The following instructions should be used to temporarily reinstate coverage for consumers who were discontinued for to Failure to Return Review via the Review Discontinuance Batch or Failure to Provide Requested Information requested during the PHE Unwinding Period. These consumers have also had a change in address reported. When a new In-State address is reported, staff can use these instructions to reinstate coverage and then send a new Pre-Populated Review form along with V008 with a 30-day due date to the consumer.
NOTE: If returned mail was received for a verification request, re-send the request to the updated address with a 12-day due date.
From the Case Summary page:
Change the Display Date to the month after consumer was discontinued and click the View button to refresh the page with the new display date.
Click the caret of the collapsed Medical program block to expand the block and review the program details.
Click the View Details button In the Medical program block.
Click the Edit button to make the page editable on the Medical Program Detail page.
Click the Rescind button. The Rescind Detail page displays.
Select the Rescind Reason Rescind Disc/Deny.
Click the radio button for the group of persons and the Effective Date to Rescind.
Click the Save and Return button. The Rescind Confirmation page displays.
Validate that the Program Status has been updated to Pending and the Begin Date reflects the first of the month benefits should begin. If something is incorrect, click the Cancel button to return to the Rescind Detail page; otherwise click the Save and Return button. The Medical Program Detail page displays.
Click the Save and Return button again. The Case Summary page displays.
Click Eligibility from the Global Navigation.
Click Reporting from the Local Navigation.
Find the most recent Pre-Populated Medical Review that shows a Document Status of Sent and click Edit.
The Review and IR/12 Month Reporting Detail page will display. Change Document Status from Sent to Received. Update Is the review application signed? to Yes. Click Save and Return.
NOTE: It is important to note the coverage the consumer was active on previously to the case being discontinued. This coverage will be reinstated with the following steps.
Navigate to Run EDBC page.
Check mark the month being run and choose RE from the Run Reason drop down. Click Run EDBC.
The EDBC List page will display. Choose the Program for the month that was run and shows a Run Status of Not Accepted.
The Medical EDBC Summary page will display. Review the coverage being approved, if it matches with what coverage the consumers previously had click Accept and continue to the next step.
If coverage is being denied, skip to step 21 to complete override.
If coverage does not match, skip to step 27 to complete override.
The EDBC List page displays. Click Save and Continue.
The Distributed Documents Search page displays. Delete the system generated approval NOA. A manual form will need to be created using the V008 and C-105 on the SCP Unwinding tab.
NOTE: If correct coverage is now reinstated and no further adjustments are needed, process is completed. If an override is needed for correct coverage to be reinstated, continue to the next step.
From the Medical EDBC Summary page, click the Override Program Configuration button.
On the Program Configuration page, update the following fields:
EDBC Override Reason: Administrative Decision,
Program status: Active,
Update Reporting Type: Semi-Annual Reporting.
Only required when overriding a Full Closure/Discontinuance, simply overriding 1 person, does not require this to be selected.
Click the Override button next to consumer(s) who need the information updated.
On the Program Configuration Override Detail page in the User Override section update the following fields:
Role: Mem,
Status: Active,
QHP Screened: No,
Claiming Code: Federal,
Status: leave blank,
Role Reason: leave blank,
Adult Child Code: leave blank.
Click Save and Return button.
On the Program Configuration Override List page, click the Save and Return button.
On the Medical EDBC Summary page, click the Override Medical Summary button at the bottom of the page.
The Medical EDBC Override List page displays.
From the Medicaid EDBC Override List page, click the Add button.
From the Medicaid EDBC Override Detail page, in the User Override complete the following fields:
Test Category: select appropriate option,
Test Result: Pass,
Premium: if applicable,
State Date: First day of the month EDBC is being ran for,
End Date: Last day of the month EDBC is being ran for,
CHIP Start Date: if applicable – date EDBC is being ran,
Premium Start Date: if applicable.
If reinstating Family Medical coverage, in the Individual Budget Unit (IBU) section complete the following fields (if not reinstating Family Medical coverage skip to step 31):
For the Individual --
Person: Name of Individual,
Role: Mem,
Aid Code: Select the appropriate Aid Code,
Click the Add button.
Note: Be sure to include all people that will be part of the individual’s IBU:
Person: Name of individual,
Role: FRI,
Role Reason: Tax Dependent (for all other children that should be considered in the IBU), Primary Tax Payer (PA), or Spouse (SP),
Aid Code: leave blank.
Click the Add button.
Click the Save and Return button to go back to the Medicaid EDBC Override List page.
Repeat for all applicants needing an override; then continue to step 30.
The Continuous Eligibility Override Detail page displays.
Enter the CE End Month using the <MM/YYYY> format or the calendar icon. The CE End Month should create a 12-month CE Period. Example: Run month is 4/23, CE End Month is 3/24.
Select the Adjustment Reason: Disaster
Repeat step 30 for all applicants requiring a CE End Month adjustment.
The Medical EDBC Override List page displays again. Check the box next to the budget and click Save and Return.
The EDBC Medical Summary page now displays showing the newly created budget for our consumer. Click the Accept button.
The EDBC List page displays. Click the Save and Continue button.
Create a Journal.
Create a manual form using the V008 and C-105 on the SCP Unwinding tab.
___________________________________________________________________________________________________________________________________________
After the 30 Day Pend - Review HAS been Returned by the Consumer
Note: If the review has NOT been returned by the consumer, please skip to following section: After the 30 day pend - Review Has NOT Been Returned by the Consumer.
From the Case Summary page:
Click View Details on the active Medical Program Block.
The Medical Detail page displays. Click Edit.
From Program Persons choose an active member and click Edit beside their name.
The Medical Person Detail page will display. In the Continuous Eligibility Periods click View CE History.
The Continuous Eligibility History page displays. Find the most recent CE that was approved when coverage was reinstated for this review. Click Edit.
The Continuous Eligibility Period Detail page displays.
Enter the CE End Month using the <MM/YYYY> format or the calendar icon. The end date will be the month before the current come-up month. Example: Come-up month is 05/2024, CE period will be shortened to end in 04/2024. This will ensure the consumer will receive the proper coverage they are now eligible for.
Select the Adjustment Reason: Late Review.
Click Save and Return.
The Continuous Eligibility History page will display showing the newly shortened CE period with the correct Adjustment Reason. Click Close.
The Medical Person Detail page will display. Click Close.
NOTE: Repeat steps 3 – 8 for all active members on the case.
Complete processing of the review with normal processing procedures.
After the 30 Day Pend - Review Has NOT been Returned by the Consumer
From the Case Summary page:
Select Negative Action.
The Negative Action Detail page displays with the come-up month as the current Benefit Month.
Select all members who have current active coverage on the case,
Negative Action Reason: Failure to Returned Signed Review,
Click Run EDBC.
The EDBC List page displays. Choose the Program for the month that was ran and shows a Run Status of Fail.
The Medical EDBC Summary page displays. Review to make sure all members show Discontinued with a Status Reason of Failure to Return Signed Review. Click Accept.
The EDBC List page displays. Click Save and Continue.
The Distributed Documents Search page displays. Open the Discontinuance NOA that was created and review for accuracy. If it is not accurate delete the NOA and create a manual discontinuance with the correct information.
Create a Journal.