Dma 5003 PDF Details

In North Carolina, the process of managing Medicaid or NC Health Choice coverage involves various steps and documentation, highlighted by the use of specific forms, one of which is the DMA-5003 form. This particular form serves as a critical notice for individuals regarding the approval or denial of their Medicaid or NC Health Choice applications. Its primary function is to inform applicants about the decisions made concerning their health coverage, including approval dates, Medicaid Identification Numbers (MID), coverage limits, and the specifics regarding what medical services are covered. Additionally, the DMA-5003 form educates recipients about their rights, including the option to request a hearing if they disagree with the decision made. It also outlines scenarios under which coverage is denied, guiding applicants toward the Health Insurance Marketplace for alternative insurance options if full Medicaid coverage is not granted. Understanding every aspect of this form is crucial for recipients, as it not only details their current Medicaid or NC Health Choice status but also educates them on how to maintain, challenge, or seek further assistance regarding their health coverage. Furthermore, the form contains important information about re-enrollment notifications, ensuring beneficiaries are aware of the need to renew their eligibility to continue receiving health benefits. This comprehensive approach underscores the form's role in the broader context of health services administration within the state.

QuestionAnswer
Form NameDma 5003
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names DMA-5300-ia.pdf. Please Read This Important Notice About Your Medicaid or NC Health Choice Approval Notice

Form Preview Example

PLEASE READ THIS IMPORTANT NOTICE ABOUT YOUR MEDICAID OR NC HEALTH CHOICE APPROVAL

NOTICE

 

NORTH CAROLINA _______________________________________County Department of Social Services

______________________

 

______________________

Date Mailed: _________________________

______________________

 

APPROVALS

□The application for __________________________________________ for ________________________________________ is approved. Medicaid Identification Number (MID) is:______________________________________________________________________________

□Eligibility for _______________________________________ for _______________________________________________ is granted.

Continues from __________________________________________ to ____________________________________________________

Medicaid Identification Number (MID) is:____________________________________________________________________________

□Medicaid is approved starting _________________________________ and ending __________________________________________

□Medicaid covers all necessary medical services.

□Medicaid pays only for services related to pregnancy and for conditions that may complicate the pregnancy

□Medicaid pays only for limited services related to Family Planning. (See page 2 for limited services)

□ Retroactive Medicaid Coverage is approved for the period(s) of _______________________________, _______________________,

_______________________________

□NC Health Choice for Children is approved starting ___________________________ and ending ________________________________

If you receive Medicare, Medicare is responsible for your prescriptions.

The State rules used to make this decision are in __________________________________________of the Family and Children’s Medicaid Manual which

says that:

DENIALS

□Medicaid

□

NC Health Choice

is denied from ____________________________________________ to ______________________________________________ because:

The State rules used to make this decision are in __________________________________________of the Family and Children’s Medicaid Manual which says that:

Individuals who are ineligible for full Medicaid coverage may be eligible for health insurance—and help paying for it—through the Health Insurance Marketplace. We sent your information to them. You can wait for a letter from the Marketplace or you can contact them directly. To contact the Marketplace, go online to Healthcare.gov or call 1-800-318-2596. After you complete your application, the Marketplace will tell you if you qualify for health coverage and financial help. In North Carolina, several non-profit organizations offer free in person assistance with health insurance applications. To schedule an appointment, call 1-855-733-3711 or go online to ncnavigator.net

HEARING RIGHTS: If you disagree with this decision, you have a right to a hearing to review the decision. Call your worker at the number below within 60 days to ask for a hearing. The 60th day is _________________________________. If you do not ask for a hearing by this date, you cannot have a hearing unless you have a

good reason for missing this deadline. You may reapply for benefits at any time. To protect your right, you may BOTH reapply AND ask for a hearing.

FREE LEGAL HELP: Free Legal Aid may be available to you. Contact your nearest Legal Aid or Legal Services office, or call 1-877-694-2464 toll free.

__________________________________

Caseworker Name and Phone Number

Address _________________________

________________________________

________________________________

FOR OFFICE USE ONLY:

County Case #:__________________________

Case ID #: _____________________________

Aid Program/Category:___________________

**YOU WILL RECEIVE A RE-ENROLLMENT NOTICE WHEN IT IS TIME TO REVIEW YOUR ELIGIBLITY FOR MEDICAID OR NC HEALTH CHOICE. IT IS IMPORTANT TO RE-ENROLL TO CONTINUE YOUR HEALTH COVERAGE.

PLEASE CONTINUE READING FOR IMPORTANT INFORMATION ABOUT YOUR RIGHT TO A HEARING

DMA-5003 12/2017

Is there a problem?

 

You can ask for a hearing.

Did you know you have the right to see your

 

 

record?

If you think we are wrong or you have new information, you have the right to a hearing. You must ask for this hearing within 60 days (or 90 days if you have a good reason for delay). This hearing is a meeting to review your case and give you the correct benefits if it was wrong.

Call or write your caseworker to ask for a hearing. A local hearing will be held within 5 days of your request unless you ask for it to be postponed. The hearing can be postponed, for good reasons, for as much as 10 calendar days. Then, if you think the decision in the local hearing is wrong, call or write your caseworker WITHIN 15 DAYS to ask for a second hearing. The second hearing is before a state hearing official.

If you are requesting a hearing about disability, call or write your caseworker to ask for a hearing. There is no local hearing. A state hearing officer holds the disability hearing.

Did you know you have the right to be represented?

You may have someone speak for you at your hearing, such as a relative or a paralegal or attorney obtained at your expense. Free legal services may be available in your community. Contact your nearest Legal Aid or Legal Services office, or call 1-877-694-2464 toll free.

If you have additional questions or concerns, contact

your caseworker for information, or call the DHHS Customer Service Center, Information and Referral Service, toll free at 1-800-662-7030. TDD/Voice for the hearing impaired is also available through the DHHS Customer Service Center number. Their hours of operation are 8 am to 5 pm, Monday through Friday.

If you ask, your caseworker will show you (or the person speaking for you) your benefits record before your hearing. If you ask, you may also see other information to be used at the hearing. You can get free copies of this information. You may see this information again at your hearing.

Do you understand your rights?

Do you understand how to get a hearing? If you have any questions, please contact your caseworker as soon as possible.

Don’t forget to report all changes to your county department of social services within 10 calendar

days (5 calendar days for Special Assistance). If you don’t know whether a change is important,

ask your caseworker. If you do not truthfully report information and changes, you may be guilty of a misdemeanor or felony.

Family Planning Limited Services

Family planning services include one annual physical exam per 365 days, which should be scheduled as your first appointment and six family planning visits per 365 days. Services include contraceptive services and supplies, permanent sterilization, and screening for sexually transmitted infections (STDs) and HIV screening. You can access these services through a health department, community health or rural health clinic, or by any provider in your community who accepts your Family Planning Medicaid coverage. If you choose permanent sterilization and the necessary post- surgical follow-up testing has occurred, or if you have no medical need for family planning services, there are no other services available under Family Planning Medicaid.

How to Edit Dma 5003 Online for Free

This PDF editor was designed to be as straightforward as it can be. As you keep up with the following actions, the procedure for filling out the Dma 5003 form will be straightforward.

Step 1: You can click the orange "Get Form Now" button at the top of the webpage.

Step 2: After you have accessed the editing page Dma 5003, you'll be able to find each of the options available for the form within the top menu.

You will have to enter the next information if you want to fill out the file:

part 1 to filling in Dma 5003

Fill in the Medicaid covers all necessary, NC Health Choice for Children is, If you receive Medicare Medicare, The State rules used to make this, DENIALS, Medicaid NC Health Choice, is denied from to because, The State rules used to make this, and Individuals who are ineligible for areas with any particulars that will be required by the software.

Filling out Dma 5003 stage 2

You'll be asked to note the information to let the program fill in the part HEARING RIGHTS If you disagree, FREE LEGAL HELP Free Legal Aid may, Caseworker Name and Phone Number, Address, FOR OFFICE USE ONLY County Case, YOU WILL RECEIVE A REENROLLMENT, PLEASE CONTINUE READING FOR, and DMA.

stage 3 to completing Dma 5003

Step 3: Once you've hit the Done button, your form is going to be available for transfer to each device or email address you specify.

Step 4: Be certain to avoid potential problems by making a minimum of 2 copies of the document.

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