KDHE Imaged Forms Desk Aid

Perceptive Content Document Type

KDHE General Form(s)

Task Name

Queue

AGO App

KC-1100 Application for Medical Assistance for Families with Children

AGO Application

Registration

AGO Unsigned App

KC-1100 Application for Medical Assistance for Families with Children

AGO Unsigned Application

Registration

Annuity Clearance

Trust Documents that are for review to determine countable resources/income.

Trust/Annuity Clearance

Trust/Annuity

Appeal

Beneficiary Request for Medicaid Fair Hearing

Any other Documents associated to a Fair Hearing

Appeal

Concerns

Barcoded Document

All Barcoded Forms

Will use logic to determine the correct Queue and Task based on the Documents barcode. 

BCC Application

ES-3100.7 Application for Medical Coverage – BCC

BCC Application

Specialty

BCC Review

KC-1400 Notice of Review – Medical Assistance – BCC Program

Process BCC Review

Specialty

Concerns

Example:

KC-6501 KDHE Civil Right Complaint

Any Document associated to a Complaint or Concern

GR-Other

Concerns

Correspondence

Example:

Fax Cover Sheet

KC-1105 E&D Supplement to the KC-1100

IROD/Incoming Documents/ Follow Up Written Correspondence

MAGI Eligibility

LTC Eligibility

E&D Eligibility

Critical Correspondence

Misc. (Follow Current Business/Policy Process)

Critical Correspondence

MAGI Eligibility

LTC Eligibility

E&D Eligibility

E&D Accelerated App

KC-1500 Application for Medical Assistance for the Elderly and Persons with Disabilities

E&D Accelerated Application

Registration

E&D App

KC-1500 Application for Medical Assistance for the Elderly and Persons with Disabilities

E&D Application

Registration

E&D Passive Review

KC-1700 Passive Elderly and Disabled Review

Process Review

MAGI Eligibility

LTC Eligibility

E&D Eligibility

E&D Pre-Populated Review

KC-1600 Pre-Populated Elderly and Disabled Review

E&D Pre-Populated Review

MAGI Eligibility

LTC Eligibility

E&D Eligibility

E&D PW App

KC-1500 Application for Medical Assistance for the Elderly and Persons with Disabilities

E&D PW Application

Registration

E&D Urgent App

KC-1500 Application for Medical Assistance for the Elderly and Persons with Disabilities

E&D Urgent Application

Registration

E&D Unsigned App

KC-1500 Application for Medical Assistance for the Elderly and Persons with Disabilities

E&D Unsigned Application

Registration

ES-3160 KanCare HCBS Services

ES-3160 HCBS Services

ES-3160 HCBS Services

LTC Eligibility

ES-3161 KanCare HCBS Changes and Updates

ES-3161 HCBS Changes and Updates

ES-3161 HCBS Changes and Updates

LTC Eligibility

Expense

Examples:

CSS/Spousal Expense

Medical Expense

Health Insurance Expense

IROD/Incoming Documents/ Follow Up Written Correspondence

MAGI Eligibility

LTC Eligibility

E&D Eligibility

FC Child Returning CH-App

KC-1100 Application for Medical Assistance for Families with Children

FC Child Returning CH-Application

Registration

FC Child Returning CH-Unsigned App

KC-1100 Application for Medical Assistance for Families with Children

FC Child Returning CH- Unsigned Application

Registration

Follow up written correspondence

Misc. (Follow Current Business/Policy Process)

Follow up Written Correspondence

Administrative-CH

Income

Examples:

Pay Stubs/Employment Verification

Benefit Amount Letter SS, Retirement, Indian Monies, etc.

Self-Employment Ledgers

Tax Documents

Oil Royalties

Loans

IROD/Incoming Documents/ Follow Up Written Correspondence

MAGI Eligibility

LTC Eligibility

E&D Eligibility

Incoming Documents

Uploaded Portal Documents (not to include the Document Upload Portal)

Incoming Documents

MAGI Eligibility

LTC Eligibility

E&D Eligibility

Specialty

Inmate Application

ES-3100.1a Correctional Facility Inmate – Qualifying Event

Inmate Application

Specialty

Institutional NB App

KC-1100 Application for Medical Assistance for Families with Children

Institutional Newborn Application

Registration

Institutional NB Unsigned App

KC-1100 Application for Medical Assistance for Families with Children

Institutional Newborn Unsigned Application

Registration

IROD

Any document received for a program that was discontinued in the past 45 days

Not an application, review, high priority, or specialty.

Info Rcvd On Denied/Disc

MAGI Eligibility

LTC Eligibility

E&D Eligibility

Journaling

Screenshots of any electronic pages used for eligibility.

No Task Created

KDHE OSW Application

KC-1100 Application for Medical Assistance for Families with Children

KC-1500 Application for Medical Assistance for the Elderly and Persons with Disabilities

Outstationed Application Form

Outstationed

Legal

Legal documents other than any associated to an Admin Role.

Legal

MAGI Eligibility

LTC Eligibility

E&D Eligibility

Legal Representative

Examples:

Facilitator Authorization Form

Medical Representative Authorization Form

DPAO

Appointment of Authorized Agent

Designated Representative Authorization

Court Order Appointing Guardian and Conservator

Admin Role Update

Administrative-CH

LTC Accelerated App

KC-1500 Application for Medical Assistance for the Elderly and Persons with Disabilities

LTC Accelerated Application

Registration

LTC App

KC-1500 Application for Medical Assistance for the Elderly and Persons with Disabilities

LTC Application

Registration

LTC PW App

KC-1500 Application for Medical Assistance for the Elderly and Persons with Disabilities

LTC PW Application

Registration

LTC Urgent App

KC-1500 Application for Medical Assistance for the Elderly and Persons with Disabilities

LTC Urgent Application

Registration

LTC Unsigned App

KC-1500 Application for Medical Assistance for the Elderly and Persons with Disabilities

LTC Unsigned Application

Registration

MAGI Accelerated App

KC-1100 Application for Medical Assistance for Families with Children

MAGI Accelerated Application

Registration

MAGI App

KC-1100 Application for Medical Assistance for Families with Children

MAGI Application

Registration

MAGI Passive Review

KC-1300 Passive Family Medical Review

Process MAGI Passive Review

MAGI Eligibility

LTC Eligibility

E&D Eligibility

MAGI Pre-Populated Review

KC-1200 Pre-Populated Family Medical Review

MAGI Pre-Populated Review

MAGI Eligibility

LTC Eligibility

E&D Eligibility

MAGI PW App

KC-1100 Application for Medical Assistance for Families with Children

MAGI PW Application

Registration

MAGI Urgent App

KC-1100 Application for Medical Assistance for Families with Children

MAGI Urgent Application

Registration

MAGI Unsigned App

KC-1100 Application for Medical Assistance for Families with Children

MAGI Unsigned Application

Registration

Medical Provider Document

Uploaded via the Document Upload Portal

Uploaded Medical Provider Document

Medical Provider Docs

Medically Needy App

KC-1500 Application for Medical Assistance for the Elderly and Persons with Disabilities

Medically Needy Application

Registration

Medically Needy Unsigned App

KC-1500 Application for Medical Assistance for the Elderly and Persons with Disabilities

Medically Needy Unsigned Application

Registration

MS-2126 Facility Admission/Discharge

 MS-2126 Facility Admission/Discharge

MS-2126 Facility Admission/Discharge

LTC Eligibility

MSP App

ES-3100.8 Medicare Savings Program Application

MSP Application

Registration

MSP Unsigned App

ES-3100.8 Medicare Savings Program Application

MSP Unsigned Application

Registration

Passive Review Letter

KC-1700 Passive E&D Review

Passive Review Response

MAGI Eligibility

LTC Eligibility

E&D Eligibility

Personal Identifying Information

Examples:

Photo ID, SSN, Birth Certificate, Shot Record, Alias Name

P-7 Declaration of Identity

P-8 Third party – Declaration of Citizenship

P-9 Declaration of Identity – Disable Adult

Marriage License

Death Certificate

IROD/Written Correspondence/Incoming Documents

MAGI Eligibility

LTC Eligibility

E&D Eligibility

PE Tool

Presumptive Eligibility Approval/Denial Letter

Presumptive Eligibility Application PDF

*Only used outside of the normal PE Process

NA

NA

PII-Newborn

KC-1100 Application for Medical Assistance for Families with Children

PII-Newborn

MAGI Eligibility

LTC Eligibility

E&D Eligibility

Pre-Release Application

ES-3100.1a Correctional Facility Inmate – Qualifying Event

Pre-Release Application

Specialty

Release of Info

Examples:

ES-3101 Release of Information and Liability

ES-3904 HIPAA Complaint Auth to Release Info to KHPA

DD-1103 Auth to Release Medical Information

ES

Admin Role Update

Administrative-CH

Resources

Examples:

Bank Statement

Land/Parcel Deed

Life Insurance

Pre-Paid Burial Agreements

Property Valuations

IROD/Written Correspondence/Incoming Documents

MAGI Eligibility

LTC Eligibility

E&D Eligibility

Returned Mail-In State

Any Returned Mail with a forwarding Address Listed in Kansas

Returned Mail - In State

Contact Updates

Returned Mail-No Fwd. Address

Any Returned mail with no Forwarding Address Listed

Returned Mail - No Fwd

Contact Updates

Returned Mail-Out of State

Any Returned Mail and Forwarding Address is Listed as Out of State

End Coverage – Program

Contact Updates

Returned Mail-PR Letter

KC-1300 Passive Family Medical Review

KC-1700 Passive Elderly and Disabled Review

End Coverage – Program

Contact Updates

SOBRA E&D App

KC-1500 Application for Medical Assistance for the Elderly and Persons with Disabilities

SOBRA E&D Unsigned Application

Registration

SOBRA E&D Unsigned App

KC-1500 Application for Medical Assistance for the Elderly and Persons with Disabilities

SOBRA E&D Unsigned Application

Registration

SOBRA MAGI App

 KC-1100 Application for Medical Assistance for Families with Children

SOBRA MAGI Application

Registration

SOBRA MAGI Unsigned

 KC-1100 Application for Medical Assistance for Families with Children

SOBRA MAGI Unsigned Application

Registration

Spousal Improvishment

Examples:

ES-3162 Designation of Community Spouse

ES-3163 Resource Assessment and Allowance Determination

M-2 Notice of Intent to Transfer Resources

M-3 Notice of Intent to Allocate Income

M-4 Spousal Impoverishment Allowance Memorandum

IROD/Follow Up Written Correspondence/Incoming Documents

MAGI Eligibility

LTC Eligibility

E&D Eligibility

SSP Uploaded Documents

All documents uploaded through the SSP

TB Application

3100.3 Certification of Need for Tuberculosis Treatment

TB Application

Specialty

Trust/Annuity Clearance

Example:

B-6 Request for Trust/Annuity Clearance

Trust/Annuity Clearance

Trust/Annuity

Unsigned CH Review

KC-1300 Passive Family Medical Review

KC-1700 Passive Elderly and Disabled Review

Unsigned Review

Registration

Urgent ES-3160 HCBS Services

ES-3160 HCBS Services

ES-3160 HCBS Services

LTC Eligibility

Urgent ES-3161 HCBS Changes and Updates

ES-3161 HCBS Changes and Updates

ES-3161 HCBS Changes and Updates

LTC Eligibility

Urgent MS-2126 Facility   Admission/Discharge

MS-2126 Facility Admission/Discharge

MS-2126 Facility Admission/Discharge

LTC Eligibility

Working Healthy 6 Month Review

N-812 Working Healthy – Six Month Review

WH-Review Registration

Registration