South carolina department of health and human services medicaid policy and procedures manual

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101.11.01 Processing Review Form (Eff. 06/01/13)

Note: For PHC cases that go into review status on or after April 1, 2011, a data match will be completed with the DSS CHIP system. If the beneficiary is currently receiving SNAP (food stamps) or TANF (FI), continuing Medicaid eligibility will be determined by MEDS. If the beneficiary is not receiving SNAP or FI, the eligibility worker must complete a regular eligibility determination as stated below.
When a beneficiary submits a review form (either signed or unsigned), the review form and any other information/verifications received must be scanned into OnBase and the “Form Received Date” must be updated in MEDS.
If the review form is signed and additional verifications are required, the beneficiary must be given ten (10) days to provide any needed information. The DHHS Form 1233 ME, Medicaid Eligibility Checklist, must be sent to the beneficiary requesting any additional information. If necessary, the eligibility worker must make a reasonable effort to assist the beneficiary. Once all information is received, an eligibility worker must complete the review process.
If the review form is not signed, an eligibility worker must send the review form along with a DHHS Form 1233 ME to the beneficiary requesting the signature and any additional information, if required. The beneficiary must be given ten (10) days to provide the requested information. If necessary, the eligibility worker must make a reasonable effort to assist the beneficiary.
If the beneficiary fails to return the review form and/or any requested information before the Next Review Date (NRD) and the case closes, the case can be re-opened if the beneficiary returns the review within 30 days from the date of closure. If necessary, the eligibility worker must make a reasonable effort to assist the beneficiary to secure additional information that may be needed to complete the review. If the information is received later than 30 days, the review form must be treated as a re-application and entered into MEDS.
TMA Quarterly Reports

For signed or unsigned reports, determine if any wages are included

If any wages are included, register the report receipt date in MEDS
If no wages are included, do not register the report receipt date in MEDS unless Good Cause is alleged

All TMA Quarterly Reports must be scanned into OnBase.

Processing a Review Flow Chart

Exception: Nursing Home, Waivered Services, and OSS budget groups (Payment Categories 10, 15, 33, and 85) do not close automatically. If a review is not received, MEDS will put the case in Maintenance Status. If the review is received after the case has been placed in Maintenance Status, the eligibility worker must treat this as a reported change and complete a redetermination.

101.12 Case Transfers (Rev. 10/01/13)

A Medicaid case is generally processed in and maintained by:

The local Medicaid office in the county/region in which the applicant/beneficiary lives; or
The Division of Central Eligibility Processing (CEP), Department of Health and Human Services; or
Eligibility, Enrollment and Member Services, Department of Health and Human Services.

When it is appropriate to transfer a Medicaid case from one location to another, the supervisor must review the case file for accuracy prior to the transfer.

When a local eligibility office maintains a beneficiary’s case, and the beneficiary moves to another county, the case file must be transferred to the other location within 10 working days from the date of the notice of address change.
When a beneficiary requests that his/her case be transferred from one location to another (such as from CEP to a local Medicaid office), transfer the case to the other location within 10 days from the date of the request.

Procedure for Transfer of Case File Ownership from Location to Location:
Originating Location:

The originating location will complete Section I of the DHHS Form 3205 ME, Case Request /Transfer Form, for each transferred case.
The originating location will include the completed DHHS Form 3205 ME with the physical case file when it is physically relocated.
The originating location will ensure the security and confidentiality of case file information during the transfer.
- Case files will be packaged such that unauthorized personnel cannot readily access protected health information. All packaging will be marked “Confidential.”
- Case files will be transported either by a contracted courier service or by United States Postal Service.

SSI-Related Cases

A full re-determination of eligibility must be made by the transferring location if one has not been completed within the preceding 10 months. If a re-determination has been completed within the preceding 10 months, the case must be transferred within 10 working days of the request.
If the receiving location receives an SSI case that has an eligibility error, the case cannot be accepted and must be sent back to the originating location for corrections.

FI and Employee Related Cases

The re-determination of eligibility must be made by the receiving location.

Exceptions:

OCWI (Pregnant Women) – these cases are not reviewed as the cases are eligible without regard to changes.
Partners for Healthy Children (PHC) – these beneficiaries age 0-19 have a one-year period of continuous eligibility without regard to changes. If the case transfers during this one-year period, no review is completed.

Receiving Location:

The receiving location will complete Section II of the DHHS Form 3205 ME upon receipt of the case file and will return a copy of the form via courier or fax within (3) working days.
The receiving location will complete Section III of the DHHS Form 3205 ME to document their determination to accept or reject the case; they will return the original DHHS Form 3205 ME, with Sections I, II and III completed, to the originating location within 30 days.

Note: SSI-related cases can be returned by the receiving location only if there are eligibility errors. Procedural or other errors not directly related to the eligibility decision are not a reason to reject a transfer. FI-related cases must be accepted by the receiving county. The receiving county will be responsible for correcting any eligibility or procedural errors.

Institutional Cases
Applications filed after an individual is placed in a nursing facility will be processed and maintained in the location where the nursing facility is located unless there is an open Medicaid case in another county. The county with the open Medicaid cases will process the application, and then transfer the case.

Exception: All Income Trusts cases are processed and maintained by the Eligibility, Enrollment and Member Services, Central Institutional Unit (CIU).

Applications filed before placement will be processed in the original location of residence and then transferred to the new location for maintenance. Persons in a general hospital or in a DMH facility will have their application processed and maintained in their location of residence.

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