits

F841

FA - Notice of Lost Benefits With Offsetting

F842

FA - Eligibility for Free School Meals

F843/843F

FA - Interim Report Form

F847/847F

Interim Report - Incomplete Notice

F845

FS - Important Information (ABAWD)

F850

FA - Adjustment Notice

   

FA SYSTEM GENERATED NOTICES

X004

Landlord/Residency Verification Request
*Must be manually requested on the ADDR Screen.

X019

Reporting the Birth of Your Child

X042

Failure to Provide Review Form

X044

Denial Failure to Complete Interview Process

X045

Notice of Missed Interview

X048

Interim Report Non-receipt Notice (English and Spanish")

X056

Immunization Notice

X057

Immunization Notice - 12 Months

X843

FA - Interim Report Form

X844

Spanish Interim Report form

X853

12 Month Report Form

X854

Spanish 12 Month Report form

   

FA MASS CHANGE NOTICE

Z048

FA - Change in Benefits (English and Spanish)

   

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MA APPROVAL NOTICES

M102

MA - Medically Needy Approval With Spenddown Met

M103

MA - Medically Needy Approval With Spenddown Not Met

M104

MA - CM - Approval - No CSS (English and Spanish)

M105

MA - CM - Approval With CSS (English and Spanish)

M106

MA - CM - Approval Due to TANF Eligibility (English and Spanish)

M107

MA - Prior Medically Needy Approved - Spenddown Met

M108

MA - Prior Medically Needy Approved - Spenddown Not Met

M110

MA - Medically Needy Review Spenddown Met

M111

MA - Medically Needy Review Spenddown Not Met

M112

MA - CM - Review Completed No CSS (English and Spanish)

M113

MA - CM - Review Completed (English and Spanish)

M114

MA - CM - Prior Medical Approval (English and Spanish)

M115

MA - CM - Prior Medical Approval Partial Denial No CSS

M116

MA - CM - Prior Medical Approval Partial Denial

M117

MA - CM - Prior Medical Approval - No CSS (English and Spanish)

M118

MA - CM - Expedited Pregnant Woman - No CSS (English and Spanish)

M119

MA - CM - Approval - Partial Denial

M123

MA - CM - Approval - Partial Denial - No CSS

M124

PE Ends / MA CM Approval No CSS (For Clearinghouse Use Only)

M125

PE Ends / MA CM Approval with CSS (For Clearinghouse Use Only)

   

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MA DENIAL NOTICES

M200

MA - Failure to Provide Information

M201

MA - Failure to Cooperate

M202

MA - Residency Requirement Not Met (English and Spanish)

M203

MA - Loss of Contact (English and Spanish)

M205

MA - Excess Income - Unlikely to Meet Spenddown

M206

MA - CM - Denial - Excess Income (English and Spanish)

M207

MA - Resources Exceed Maximum

M208

MA - Denial - Other Reasons

M209/209M

MA - Application Withdrawn

M211

MA - Citizenship/Alien Status

M212

MA - CM - Prior Medical Denial

M214

MA - CM - Denial Residency Requirement Not Met (English and Spanish)

M215

MA - CM - Denial Other Reasons

M216

MA - CM - Denial Loss of Contact (English and Spanish)

M217

MA - CM - Denial Citizenship/Alien Status (English and Spanish)

M218

MA - CM - Denial Application Withdrawn (English and Spanish)

M219

MA - CM - Denial Failure to Cooperate

M220

MA - CM - Denial Failure to Apply for Potential Benefits

M221

MA - CM - Denial Failure to Provide Information

M222

PE Ends / MA CM Denied Failure to Provide Information (For Clearinghouse Use Only)

M223

PE Ends / MA CM Denied Income Exceeds Maximum (For Clearinghouse Use Only)

M224

PE Ends / MA CM Denied Residency or Citizenship (For Clearinghouse Use Only)

M225

PE Ends / MA CM Denied Other Reasons (For Clearinghouse Use Only)

M240

MA - Failure to Apply for Potential Benefits

M241

MA Denial – FFM

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MA CLOSURE NOTICES

M400

MA - Failure to Provide or Verify Information

M401

MA - Failure to Cooperate

M402

MA - Residency Requirements Not Met

M403

MA - Loss of Contact

M404

MA - To the Family of the Deceased

M405

MA - Spenddown Not Met

M406

MA - CM Closure Excess Income Medical Continue (English and Spanish)

M408

MA - Closure - Other Reasons

M409

MA - Closure at Client's Request

M411

MA - CM - Failure to Complete Review

M412

MA - CM - Failure to Cooperate

M414

MA - CM - Failure to Provide Information

M415

MA - CM - No Eligible Individual

M416

MA - CM - Closure Client's Request

M417

MA - CM - Residency Requirements Not Met

M418

MA - CM - Closure Other Reasons

M419

MA - CM - To the Family of the Deceased (English and Spanish)

M443

MA - No Eligible Child

M450

MA - Failure to Complete Review

M451

MA - EM Extended Medical Closure

   

MA SUSPEND NOTICES

M500

MA - Suspend - General

M501

MA - Suspend - New Spenddown

M502

MA - CM - Suspend General

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MA REINSTATEMENT NOTICES

M600

MA - Reinstate After Suspension

M601

MA - Erroneous Discontinuance

M602

MA - Benefits Paid Pending Hearing Decision

M603

MA - CM - Erroneous Discontinuance (English and Spanish)

M604

MA - CM - Benefits Paid Pending Hearing Decision (English and Spanish)

M605

MA - CM - Reinstate after Suspension No CSS (English and Spanish)

M606

MA - CM - No CSS Benefits Paid Pending Hearing Decision (English and Spanish)

M607

MA - CM - No CSS - Erroneous Discontinuance (English and Spanish)

M608

MA - CM - Reinstate After Suspension

   

MA CHANGE NOTICES

M700

MA - Change - General

M701

MA - Medially Needy Change Spenddown Amount

M702

MA - CM - To Extended Medical

M703

MA - CM - Approval - TransMed - No CSS  (English and Spanish)

M704

MA - Medically Needy Spenddown Now Met

M705 MA-CM to Transmed  

M706

MA - CM - Excess Income - Medical Continues for Some Household Members

M707

MA - CM - First CSS Penalty

M709

MA - CM - Reinstatement Following CSS Penalty

M710

MA - CM - Approval TransMed Closure (English and Spanish)

M711

MA RM - Excess Income - Eligible Extended Medical

M712

TransMed End - Excess Income - Medical Continues

M713

MA - Prior Medically Needy Spenddown Now Met

M714

MA - Prior Medically Needy Change Unmet Spenddown

M715

MA to TransMed With 6 Month Eligibility

M716

TransMed Close - Fail Return Income - Medical Continues for Some Members

M717

TransMed Close - Fail to Provide Information - Medical Continues for Some Members

M718

TransMed 6 Month Review - Medical Continues

M719

TransMed 6 Month Income Review Letter

M720

TransMed Denial - Information Untimely - Medical Continues

M721

Newborn Approval - Month of Birth Only

M750

MA - Mass Change - Change in Unmet Spenddown

M751

MA - Mass Change - Change in Met Spenddown

   

MA MISCELLANEOUS NOTICES

M801

MA - Caseload Transfer

M802

Potential Spenddown Information Notice

M803

Reporting Requirements for Family Medical (send for all MACM approvals) (English and Spanish)

M834

MA - Notice of Repayment

M836

MA - The Medically Needy Health Plan

M837

MA - Medical Card Returned

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MA SYSTEM GENERATED NOTICES

X019

Reporting the Birth of Your Child

X020

SSN Reminder

X056

Immunization Notice

X057

Immunization Notice - 12 Months

X065

MA - CM Closure for Failure to Return Review

X086

An Important Reminder From DCF

X095

HealthWave - 21 and HealthWave 19 - HealthConnect Kansas - Closure Failure to Return Review

   

MA MASS CHANGE NOTICES

Z050

MA Mass Change - Change in Unmet Spenddown

Z051

MA Mass Change - Change in Met Spenddown

Z052

MA Mass Change - Results in Spenddown

Z053

MS Mass Change/Spenddown Change

Z054

MS Mass Change/Spenddown Change

Z055

MS Mass Change/Spenddown Change

Z056

MS Mass Change/Change in Client Obligation

Z057

Mass Change

   

MK APPROVAL NOTICES

K103

Presumptive Eligibility Approval Information (For Clearinghouse Use Only)

   
 

MK CLOSURE NOTICES

K406

PE Ends / Other Reasons (For Clearinghouse Use Only)

K407

PE Ends / Prior PE within 12 Months (For Clearinghouse Use Only)

   
 

MK ReinSTATEMENT NOTICES

K603

PE Reinstatement (For Clearinghouse Use Only)

   
   

MP APPROVAL NOTICES

P100

Expedited MP-Postponed Verif. No CSS (English and Spanish)

P101

MP - Medicade Approval (English and Spanish)

P102

MP - Pregnant Woman Medicaid Approval (English and Spanish)

P103

MP-Medicaid Approval/Partial Denial

P105

MP-Prior Medical Approval (English and Spanish)

P106

MP-CHIP Approval  (English and Spanish)

P107/107P

MP - Blended Approval (English and Spanish)

P108

MP-CHIP Approval/Partial Denial

P109

MP-Medicaid Review Completed (English and Spanish)

P110

MP-CHIP Review Complete (English and Spanish)

P111

MP-Blended Review - Late Review (English and Spanish)

P112

MP-CHIP Review/Late Review (English and Spanish)

P113

MP-Blended Review - Coverage Change  (English and Spanish)

P114

MP-Blended Review Complete (English and Spanish)

P115

MP-Blended - Late Review - Coverage Change       (English and Spanish)

P116

Prior Medical Approval - Partial Denial

P117

Pregnant Woman Approval - Added to an Open Case

P119

PE Ends - Medicaid Approval (For Clearinghouse Use Only)

P120

PE Ends - CHIP Approval (For Clearinghouse Use Only)

P121

PE Ends - Blended Approval (For Clearinghouse Use Only)

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MP DENIAL NOTICES

P200

MP - Denial - Failure to Provide Information

P201

MP - Denial - Failure to Cooperate

P202

MP - Denial- Residency Requirements Not Met (English and Spanish)

P203

MP - Denial - Loss of Contact (English and Spanish)

P204

MP - Prior Medical Denial

P205

MP - Denial - Income Exceeds Maximum (English and Spanish)

P206

PE Ends / MP Denied Failure to Provide Information (For Clearinghouse Use Only)

P207

PE Ends / MP Denied Income Exceeds Maximum (For Clearinghouse Use Only)

P208

MP - Denial - Other Reasons

P209

MP - Application Withdrawn (English and Spanish)

P210

PE Ends/CHIP Denial Health Insurance or State Employee (For Clearinghouse Use Only)

P211

MP - Denial - Citizenship/Alien Status Met (English and Spanish)

P213

PE Ends / MP Denied Residency or Citizenship (For Clearinghouse Use Only)

P215

MP - Denial Failure to Cooperate With HIPPS

P216

CHIP Denial - Health Insurance (English and Spanish)

P217

CHIP Denial - Access to State insurance

P218

CHIP Denial - Already have Medicaid (English and Spanish)

P219

MP-CHIP Denial - 8 month Waiting Period

P221

PE Ends / MP Denied Other Reasons (For Clearinghouse Use Only)

P222 MP- Approval with MACM Denial

P224 

MP Denial – FFM

   

MP CLOSURE NOTICES

P400

MP - Closure - Failure to Provide or Verify Information

P401

MP - Closure - Failure to Cooperate

P402

MP - Closure - Residency Not Met (English and Spanish)

P403

MP - Closure - Loss Of Contact

P404

MP- Closure - Deceased Individual (English and Spanish)

P405

MP - Closure - Income Exceeds Maximum

P408

MP - Closure - Other Reasons

P409

MP - Closure - Client's Request  (English and Spanish)

P416

MP - Closure - Failure to Cooperate With HIPPS

P443

MP - Closure - No Eligible Individual

P444

MP - Closure - Postpartum Period Ends (English and Spanish)

P445

MP Closure - PW Coverage Ends, Newborn Not Reported

P450

MP - Closure - Failure to Complete Review

P451

MP- CHIP Closure - Failure to Pay Premiums

P452

MP- CHIP Closure - Other Health Insurance Coverage

   

MP SUSPEND NOTICE

P500

MP - Suspend - General

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MP REINSTATEMENT NOTICES

P600

MP - Reinstate After Suspension

P601

MP- Reinstate - Erroneous Discontinuance

P602

MP- Reinstate - Pending Hearing Decision

   

MP CHANGE NOTICE

P700

MP - Change General

P701

MP- Blended - Child Added

P702

MP - CHIP - Premium Now Required

P703

MP - CHIP - Premium Amount Change

P704

MP - Medicaid - Child Added

P705

MP - CHIP - Child Added

P721

MP - Newborn Added Month of Birth Only

   

MP MISCELLANEOUS NOTICES

P801

Medical - Caseload Transfer

P803

Reporting Requirements for Children's Medical (send for all MP approvals) (English and Spanish)

P834

MP - Notice of Repayment

   
 

MP SYSYEM GENERATED NOTICES

X019

Reporting the Birth of Your Child

X020

SSN Reminder Notice

X056

Immunization Notice

X057

Immunization Notice - 12 Months

X065

MA/CM Close for Failure to Return Review

X094

MP - Failure to Complete Interview Process

X095

Closure for Failure to Return Review

X105

Presumptive Eligibility Coverage Ending

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MS APPROVAL NOTICES

N101

MS Approval Without Spenddown

N102

MS Approval With Spenddown Met

N103

MS Approval With Spenddown Not Met

N104

TB Approval

N105

Working Healthy Approval - No Premium

N106

Working Healthy Approval - With Premium

N107

HCBS Approval - No Obligation

N108

HCBS Approval - with Obligation - 1 Month

N109

MS Review Complete Without Spenddown

N110

MS Review Complete With Spenddown

N111

MS Review Complete With Spenddown Not Met

N112

Approval - Special Medical Program

N113

MS Review-Spenddown Not Met - QMB Benefits Continues

N114

MS - Prior Medical Approval Without Spenddown

N115

MS Prior Medical Approval with Spenddown Met

N116

MS Prior Medical Approval with Spenddown Unmet

N117

WH Prior Medical - No Premium

N118

WH Prior Medical - With Premium

N119

WH-MI Approval - No Premium

N120

WH-MI Approval - With Premium

N121

NF Approval - One Month

N122

NF Approval - Two Months

N123

NF Approval - Three Months

N124

Approval - NF Deny - 1st Mo/ Approve 2nd Mo

N125

Approval - NF Deny - 1st & 2nd Mo/ Approve 3rd Mo

N126

Approval - NF Deny - 1st Mo/ Approve 3nd & 3rd Mo

N127

MS-AC Review Complete

N128

MS Approval/Excess Liability/Spenddown Met

N129

MS Approval/Excess Liability/Spenddown Unmet

N130

MS Review/Excess Liability/Spenddown Met

N131

MS Review/Excess Liability/Spenddown Unmet

N134

HCBS Approval - with Obligation - 2 Months

N135

MS HC App-1 mo with Oblig-Prior Met Spenddown

N136

HCBS App -2 Mo- with Oblig -Prior Met Spenddown

N137

HCBS App -1 Mo- with Oblig -Prior Unmet Spenddown

N138

MS HC App-2 mo with Oblig-Prior Unmet Spenddown

N141

Approval for Expanded LMB and Subsidy D Benefits

N142

BCC Approval

N143

PACE Approval No Obligation

N144

PACE Review Complete

N145

TB Review

N146

WH-MI Review - No Premium

N147

PACE Approval One Month With Obligation

N148

Pace Retro Approval - Existing Case

N149

PACE Approval - Two month With Obligation

N150

Working Healthy Review - No Premium

N151

Working Healthy Review - With Premium

N152

WH Desk Review Complete - No Premium

N153

WH Desk Review Complete - With Premium

N154

MS-HC Review Complete - No Obligation

N155

MS-HC Review Complete - With Obligation

N160

MS - QMB Approval - MIPPA

N161

MS - LMB Approval - MIPPA

N162

MS - ELMB Approval - MIPPA

N173

Review Complete for Expanded LMB-Only Benefits

N192

MS/FA Approval-No Spenddown-FA 1st & 2nd Mos.

N193

Approval for LMB and Subsidy D Benefits

N194

Review Complete for LMB-Only Benefits

N195

Review Complete - Spenddown Not met - LMB Cont

N196

MS/FA Review Completed - No Spenddown

N197

Approval for QMB and Subsidy Benefits

N198

Review Complete for QMB-Only Benefits

   
 

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MS DENIAL NOTICES

N200

MS Failure to Provide Information

N201

MS Failure to Cooperate

N202

MS - Residency Requirement Not Met

N203

MS Loss of Contact

N205

MS Excess Income/Won't Meet Spenddown

N207

MS - Resources Exceed Maximum

N208

MS Denial - Other Reasons

N209

MS Application Withdrawn

N211 MS - Citizenship/Alien Status

N217

MS Deny LTC Payment - Transfer of Property

N240

MS - Failed to Apply For Potential Benefits

N246

MS - Residing In An Institution

N247

MS - Aged, Blind or Dis Crit Not Met

N255

MS-WH Denial - Other Reasons

N256

TB Denial

N260

MS Change in Living Arrangement - Left ACH

N261

MS - Fail to Meet LTC Criteria

N262

Denial For QMB-Only Benefits

N263

Denial For LMB-Only Benefits

N264

Denial - Expanded LMB

N266

MS - MSP Denial - MIPPA

N267

MS Denial – FFM

N290

MS/FA Denial Failure to Provide Information

N291

MS/FA Denial - Failure to Cooperate

N292

MS/FA Denial - Residency Requirement Not Met

N293

MS/FA Denial - Loss of Contact

N297

MS/FA Denial - Resources Exceed Maximum

N298

MS/FA Denial - Other Reasons

N299

MS/FA Denial - Applications Withdrawn

   

MS Approval Notices

N300

Presumptive Medicaid Approval

N305

PMD - SSI Related Approval

   

MS Denial Notices

N320

PMD Denied - Non Coop with PMDT

N321

PMD Denied - Fail Disability - No SSA

N322

PMD Denied - Fail Disability - SSA Pends

   

MS General Notices

N332

Open PMD - Medicaid and SSA Pending

N395

Medicaid Advocacy Information

 

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MS CLOSURE NOTICES

N340

PMD Closure - SSA Disability Denied

N341

PMD Ends - Regular Medical Approved

N400

Failure to Provide/Verify Information

N401

Failure to Cooperate

N402

MS Residency Requirement Not Met

N403

MS Closure/Loss of Contact

N405

MS Closure/Spenddown Not Met

N407

MS Closure - Resources Exceed Maximum

N408

MS Closure - Other Reasons

N409

MS Closure At Client's Request

N425

WH Closure - Other Reasons

N440

Failure to Apply for Potential Benefits

N447

Disability Criteria No Longer Met

N450

Failure to Complete Review

N452

MCD Closure - QMB/Sub D Continue

N454

Closure MCD - LMB/Sub D Continues

N470

Closure LMB and Subsidy D

N471

Closure QMB and Subsidy D

N490

Closure Failure to Provide Information - MS & FA

N491

Closure Failure to Cooperate - MS & FA

N492

Closure Residency Requirement Not Met - MS & FA

N493

MS and FA Closure/Loss of Contact

N497

MS and FA Closure/Resources Exceed Maximum

N498

MS and FA Closure/Other Reason

N499

MS and FA Closure/Client's Request

   

MS SUSPEND NOTICES

N500

MS Suspend - General

N504

MS-Discontinued ACH/HCBS Payment - General

   

MS REINSTATEMENT NOTICES

N600

Reinstate After Suspension

N601

Erroneous Discontinuance

N602

Benefits Paid Pending Hearing Decision

N603

Reinstate ACH/HCBS Payment

 

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MS CHANGE NOTICES

N700

MS Change - General

N701

MS - Change in Unmet Spenddown Amount

N702

MS - Change in ACH/HCBS Liability - 1 Month

N703

MS - Change in ACH/HCBS Liability - 2 Months

N704

MS - Change Spenddown - Spenddown Met

N705

MS - NF Payment Start - Shorten Base

N706

MS - NF Payment Start

N713

MS - Prior Medical Spenddown Met

N715

MS-HC Payment Start - No Obligation

N716

MS-HC Payment Start - 1 Mo W/ Obligation

N717

MS-HC Payment Start - 2 Mo W/ Obligation

N721

NF Payment Discontinued - LOC Not Met

N722

Retro Client Obligation Change - HCBS

N723

Retro Client Obligation Change - ACH

N725

Change in ACH Liability to Zero-QMB

N726

MS - PACE Obligation Change

N727

MS - PACE Change, General

N730

HCBS to ACH - Temp Stay W/O Obligation

N731

HCBS to ACH - Temp Stay W/ Obligation

N732

HCBS to ACH - Without Obligation

N733

HCBS to ACH - 2 Months With Obligation

N734

ACH to HCBS - No Obligation

N735

ACH to HCBS - 2 Months With Obligation

N740

Change - MS to WH Without Premium

N741

Change - MS to WH With Premium

N742

Working Healthy Premium Change

N743

Change - Working Healthy Premium Levels

N744

WH - Unemployment Plan Request

N753

MS Mass Change - Change Spenddown Amount

N754

MS Mass Change - Change Met Spenddown

N756 

MS Mass Change - Liability/Obligation Change

N755

MS Mass Change - Results in Spenddown

N757

MS Mass Change - Change In Obligation

   
 

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MS MISCELLENOUS NOTICES

N810

Working Healthy Premium Information

N812

Working Healthy Desk Review

N832

Medical Assistance Pending SSA Decision

N834

MS Notice of Repayment

N836

MS Spenddown Informational Notice

N837

Medical Card Returned

N838

Termination/Decertification of ACH Facility

N839

Transfer to Another Nursing Facility

N850

CH HCBS Approval-No Obligation (Corresponds with N107)

N851

CH HCBS Approval With Obligation 1 Month (Corresponds with N108)

N852

CH NF Approval - One Month ] (Corresponds with N121)

N853

CH MS-HC Payment Start-No Obligation (Corresponds with N715)

N854

CH HCBS to ACH-Temp Stay W/O Obligation (Corresponds with N730)

N855

CH HCBS to ACH-Temp Stay With HCBS Obligation (Corresponds with N731)

N856

CH Facility Notice - Approval ACH One Month (Corresponds with N911)

N857

CH MS-Facility Notice-Approval Temp Stay (Corresponds with N914)

N858

CH MS-Facility-Approval-Temp Stay From HCBS (Corresponds with N915)

N859

CH ACH-Facility-Rev Comp/Remains Eligible (Corresponds with N974)

   

MS NOTICES TO FACILITY

N900

MS - Facility Notice - General

N911

MS - Facility Notice - Approval ACH One Month

N912

MS - Facility Notice - Approval ACH 2 Months

N913

MS - Facility Notice - Approval ACH 3 Months

N914

MS - Facility Notice - Approval Temp Stay

N915

MS - Facility Approval - Temp Stay From HCBS

N921

MS - Facility - General Denial

N941

MS - Facility - General Closure

N961

MS - Facility - Reinstatement After Suspension

N962

MS - Facility - Reinstate ACH Payment

N971

MS - Facility - Mass Change

N972

MS - Facility Notice - Liability Change - 1 Month

N973

MS - Facility - Suspension ACH Payment

N974

MS - Facility - ACH Review Complete/Remains Eligible

N975

MS - Facility - Failure to Complete Review

N976

MS - Facility - ACH Payment Ending - Transfer to New ACH

N978

MS - Facility - Excess Liability - No Spd/Spd Met

N980

MS - Facility - Review Complete/Excess Liability

N983

MS - Facility - Liability Change - 2 Months

N985

MS - Facility - ACH Payment Ending - Move to Ind Living

N986

MS - Facility - Retro Patient Liability Change - NF

N987

MS - Facility - Zero Liability - QMB

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MS SYSTEM GENERATED NOTICES

X019

Reporting the Birth of Your Child

X056

Immunization Notice

X057

Immunization Notice - 12 Months

X074

Failure to Complete Interview Process

X075

Closure for Failure to Return Review

   

MS MASS CHANGE NOTICES

Z053

MS - Mass Change - Change in Unmet Spenddown

Z054

MS - Mass Change - Change in Met Spenddown

Z055

MS - Mass Change - Results in Spenddown

Z056

MS - Mass Change - Change in Patient Liability

   

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SI APPROVAL NOTICES

S101

SI Approval

S107

SI HCBS Approval

S121

SI NF Approval

S122

SI NF Approval - Two Months

S192

SI and FA Approval - 1st and 2nd Months

S193

SI/FA Apprvl 1/2 Mos W/24 Mo Review Per

   

SI DENIAL NOTICES

S208

SI - General Denial

S261

SI - Fail to Meet Long Term Care Criteria

S298

SI & FA Denial/General

   

SI CLOSURE NOTICES

S402

SI Closure/Residency Requirement Not Met

S403

SI Closure/Loss of Contact

S408

SI Closure/Other Reasons

S409

SI Closure at Client's Request

S410

No Longer Receiving SSI

S492

SI/FA Closure Residency Requirement Not Met

S493

SI/FA Closure - Loss of Contact

S498

SI/FA Closure/Other Reasons

S499

SI/FA Closure/Client's Request

   

SI SUSPEND NOTICES

S500

SI - Suspend - General

S502

SI-Discontinued ACH/HCBS Payment - General

   

SI REINSTATEMENT NOTICES

S600

Reinstate After Suspension

S601

Erroneous Discontinuance

S602

Benefits Paid Pending Hearing Decision

S603

Reinstate ACH/HCBS Payment

   

SI CHANGE NOTICE

S702

SI - Change in Patient Liability

S706

HCBS Payment Start

S721

NF Payment Discontinued - LOC Not Met

S729

SI PACE Enrollment

S730

SI - HCBS to ACH Temporary Stay

S732

SI - HCBS Terminates - Approval ACH

S734

SI - ACH Ends - Approve HCBS

S750

SI - HCBS Ends - Medicaid Continues

S756

SI Mass Change/Change in Obligation

   

SI MISCELLANEOUS NOTICES

S834

SI - Notice of Overpayment

S837

SI - Medical Card Returned

S838

Decertification of ACH Facility

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SI NOTICES TO FACILITY

S911

SI - Facility - Approval ACH One Month

S912

SI - Facility - Approval ACH Two Months

S914

SI - Facility - Approval - Temporary Stay

S921

SI - Facility - Denial General

S941

SI - Facility - General Closure

S961

SI - Facility - Reinstatement After Suspension

S971

SI - Facility - Mass Change

S973

SI - Facility - Suspension ACH Payment

   

SI SYSTEM GENERATED NOTICES

X019

Reporting the Birth of Your Child

   

UNIVERSAL VERIFICATION/INFORMATIONAL NOTICES

060V

Simplified Reporter – FS and Cange Reporter – SI

V000

General Verification Request

V001

School Verification Request

V003

Request for Employment Information

V004

Landlord/Residency Verification Request

V005

Health Insurance Information Request

V006

Unreported Income Verification Request

V007

Medical Expense Verification Request

V008

General Correspondence
*(Due to storage limits, the maximum number of lines that can be entered in the text of the notice is 120. It is also necessary for staff entering information on this notice to use @@ at the end of a paragraph and >> got a line between paragraphs.)

V009

Authorization for Release of Information

V010

Social Security Number Request

V011

Kan-Be-Healthy Notice

V012

Incomplete Change - New Household Member

V013

Expenses Exceed Income

V014

Dependent Care Verification Request

V015

Potential Benefits Request

V017

Intercounty Transfer

V018

TANF Protective Payee Agrmt

V019

P-3 Attachment

V025

General Pending Notice

V026

Notice of Interview Scheduled (English and Spanish)

V027

Assessment of Resources - Spousal Impoverishment

V030

Separate Purchase and Prepare Letter

V032

Medical Determination Pending

V033

QMB Added to Open Case

V037

Closure - Citizenship/Alien Status

V038

Change - Citizenship/Alien Status

V043

HealthWave Case Transfer

V044

HealthWave Verification Request (For Clearinghouse Use Only)

V054

Simplified RePorter - FS

V057

Simplified Reporter – FA and Change Reporte – Child Care

V059/059V

Simplified Reporter - FS and MS Change Reporter

V061

FS SR w/24 month review period(English and Spanish)

V062

Simplified Reporter – No IR requirement (English and Spanish)

V063/063V

Simplified Reporter FS (No IR) and MS

V064 Simplified Reporter – No Reporting Requirement
V070 ID & Citizenship Verification Request

V071

Citizenship and ID Info Pending

V073

Medical Cont. at Review Citiz Info Needed.

V074 Affidavit of Identity
V075 REQ - Auth for Medical Agent for Minor

V080

SSPP Replacement

V081

SSPP Stale Check

V082

SSPP Direct Deposit Request

V100

Approval LTC - Spousal Impoverishment Information

V101

Notice of Phone Interview

V102

Address Change - Voter Registration Information

V103

EBT-Benefit Repayment Agreement

V105

EBT - Training Appointment

V106

EBT - Training Session

V107

EBT- Important Notice (FS)

V109

EBT - Important Notice (Cash)

V110

GA - VR - Ref Request for Medical Information

V111

GA - VR - Ref Request Medical Information - New Client

V112

Claim Balance Change - Paid With EBT Benefits

V113 GA Tier II Time Limit Information

V116

Conditional Eligibility Approval

V117

SSPP Approval

V118

SSPP Approval with DD

V200

LTC Denial - Resources Exceed Spousal Impoverishment Limit

V201

Denial for Failure to Complete Interview Process (Cash Only)

V203

General Denial – FFM

V204

General Verification Request – FFM

V205

Pending Non-MAGI Determination – FFM

V301/301V

Notice of Phone Interview (BPR)

V302

Review Interview Notice

V304

Funeral Agreement Information

V398 Funeral Assistance Suspension Notice
V399 Burial Assistance Denial

V400

Burial Assistance Approval

V401

SOBRA Approval (English and Spanish)

V402

SOBRA Denial - No Emergency (English and Spanish)

V403

SOBRA Denial - Other Reasons (English and Spanish)

V404

SOBRA Approval - Spenddown Unmet

404V

SOBRA Approval - Spenddown Unmet

V405

SOBRA Approval - Spenddown Met (English and Spanish)

V408 SSPP Closure
V414 SSPP to the Familiy of the Deceased
V494 To the Family of the Deceased

V498

Closure - Other Reasons

V501

Inmate Inpatient Hospital Approval

V502

Inmate Inpatient Hospital Denial

V503

Inmate Inpatient Hospital - Spenddown

V504

MAGI – Refer To Insurance Marketplace

V600

Certificate of Creditable Coverage

V601

Spousal Elective Share Request

V723

Initial Contact about Loss of Exemption

V724

Second Contact about Loss of Exemption

V801 Case Transfer Notice

V810

Notice of Elighbility Review

V828

Repayment Agreement Reminder/All Progrms

V830

Demand Notice at Closure

V831

Unused EBT Benefits Applied to Claim

V832

Cash and FS Demand Notice at Closure

V835

60 Months for DI Persons

V836

TANF - GA Monthly Counter Adjustment Notice

V837

Excessive EBT Card Replacement Notice

V838

Excessive EBT Manual Entry Transactions

*(Due to storage limits, the maximum number of lines that can be entered in the text of the notice is 120. It is also necessary for staff entering information on this notice to use @@ at the end of a paragraph and >> got a line between paragraphs.)

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COLLATERAL CONTACT LETTERS

I001

Employer Letter

I002

Landlord Letter

I003

Bank Letter

I004

Life Insurance Letter

I005

General Correspondence to Collaterals

I006

HCBS Case Manager Notice - Referral

I007

HCBS Changes - Updates to Case Manager

I008

Retro Client Obligation Change - HCBS

I009

Retro Patient Liability Change - NF

I010

Repay Letter to Treatment Center

I011

Field Notice - Expunged FS/Cash Claim Change

I012

Funeral Agreement Referral

I013 Annuity Referral
   

KsCares NOTICES

CHILD CARE CLIENT

C103

Enrollment Fee Request Form

C104

Enrollment Fee Approval - Denial

C105

Change in DCF Service Center

C106

CC Approval Existing Card

C107

Vision Card - Important Notice (CC)

C108

EBT CC Training

C109

Provider Information Request

C110

Child Care Benefits Balance

C112

Claim Balance Change - Paid with EBT Benefits

C120

CC Approval - Remote PIN

C130

20 Hour Work Requirement

C201

Incomplete Application Notice

C202

Eligibility Notice

C204

Ineligibility Notice

C205

General Verification Request

C302

Incomplete Review Notice

C303

Overdue Case Review Notice

C304

Review Eligibility Notice

C305

Review Ineligibility Notice

C306

CC Plan - Case Review Notice

C310

Graduated Phase Out

C401

Change Notice

C402

Information Received Notice

C403

Case Transfer Notice

C404

Mass Case Transfer

C410

Continuation of Child Care

C502

Termination Notice

C511

Termination 1st CSS Penalty

C512

Termination 2nd CSS Penalty

C513

Termination 3rd CSS Penalty

C514

Termination 4th or Subsequent CSS Penalty

C701

Child Care Denial/Closure for Excess Resources

C806

Child Care - Additional Benefits

C807

Child Care - Restoration of Benefits

C810

Child Care Service Plan

C811

Direct Pay Review Eligibility Notice

C899

Printer Family Plan - Remail

C911

Overpayment Claim Initiation - Repayment Agreement

C912

Overpayment Claim Change - Reduction

C915

Overpayment Repayment Plan

C917

Child Care & Temporary Assistance for Needy Families(Cash)Fraud Disqualified

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WORK PROGRAMS

W001

Appointment Letter

W002

Review Of Activities Appointment Letter

W101

Work Program Activity Assignment Letter

W104

Participation Review Request

W106

Request for Good Cause

W107

General Correspondence

W108

Notice Of TANFMonths/Schedule Review

W201

Work Experience Appointment Letter

W205

Work Experience Assignment Letter

W206

Work Experience Evaluation

W251

Life Skills Letter

W351

Job Search/ Job Readiness Letter

W353

Job Search Verification

W354

Job Contact Disallowance

W355

Job Club Letter

W358

Assessment Letter

W404

Transitional Service Expiration

W405

Employment Follow-up

W407

Transitional Service Offer

W451

Self-sufficiency Plan Review 1st Letter

W452

Self-sufficiency Plan Review 2nd Letter

W455

Referral Letter

W501

Notice of Change

W502

Notice of Closure

W503

1st Request for Information

W506

Repayment - 1st Letter

W507

Repayment - 2nd Letter

W802

Check Enclosed

W806

Work Program Payment

W888

EBT Mass Notice

W901

Returned Payment

W911

Repayment Agreement

W912

Overpayment Claim Reduction

W913

Overpayment Claim Deletion

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CHILD CARE PROVIDER

P101

General Notice

P102

Rate Modification Request - CCC

P103

Rate Modification Request - Lic/Reg

P104

Rate Change Completed - CCC

P105

Rate Change Completed - Lic/Reg

P106

Child Care Provider – Change/Review/Update Completed

P107

Child Care Provider Approval Notice

P108

Request for Information

P109

Relative/In-Home Renewal

P110

Regulated Provider Renewal

P201

Denial or Termination Notice

P202

Eligibility Notice

P501

Provider Notice – Auto closure

P502

Provider Notice - Plan Ended

P888

EBT Child Care Notice - Provider

P911

Overpayment Claim Initiation - Repayment Agreement

P912

Overpayment Claim Change - Reduction

P913

Overpayment Claim Deletion

P914

Overpayment Claim Addition

P915

Overpayment Repayment Plan

P917

Failed Audit Notice

P918

Child Care Provider Audit

   
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This page was last updated: February 22, 2017 1:08 PM