This business process is effective with the June 2024 Policy Memo.
Sections A and B help staff determine which cases had a mixed review type determined. Passive individuals and pre-populated individuals. These outline what steps need taken to finish processing the review.
Sections C, D, and E below are possible reasons a pre-populated review was sent to the household. For members that could have been passively reviewed but was determine pre-pop due to missing information.
Check Perceptive Content to see if there was only a signature page received.
Check Distributed Documents after Review Discontinuance Batch ran for the Passive renewal form. Page one of the renewal will inform staff which individuals were determined passively reviewed (Table 1) and which persons were determined for a Pre-Populated review (Table 2) and need to return the form.
Check EDBC Results screen and select the Begin Month hyperlink for the month after the review was due. If the Medical EDBC Summary page shows BATCH EDBC in the Accepted By field and RE in the EDBC Run Reason field, that means a Passive review was done.
Reporting record will be added for passively renewed beneficiaries, and the pre-populated review record will be incomplete.
Check case to see if all members requesting coverage on the Pre-Populated review are still receiving coverage.
Use steps from Section A to determine what members were determined for a pre-populated review.
If there are members who lost coverage due to not returning the review, rescind their coverage.
If there are members who are requesting new coverage on the review, reapply in the month the review was received.
Use normal Business Process to work the review for those members.
Staff will need to make sure that the Pre-Populated IR record is updated after they have updated all information on the late review.
NOTE: Anything reported on the late Review will be treated as a reported change for members already actively receiving coverage. The changes will not have a negative impact to anyone’s CE period.
In this situation, if the consumer fails to return the Pre-Populated form but does contact the agency and supply the missing SSN during the reconsideration period, this will nullify the requirement to provide the form for coverage to continue if that was the only missing information. Staff need to determine if there is any other missing information needed from the consumer. If not, the information used in the Passive review for other household members may also be used to administratively renew the individual if other eligibility criteria are met.
Use steps from Section A to determine what members were determined for a pre-populated review.
Check Individual Demographics for the child who was determined Pre-Populated on the Review in table 2.
Check EDBC Results for come-up month, if there is a Read Only EDBC with Soft EDBC as the reason, it will give the Pending SSN Verification reason for the child.
Please see the KEES User Manual to finish processing: Administrative Reviews.
Staff will need to make sure that the Pre-Populated IR record is updated after they have updated all information on the administrative review.
Document Status: Received
Report Status: Complete - EDBC Accepted
Is the review application signed? Yes
In this situation, if the consumer fails to return the Pre-Populated form, and the consumer is failing for CIT/ID, but have previously had coverage, staff need to determine if CIT/ID has previously been verified.
Use steps from Section A to determine what members were determined for a pre-populated review.
Check All People Associated with the case. If there is coverage there that is not SOBRA coverage, staff should then check EDBC Results.
Select the Read Only EDBC for the come-up month, it will give the reason for the beneficiary.
Pending Citiz Verif - unverified citizenship and identity
Pending Citiz Verif - unverified citizenship
Pending ID Verif - unverified identity
Staff will need to look at the Real Time Interface History to find if Citizenship/SSA verification is showing for that consumer as a success from a previous HUB run.
If this shows a previous success for the consumer, staff will need to update the Citizenship/Identity Detail page to verified for that consumer.
Please see the KEES User Manual to finish processing: Administrative Reviews.
Staff will need to make sure that the Pre-Populated IR record is updated after they have updated all information on the administrative review.
Document Status: Received
Report Status: Complete - EDBC Accepted
Is the review application signed? Yes
In this situation, if the consumer fails to return the Pre-Populated form, and the consumer is failing for SSN, but have previously had coverage, staff need to determine if SSN has previously been verified.
Use steps from Section A to determine what members were determined for a pre-populated review.
Check All People Associated with the case. If there is coverage there that is not SOBRA coverage, staff should then check EDBC Results.
Select the Read Only EDBC for the come-up month, it will give the Pending SSN Verification reason for the beneficiary.
Staff will need to look at the Real Time Interface History to find if Citizenship/SSA verification is showing for that beneficiary as a success from a previous HUB run.
If this shows a previous success for the consumer, staff will need to re-verify the SSN through the data HUB with a living arrangement to verify the SSN for that beneficiary.
Please see the KEES User Manual to finish processing: Administrative Reviews.
Staff will need to make sure that the Pre-Populated IR record is updated after they have updated all information on the administrative review.
Document Status: Received
Report Status: Complete - EDBC Accepted
Is the review application signed? Yes