|
ES-3100.1a |
Correctional Facility Inmate - Qualifying Event |
|
ES-3100.8 |
Redetermination of Medicare Savings Plan |
|
KC1400 |
Notice of Review - Medical Assistance - BCC Program |
|
VMed830 |
Demand Notice at Closure |
|
I012 |
Funeral Agreement Referral |
|
M834 |
Medical Program - Notice of Repayment |
|
VMed828 |
Repayment Agreement Reminder/All Programs |
|
KC4110 |
Clearinghouse Unsigned Application Letter |
|
KC4120 |
Clearinghouse Unsigned Application Letter - Minor Signed |
|
V002 |
General Verification Request |
|
V005 |
Health Insurance Information Request |
|
V012 |
Incomplete Change - New Household Member |
|
KC4100 |
KanCare Clearinghouse Registration - More Information Letter |
|
V044 |
KanCare Verification Request |
|
M837 |
Medical Card Returned |
|
M-N836 |
Medically Needy Health Plan Spenddown Informational Notice |
|
D832 |
Open MediKan - Medicaid Pending |
|
V015 |
Potential Benefits Request |
|
M802 |
Potential Spenddown Informational Notice |
|
X019 |
Reporting the Birth of Your child |
|
ES-3105.2 |
Request for Medical Program Information |
|
V075 |
Required Authorization for Medical Agent for Minor |
|
V601 |
Spousal Elective Share Request |
|
V082 |
State Supplemental Payment Program Direct Deposit Request |
|
V777 |
TIAR Form |
|
V006 |
Unreported Income Verification Request |
|
V001 |
Verification Request List |
|
N744 |
Working Healthy - Unemployment Plan Request |
|
N810 |
Working Healthy Premium Information |
|
I013 |
Annuity Referral |
|
ES-3122 |
VA Potential Benefit Request |
|
V100 |
Approval Long Term Care - Spousal Impoverishment Information |
|
V027 |
Assessment of Resources - Spousal Impoverishment |
|
KC5820 |
Child in a PRTF Temporary Stay - Consumer Notice |
|
I009 |
Facility Notice - Retroactive Patient Liability Change |
|
D200 |
General MediKan Denial |
|
D400 |
General MediKan Discontinuance |
|
V115 |
General Notice of Approval |
|
V700 |
General Notice of Change |
|
V200 |
General Notice of Denial |
|
V400 |
General Notice of Discontinuance |
|
V600 |
General Notice of Reinstatement |
|
D100 |
MediKan Approval |
|
D204 |
MediKan Denied or Discontinued - Family of Deceased |
|
D701 |
MediKan to Medicaid - SSA Approved |
|
PPS7235 |
Notice of Action Medical Card Extension Program Initial Eligibility |
|
N729 |
PACE Disenrollment Notice |
|
V117 |
State Supplemental Payment Program Approval |
|
V118 |
State Supplemental Payment Program Approval with Direct Deposit |
|
V408 |
State Supplemental Payment Program Closure |
|
V080 |
State Supplemental Payment Program Replacement Notice |
|
N-S838 |
Termination - Decertification of Adult Care Home Facility |
|
PPS7250 |
Termination of Medical Card |
|
N-S839 |
Transfer to Another Nursing Facility |
|
V801 |
Case Transfer Notice |
|
V064 |
Change Reporting - Medical |
|
V304 |
Funeral Agreement Information |
|
V008 |
General Correspondence |
|
KC5730 |
KDHE Notice of Privacy Practice |
|
KC5710 |
KDHE Request for Dismissal of Appeal |
|
N832 |
Medical Assistance Pending Social Security Administration Decision |
|
V032 |
Medical Determination Pending |
|
D854 |
MediKan Time Limit Information |
|
M-3 |
Notice of Intent to Allocate Income |
|
M-2 |
Notice of Intent to Transfer Resources |
|
P803 |
Reporting Requirements - Children and Family Medical |
|
KC5705 |
Request for Administrative Hearing |
|
B-6 |
Request for Trust/Annuity Clearance |
|
KC5720 |
Rights and Responsibilities |
|
KC5810 |
Child in Psychiatric Residential Treatment Facility - Facility Notification |
|
N-S911 |
Facility Notice - Approval - One Month |
|
C-N911 |
Facility Notice - Approval of Long Term Care - One Month |
|
C-N913 |
Facility Notice - Approval of Long Term Care - Three Months |
|
C-N912 |
Facility Notice - Approval of Long Term Care - Two Months |
|
N-S914 |
Facility Notice - Approval Temporary Stay |
|
N915 |
Facility Notice - Approval Temporary Stay From Home and Community Based Services |
|
N-S912 |
Facility Notice - Approval Two Months |
|
C-N-S972 |
Facility Notice - Change in Patient Liability |
|
C-N978 |
Facility Notice - Excess Liability - No Spenddown - Spenddown Met |
|
C979 |
Facility Notice - Excess Liability - Spenddown Unmet |
|
N975 |
Facility Notice - Failure to Complete Review |
|
N900 |
Facility Notice - General |
|
C-N-S941 |
Facility Notice - General Closure |
|
C-N-S921 |
Facility Notice - General Denial |
|
N983 |
Facility Notice - Liability Change - Two Months |
|
C-N-S971 |
Facility Notice - Mass Change |
|
N985 |
Facility Notice - Payment Ending - Move to Independent Living |
|
N962 |
Facility Notice - Reinstate Payment |
|
N976 |
Facility Notice - Payment Ending - Transfer to New Facility |
|
C-N-S961 |
Facility Notice - Reinstatement |
|
N986 |
Facility Notice - Retroactive Patient Liability Change to Nursing Facility |
|
C-N980 |
Facility Notice - Review Complete - Excess Liability |
|
C-N974 |
Facility Notice - Review Complete - Remains Eligible |
|
C-N-S973 |
Facility Notice - Suspension Payment |
|
N987 |
Facility Notice - Zero Patient Liability - Qualified Medicare Beneficiary |
|
MS-2156 |
Medical Review of Emergency Services for Establishing SOBRA Eligibility |
|
C981 |
Review Complete - Excess Liability - Spenddown Unmet |
|
MEQC-34 |
MEQC - PERM Agency Memo of Failure to Provide |
|
MEQC-30 |
MEQC Collateral - Bank Letter |
|
MEQC-4 |
MEQC Collateral - Birth Certificate Verification Request |
|
MEQC-1 |
MEQC Collateral - Civil Service Letter |
|
MEQC-31 |
MEQC Collateral - County Letter All Medicaid Programs |
|
MEQC-2 |
MEQC Collateral - Dept. of Defense Letter |
|
MEQC-3 |
MEQC Collateral - Employer Letter with Health Insurance |
|
MEQC-5 |
MEQC Collateral - Employment Termination |
|
MEQC-6 |
MEQC Collateral - Funeral Home Letter |
|
MEQC-9 |
MEQC Collateral - General Information Request |
|
MEQC-7 |
MEQC Collateral - HCBS Letter |
|
MEQC-8 |
MEQC Collateral - KPERS Letter |
|
MEQC-11 |
MEQC Collateral - Landlord Letter |
|
MEQC-12 |
MEQC Collateral - Level of Care Request |
|
MEQC-10 |
MEQC Collateral - Life Insurance Letter |
|
MEQC-15 |
MEQC Collateral - Medical Expense Letter |
|
MEQC-13 |
MEQC Collateral - Non-Relative Letter |
|
MEQC-16 |
MEQC Collateral - Nursing Facility Verification |
|
MEQC-14 |
MEQC Collateral - Pension Letter |
|
MEQC-17 |
MEQC Collateral - Per Capita Verification |
|
MEQC-18 |
MEQC Collateral - Post Office Request |
|
MEQC-21 |
MEQC Collateral - Railroad Letter |
|
MEQC-19 |
MEQC Collateral - School Request for Identity and Citizenship Verification |
|
MEQC-22 |
MEQC Collateral - School Verification |
|
MEQC-20 |
MEQC Collateral - VA Letter |
|
MEQC-32 |
MEQC Household - Alias Letter |
|
MEQC-25 |
MEQC Household - Client Statement of Child Support |
|
MEQC-27 |
MEQC Household - Gift or Loan |
|
MEQC-26 |
MEQC Household - HH Composition Letter |
|
MEQC-33 |
MEQC Household - HIPPA Release for Medical |
|
MEQC-28 |
MEQC Household - Non-Relative Letter |
|
MEQC-23 |
MEQC Household - Verification Request Letter |
|
MEQC-29 |
MEQC Household - Zero to Little Income Letter |
|
MEQC-24 |
MEQC Household or Responsible Person - Release of Information |
|
P-11 |
KDHE Authorization for Release of Protected Health Information |
|
ES-3101 |
Release of Information and Liability |
|
N812 |
Working Healthy - Six Month Review |