The CAO must make a determination of eligibility within 30 calendar days of the date a completed, signed application is filed unless the application is a COMPASS application. For COMPASS applications, the eligibility determination must be made within 30 days of the date the COMPASS application is submitted. If a determination cannot be made in 30 days, the CAO must send a notice to the applicant explaining why a determination cannot be made and saying that the 30-day period will be extended to 45 days. 55 Pa Code § 125.84 (e)
Exceptions:
A determination for Healthy Beginnings must be made within 45 days of the opening date for presumptive eligibility. 55 Pa. Code 140.142
See Section 317.6, Determining Eligibility for how much time is allowed for processing of Breast and Cervical Cancer Prevention and Treatment (BCCPT) applications. Public Law 106-354
At application, the CAO must record the following information in the case record: 55 Pa. Code § 125.74 55 Pa Code § 125.84
Any information that should be on the application form but is not.
The date and place of the interview if an application interview was necessary.
Another explanation, if needed, of why the individual is applying, in addition to the reasons stated on the application form (for example, past management)
Any plans made with the applicant.
An explanation of why there is different information stated on the application compared with the information in the case record.
The application process ends when any one of the following occurs:
The applicant withdraws his or her application.
The applicant is found to be ineligible.
The applicant is found to be eligible and benefits are allowed.
The CAO must send the Notice to Applicant to the individual when a determination of eligibility is made. If a provider submitted the application, the CAO must also send copies to the provider. If the individual is eligible but owes money as a patient to one or more providers, the CAO must send copies to each provider to whom the individual is responsible for making a payment. 55 Pa. Code § 125.1(k)
An applicant may withdraw his or her application at any time before the eligibility determination is made. 55 Pa. Code § 125.84(e)(2)(iii)
NOTE: The CAO must discuss any misunderstanding of MA requirements or agency procedures with the applicant to prevent him or her from withdrawing an application if it is not necessary or smart to do so. The CAO must not advise or try to convince an individual to withdraw.
If the applicant withdraws the application, the CAO must have the individual fill out a voluntary withdrawal form and make sure that the following information is included:
The program from which the applicant is withdrawing.
The applicant’s signature and the date he or she asked for the withdrawal.
The reason that the applicant asked to withdraw the application.
The CAO must then take the following actions:
Deny MA, using reason code 063.
Record in the notes section why the applicant withdrew the application (if he or she gave a reason).
Send a Notice to Applicant to let the applicant know that the application was denied because the applicant asked to have it withdrawn. Send a copy to the provider, if appropriate.
Complete the “Not Authorized” section of the application form.
If an individual cooperates with the application process and is found ineligible, the CAO must take the following actions:
Deny MA, using the correct code.
Record the appropriate information and reason for denial in the case record.
Send a Notice to Applicant to let the applicant know that he or she is not eligible. Send a copy to the provider if needed.
Complete the “Not Authorized” section of the application form.
The applicant is responsible for providing, to the extent that he or she can, the required proof to show that he or she is eligible. The CAO will not deny eligibility for lack of proof if the individual cooperates but does not obtain proof for reasons beyond his or her control. 55 Pa. Code § 201.1
The CAO will help the individual, if necessary, to obtain the required proof or make a reasonable plan with the individual to obtain proof on his or her own.
If the individual does not cooperate in providing the necessary verification, the CAO must take the following actions:
Deny MA, using reason code 042 for the denial.
Send a Notice to Applicant that includes:
What information was not provided or what action was not taken.
The regulation that required this information or action.
What actions the CAO took to help in obtaining this information.
Send a copy of the Notice to Applicant to the provider.
Complete the “Not Authorized” section of the application form.
Authorization of benefits is the process of completing and processing all of the data necessary to approve MA benefits on CIS/eCIS.
When the CAO receives a complete MA application and approves it, the CAO must take the following actions: 55 Pa Code § 125.84 (d)
Explain the type of benefit provided and how eligibility was found.
Explain the services covered by the type of benefit being allowed and any copayments or GA-related deductible requirements. (See Chapter 338, Appendix D and Section 338.522.)
Explain that the ACCESS card will be mailed, when to expect it, and how to use it when the individual receives it.
NOTE: The individual should receive the ACCESS card within 7 calendar days.
Find out if any member of the applicant/recipient group needs immediate medical care. If so, provide a Temporary Access Card (TAC) (See Chapter 380, Issuing the ACCESS Card.)
Explain that a third-party medical resource (such as insurance) must be used before MA.
If asked to help the individual find medical care, access MA CARES and give the individual a list of providers who participate in the MA Program. (See Chapter 338, Medical Assistance Benefits.)
Explain SNAP.
Give referrals to the EPSDT, DAP, LIHEAP, WIC, and PACE programs, as appropriate.
Discuss other social services that are available.
Discuss the responsibility of the recipient for reporting changes.
Between January 1 and June 30 of each year, send an Income Tax Refund Notice (CM 126) to all approved individuals who had income in the previous year. After June 30, provide the CM 126 to eligible individuals who continue to expect an income tax refund.
Enter all information required for the approval process into the computer system.
Send a Notice to Applicant to let the individual know what type of benefit has been approved, the date eligibility begins, and the amount, if any, that the patient must pay for an unpaid medical expense. Send copies to the provider. 55 Pa. Code § 125.1(k)
Updated February 14, 2012, Replacing June 27, 2008