07-21 HHSA Form – Fill Out and Use This PDF

A.9.1

Forms

Forms

FORM NUMBER	FORM TITLE
07-16 HHSA / 07-16 HHSA	Request for Withdrawal or
(SP)	Discontinuance of Benefits
07-21 HHSA / 07-21 HHSA	Employment Verification
(SP)
07-27 DSS	Case Narrative
07-227 DSS / 07-227 DSS	Statement of Contribution &
(SP)	Declaration of a Loan/Gift
07-66 HHSA / 07-66 HHSA	Self Employment Income
(SP)	Statement
14-4 DSS	Medical Services Screening
14-08 DSS	Applicant Notice of
	Decentralization
14-10 HHSA	Transmittal of CMS/Medi-Cal
	Information
14-12 DSS	District Notice of
	Decentralization
16-42 HHSA / 16-42 HHSA	Sworn Statement
(SP)
CW 60 / CW 60 (SP)	Release of Information –
	Financial Institution
DHS 6155	Health Insurance
	Questionnaire
HHSA: CMS-007/HHSA:	CMS General Property
CMS-007 (SP)	Limitations Notice
HHSA: CMS-2/HHSA: CMS-	CMS SSI Advocacy Referral
2(SP)
HHSA: CMS-3	CMS Weekly Screening Log
HHSA: CMS-4	Registration Information
HHSA: CMS-5	Medi-Cal Referral
HHSA: CMS-7	Third Party Liability Report
HHSA: CMS-9	Sign-in Sheet
HHSA: CMS-13 / HHSA:	Affidavit Residence (Spanish
CMS-13 (SP)	on Reverse)
HHSA: CMS-14 / HHSA:	Rights of Applicants
CMS-14 (SP)
HHSA: HCPA 14-187/HCPA	Authorization for Release of
14-187 (SP)	Information
HHSA: CMS-15 / HHSA:	Responsibilities of Applicants
CMS-15 (SP)

A.

CMS Notices of Action (NOA)

verifications will be stored on the CMS IT System. The CMS IT System will also afford CMS contracted providers the ability to access the website to view CMS case status.

1) NOAs requiring manual mailing

a) Homeless

The CMS IT System will create various NOAs and Informing Notices for homeless patients, but will not automatically mail the notices. The notices will be stored in the patient’s record on the CMS IT System.

If the patient requests a copy of their NOA or Informing Notice, the worker will be able to access the notice and print it on site for the patient. The worker shall make a narrative entry indicating the date the notice was provided, and shall specify which notice was provided.

b)Excess Income Only Denials

The CMS IT System will create the Excess Income Only Denial NOA, but will not automatically mail the notice. The denial NOA will be available in patient’s record on the CMS IT System the following workday after the denial action was taken by the worker.

The worker shall access the patient’s record the next workday following the denial action and shall print the Excess Income Only Denial NOA. The worker shall mail the Excess Income Only Denial NOA and CMS Hardship Application (refer to Article A, Section 13) to the patient. The worker shall make a narrative entry indicating the date the notice was provided, and shall specify which notice was provided.

2)NOAs which will be automatically mailed

a)CMS Approval

The certification period will be automatically filled in prior to the NOA being mailed.

b)Denial NOAs except Excess Income Only

Workers shall enter all case specific information applicable to the denial into the system at the time the denial action is taken (ie, what specific items the patient failed to provide, the amount the patient needs to spend down). The case specific information will be

B.

Approval

Action

C.

Denial Action

D.

Credit Report

Request

automatically filled in prior to the NOA being mailed.

Based on the applicant’s/beneficiaries information entered, the CMS IT System will determine if the client is approved for CMS benefits.

All approval actions taken by the worker will remain in a “pending approval” status for a minimum of one night. Fifty percent of all approvals must be reviewed and released by a supervisor. Each night the CMS IT System will randomly select from the pending approvals, which approvals are to be reviewed by a supervisor, which pending approvals can be approved without a supervisor review.

Based on the applicant’s/beneficiaries information entered, the CMS IT System will determine the appropriate denial action, generate a denial NOA and automatically mail it to applicant as appropriate. Some denial NOAs require manual mailing.

Worker must order a credit report at initial application, recertification or reapplication when information is received from applicant/beneficiary or circumstances are noted which could indicate the possibility of fraud. Reasonable care must be taken to input the applicant’s/beneficiary’s identification information accurately when requesting a credit profile report. CMS will use the credit report as a verification tool for financial, property and eligibility information, which the applicant/beneficiary has provided on their application for CMS. At the end of each business day, the CMS IT System will batch and submit all credit report requests to Experian. The credit profile report is received from Experian on the following business day. Worker must follow-up with applicant/beneficiary on discrepancies

found on report. Worker must verify that all verifications/documents are provided to clear up discrepancy on report to evaluate for CMS eligibility as described in MPG Article A Sections 2 and 13. NOTE: The credit check authorization is good for only one (1) credit report profile request.

Credit reports obtained through the CMS IT System may not be given to the applicant/beneficiary. If the applicant/beneficiary requests a copy of their credit report, refer them to the sources