Running EDBC for Reviews Business Process

 

Until KEES is running the Medical Reviews Discontinuance Batch timely, staff will need to follow the below steps to determine when to run EDBC with ‘RE’ when coverage has continued/extended past the review due month at the time of processing a review.

  1. Run EDBC using the RE Run Reason for the month after the review is due.

    1. If this results in a negative change, close out of the EDBC result and skip to step 3.

    2. If the coverage is same or better at review, proceed with steps 2, 5, and 6.

Note: If the review due month does not populate correctly from your determination, submit a KEES Help Desk ticket.

  1. Run EDBC using the RE Run Reason through the KEES come-up month. Skip to step 5.

  2. Change the CE End Date to the last paid month.

    1. Please follow the steps in the KEES User Manual: Updating Individual Continuous Eligibility.

    2. Adjustment Reason will be Late Review.

    3. Repeat step 3 for each beneficiary that has a CE period.

  3. Run EDBC for the KEES come-up month with RE.

    1. Review the EDBC for accuracy. If correct, Accept and Save the results.

  4. Review system generated NOA for accuracy then send the NOA.

  5. Journal actions taken.

 

RE Run EDBC Chart

 Review Received -

Timely vs. Untimely?

 Positive, Negative,

No Change?

Existing Review

Due Month

Scenario

When to Run EDBC

Using RE?

New Review Due Month

After EDBC is Ran

Timely*

Positive

June 2024

Family Medical - Initial determination for the CH was CHIP. At review, CH moves to PLN. EDBC is run using 'RE' beginning July 2024.

 

ED/LTC - PA is active with QMB and enters the nursing facility on 06/05/2024. A review is returned timely and is found eligible for nursing facility coverage upon admission. EDBC is ran for June 2024 to establish the LOC change. EDBC is ran with RE run reason for July 2024 to process the review. EDBC is ran through come up month to continue the LOC change as appropriate.

Month After Review Due Month

June 2025

Negative

June 2024

Family Medical - Initial determination for CH was PLN. At review, CH is determined eligible for CHIP. EDBC is run using 'RE' beginning August 2024 due to a negative change and timely notice applies.

 

ED/LTC - Initial determination for PA resulted in approval of MSP/QMB. At review, PA experienced an increase in income which led to being determined eligible for MSP/ELMB. Due to being a negative change, EDBC is ran using 'RE' beginning August 2024 and timely notice applies.

KEES Come-Up Month

July 2025

No Change

October 2024

Family Medical - Last review, CH was PLN/C2. At review in 2024, CH is determined PLN/C3. EDBC is run using 'RE' beginning November 2024.

 ED/LTC - Last review, PA was approved for 300/OA and MSP/LMB. At the next review, PA remains eligible for 300/OA and MSP/LMB. EDBC is therefore ran using 'RE' beginning November 2024.

Month After Review Due Month

October 2025

*Timely processing- please refer to PM2024-10-01 for determining if the received review is timely.

*Setting CE dates at review – please refer to PD2021-12-01 for policy requirements.

Outside the Review Reconsideration

 

Treat the review as an application and if eligible, establish a new review due month/review period.