A case or person can be denied or discontinued by using the data collection pages and running EDBC. A user can also make a decision to deny or discontinue a program or person without using EDBC rules. This is known as Negative Action. See the sections below for information on how to deny or discontinue a program:
Deny or Discontinue a Program or Person Using Data Collection Pages
Deny or Discontinue a Program or Person When Spenddown is Not Met
Deny or Discontinue a Program or Person Using the Non-Compliance Page
Deny or Discontinue a Program or Person Using Negative Action
Deny or Discontinue When Multiple Program Blocks Exist Using Negative Action
NOTE: The individual closures are displayed on the EDBC Summary page. If a program is closed for a Negative Action reason, the Batch uses the Negative Action Reason and displays the reason. If there is a Non-Compliance record, the reason is specific to the Non-Compliance. For all other closure reasons KEES pulls in whatever is applicable from the Rules Closure Reason table (decision points within the use cases) and displays the reason.
Ineligibility Status Reason Table
The EDBC Summary page within the Program Configuration Section displays a Role of “MEM” and a status of “Discontinued” with a Status Reason.
Select Eligibility from Global Navigation. Select Customer Information from Local Navigation. Select Run EDBC from Task Navigation. The Run EDBC page displays.
The Benefit Month defaults to the first month of determining eligibility for initial determinations, including prior medical months. The Benefit Month defaults to the come up month for ongoing eligibility.
Select or de-select the appropriate Program check box(es).
Select the appropriate answer for Timely Notice Exception if applicable.
Click the Run EDBC button on the right side of the page. The EDBC List page displays.
Click the Medical hyperlink under Program to navigate to the Medical EDBC Summary page.
Review the EDBC results the Medical EDBC Summary page:
The Program Configuration section should show Online EDBC rules were run.
The Program Status should be Denied or Discontinued.
All Denied or Discontinued programs have a program Status Reason. For example:
A Status Reason of Deceased means the program was discontinued because the consumer died.
A Status Reason of State Residency means the program was denied or discontinued because the consumer has an out of state address.
A Status Reason of Doesn’t Meet Program Requirement means the program was denied or discontinued because the consumer doesn’t meet program requirements. For example, resources exceeding the maximum allowable amount.
Click the Accept button if the results are correct. Click the Cancel button if the results are not what the user expected.
Review the EDBC Results from the EDBC List page. Click the Save and Continue button.
Review all generated Notice of Actions (NOAs) from the Distributed Documents Search page. See NOAs (Notices of Action) for more information.
Select Journal from Utility Navigation. Add a journal entry to document all program action. See Journal for more information about journaling functionality.
The Customer Options Detail page is used to indicate that a consumer does not want eligibility determined for a particular program. Rules use this record to exclude any indicated programs when EDBC is run. This page is also used to deny or discontinue a medical program when the consumer fails to meet their spenddown amount or is unlikely to meet their spenddown amount.
Select Eligibility from Global Navigation. Select Customer Information from Local Navigation. Select Customer Options from Task Navigation. The Customer Options List page displays.
Click the Add button to access the Customer Options Detail page.
Select the consumer from the Name drop-down menu.
Select Medically Needy from the Type drop-down menu.
Set the Begin Date using the <mm/dd/yyyy> format or the calendar icon to the 1st day of the month the spenddown program needs denied or discontinued.
Set the End Date using the <mm/dd/yyyy> format or the calendar icon to the last day of the month the spenddown program needs denied or discontinued.
Click the Save and Add Another button to add additional records. Otherwise, click the Save and Return button.
Run EDBC for the month the program should be denied or discontinued.
Send a Manual NOA (Form). See Manual NOA Generation for more information.
Select Journal from Utility Navigation. Add a journal entry to document all program action. See Journal for more information about journaling functionality.
Non-Compliance is most frequently a failure to provide, failure to cooperate, or a penalty record. It also is used for transfer of property, and failure to pursue potential resources. This record is used by EDBC to deny or discontinue a consumer or a program. Rules use the non-compliance record when determining eligibility.
Add a Non-Compliance record.
Select Eligibility from Global Navigation. Select Customer Information from Local Navigation. Select Run EDBC from Task Navigation. The Run EDBC page displays.
Verify the Benefit Month defaults to the first month of determining eligibility for initial determinations, including prior medical months. The Benefit Month defaults to the come up month for ongoing eligibility.
Select or de-select the appropriate Program check box(es).
Select the appropriate answer for Timely Notice Exception if applicable.
Click the Run EDBC button on the right side of the page. The EDBC List page displays.
Click the Medical hyperlink under Program to navigate to the Medical EDBC Summary page.
Review the EDBC results the Medical EDBC Summary page:
The Program Configuration section should show Online EDBC rules were run.
The Program Status should be Denied or Discontinued.
The program Status Reason should reflect the non-compliance reason. For example:
A Status Reason of FTP Income means the consumer failed to provide proof of income.
Click the Accept button if the results are correct. Click the Cancel button if the results are not what the user expected.
Review the EDBC Results from the EDBC List page. Click the Save and Continue button.
Review all generated Notice of Actions (NOAs) from the Distributed Documents Search page. See NOAs (Notices of Action) for more information.
Select Journal from Utility Navigation. Add a journal entry to document all program action. See Journal for more information about journaling functionality.
Non-Compliance Penalties either close an individual or everyone on the program. In KEES a non-compliance penalty for ‘Failure to Provide Proof of Income and Failure to Provide Proof of Trust’ are applying to the program.
Example: Application received for Mom, her child, and her niece. Mom fails to provide her income. A non-compliance record of ‘Failure to Provide Proof of Income’ is created. The niece is denied incorrectly because the non-compliance reason is being applied at the program level.
NOTE: This process assumes a request for verification has been requested and has not been provided and the worker needs to complete the processing of the application.
Set the pending verification to Refused. In the example above income verification was requested, therefore on the Income Amount Detail page update the Verified drop-down to ‘Refused’.
Navigate to the Eligibility Non-Compliance List page.
Click the Add button to add a new non-compliance record. The Eligibility Non-Compliance Detail page displays.
Select the following:
Name: select the consumer who failed to provide the verification
Type: Failure to Provide
Reason: Information needed for Medical eligibility
Begin Date: enter the appropriate date using the <mm/dd/yyyy> format or the calendar icon
Comments: provide detail about information that was requested and not provided
Click the Save and Return button.
Run EDBC. Only a passing budget is created for the niece.
Accept and Save the EDBC result.
On the Distributed Documents Search page delete the ‘NOA-Medical-Approval’ notice.
Send a manual Approval form for the approved individuals.
Send a manual Denial form for the denied individual. Specific denial reasons needs to be explained on the form.
* Please follow the verification status below based on the situation. *
Verification status of ‘Refused’ should be used when the consumer fails to provide information needed for a medical determination.
Verification status of ‘Pending’ should be used when the consumer is not categorically eligible for any KanCare program.
Verification status of ‘Not Applicable’ should be used when a consumer fails to provide information needed for a prior medical determination, but the information for the application month is verified.
Verification status of ‘Refused’ or ‘Pending’ that was used previously and not needed for the current medical determination, keep the verification status the same.
Negative Action is a user making a decision to deny or discontinue a program or person without using EDBC rules. In some instances EDBC could approve assistance-a Negative Action prevents this. For example, a consumer may meet medical eligibility requirements, but chooses to withdraw their application. Using a Negative Action reason of Voluntary Withdraw denies or discontinue the Medical program without using EDBC rules.
NOTE: To deny or discontinue a program person for no longer living in the home, use the Household Status Detail page to update their status and run EDBC. See Household Status for help completing this page. See Hiding a Case Person to remove the person(s) from the drop-down menus associated to the case after they have been denied or discontinued.
Select Case Info from Global Navigation. The Case Summary page displays.
Select Negative Action from Task Navigation. The Negative Action Detail page displays.
Select the Consumer whose assistance is being denied or discontinued.
Select a Negative Action Reason from the drop-down menu.
Click the Run EDBC button. The EDBC List page displays.
Click the Medical hyperlink under Program to navigate to the Medical EDBC Summary page.
Review the EDBC results the Medical EDBC Summary page:
The Program Configuration section should show Online EDBC rules were run.
The Program Status should be Denied or Discontinued if denying or discontinuing a program.
The program Status Reason should reflect the negative action reason selected from the Negative Action Detail page.
Click the Accept button if the results are correct. Click the Cancel button if the results are not what the user expected.
Review the EDBC Results from the EDBC List page. Click the Save and Continue button.
Review all generated Notice of Actions (NOAs) from the Distributed Documents Search page. See NOAs (Notices of Action) for more information.
Select Journal from Utility Navigation. Add a journal entry to document all program action. See Journal for more information about journaling functionality.
Negative Action is a user making a decision to deny or discontinue a program or person without using EDBC rules. In some instances EDBC could approve assistance, Negative Action prevents rules from approving the assistance. For example, a user may have created a program block in error when there is already an existing program block on the case that is able to be utilized.
Select the correct Negative Action Reason for each Program Block.
Click Run EDBC for this program ONLY for the program block that requires the Negative Action.
Each Program Block has a unique ID that matches the ID from the Case Summary page.
Be absolutely certain that the correct Program Block is selected before running EDBC.