Mass Health Review Form PDF Details

The Mass Health Review Form (MHRF) is a way for providers to review medical services and submit claims for payment to MassHealth. The form is used to determine the necessity and appropriateness of the services provided, as well as the amount of payment that should be made. In order to complete the MHRF accurately, it's important to understand how it works and what information is required. This article will provide an overview of the MHRF, including its purpose, who completes it, and what information is included.

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QuestionAnswer
Form NameMass Health Review Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesmasshealth renewal application, masshealth application pdf, masshealth renew, renew mass health

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COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

OFFICE OF MEDICAID

600 Washington Street Boston, MA 02111 www.mass.gov/masshealth

Eligibility Operations Memo 09-05

April 1, 2009

TO:

MassHealth Eligibility Operations Staff

FROM: Russ Kulp, Director, MassHealth Operations

RE: Prepopulated Eligibility Review Form

Introduction Federal regulations require that MassHealth conducts annual eligibility reviews. To support this requirement and help members with the annual review process, MassHealth is providing, to selected households, an Eligibility Review Form (ERV) that is “prepopulated” with the most recent household information. The implementation of this new ERV — the Prepopulated ERV (PPE) — is outlined in this memo.

Prepopulated The Prepopulated ERV (PPE) is designed to provide a member with the

ERV Overview household information that is currently on MA21. The member will have the opportunity to review the existing information and make corrections as needed. In addition, the PPE will allow a member to report any new information about their household. A household selected for the PPE process will get the PPE in place of a blank ERV.

The PPE will include information on all members who are still active in the household, whether they are open, closed, or pending. Active members are those who do not have a family group number of 00. Households with multiple family groups or with a head of household (HOH) not coded as “self 1” will be excluded from selection for the PPE process.

The pilot for the PPE will select Commonwealth Care-households only.

(continued on next page)

 

Eligibility Operations Memo 09-05

 

April 1, 2009

 

Page 2

Prepopulated

 

 

The member’s address that will be printed on the PPE is the residential

ERV Format

address. The other fields on the PPE that will be prepopulated are

 

HOH event — Head of Household and Other Family Members;

 

EIN event — earned income records under Current Working Income

 

section;

 

UIN and REN events — unearned income records under the Current

 

Nonworking Income section, including rental income;

 

HIN event — health insurance records under Current Health

 

Insurance section, including private health insurance and Medicare;

 

and

 

DDU event — members under the Injury, Illness, or Disability section

 

(only those members who are already disabled).

Under the Proof of Citizenship/National Status and Identity section, only those family members who are citizens will be listed. The following will be prepopulated in the Proofs We Need column:

Citizenship — if proof of citizenship is needed;

Identity — if proof of identity is needed;

Citizenship an Identity — if proof of both citizenship and identity is needed;

None — if no proof of citizenship and identity is needed.

In any section that contains social security numbers, only the last four digits will be printed and the other digits will be replaced by Xs. At this time, health insurance claim numbers cannot be truncated.

PPE Mailing

In addition to the PPE form, the mailing will include the following forms:

 

Eligibility Representative Designation (ERD);

 

Affidavit of Parent or Guardian on Identity of Child under Age 16;

 

and

 

UNIV-5 (Babel).

 

A sample PPE is attached. Only the sections that could be prepopulated

 

have been reproduced for this example. An actual PPE also contains the

 

entire ERV form, including the sections that will not be prepopulated,

 

such as the cover sheet and instructions.

 

 

 

 

(continued on next page)

 

Eligibility Operations Memo 09-05

 

April 1, 2009

 

Page 3

MEC

 

 

Starting in March 2009, MA21 will generate the new PPEs and send them

Responsibilities

to Commonwealth Care-only households. For the initial pilot, the PPEs

 

will be processed at the Taunton MassHealth Enrollment Center (MEC).

 

When the PPE is received at the MEC, staff will record the receipt in

 

MA21 for processing. This action will reactivate the eligibility time for the

 

Commonwealth Care member.

 

PPEs are to be processed following the current procedures for processing

 

ERVs.

Questions

 

 

If you have any questions about this memo, please have your MEC

 

designee contact the Policy Hotline.

 

 

 

EOM 09-05

April 1, 2009

Attachment

Page 1

Sample of Prepopulated Areas on the PPE

A. Head of Household and Other Family Members:

Head of Household

1.Name: REVIEW, JOHN

SSN: XXX-XX-1234 Date of birth: 05/01/1955

Street: 1

MAIN STREET

 

City: BOSTON

 

State: MA

Zip: 02111

 

Phone #:(Home/Cell) 617-222-3333

(Work) 617-333-4444

Does this person want benefits? ( )Yes ( )No

Enter address and phone # below if different

Home address

 

Street: ___________________________

City: _______________________

State: ___ Zip: ________ Phone #: (Home/Cell) _________ (Work): __________

Mailing address (if different from home address or living in a shelter) Street: ___________________________ City: _______________________

State: ___ Zip: ________

( ) Homeless

Other Family Members

2.Name: REVIEW, WIFE

SSN: XXX-XX-3456 Date of birth: 05/01/1948

Relationship to head of household: SPOUSE

Is this person still living in this household? ( )Yes ( )No

Does this person want benefits? ( )Yes ( )No

3.Name: REVIEW, DAUGHTER

SSN: XXX-XX-7890 Date of birth: 05/15/1999

Relationship to head of household: CHILD

Is this person still living in this household? ( )Yes ( )No

Does this person want benefits? ( )Yes ( )No

4.Name: REVIEW, SON

SSN: XXX-XX-1234 Date of birth: 05/15/1997

Relationship to head of household: CHILD

Is this person still living in this household? ( )Yes ( )No

Does this person want benefits? ( )Yes ( )No

B. Proof of Citizenship/National Status and Identity:

Proof of Citizenship/National Status and Identity

Federal law requires us to get proof of U.S. citizenship/national status and identity for all individuals applying or having their eligibility reviewed for benefits who claim to be U.S. citizens/nationals. You have to give us this proof only once. If you have not given us these proofs before, please see the insert that came with this notice for complete information about acceptable proofs of U.S. citizenship/national status and identity. The insert also provides exceptions for those individuals who may not have to provide this proof.

EOM 09-05

April 1, 2009

Attachment

Page 2

Below is a list of the family members we have on file who claim to be U.S. citizens/nationals. The information we need for each family member is listed under “Proofs We Need.” If we already have this information, or we do not need proofs at this time, “none” will be listed.

Name

Date of Birth

SSN

Proofs We Need

REVIEW, WIFE

05/01/1955

XXX-XX-1234

Citizenship and Identity

REVIEW, CHILD

05/01/1955

XXX-XX-1235

Identity

C. Current Working Income:

Current Working Income

Please review the current income we have on file and answer the questions (Yes or No).

If you are still working, please send proof of income, like a copy of two recent pay stubs. If self-employed, see the MassHealth Member Booklet for more information about the needed proof.

1. Name of person working: REVIEW, JOHN

 

 

Employer name: BANK OF AMERICA

 

 

Employer address: 100 MAIN ST

 

 

City: BOSTON

State: MA

Zip: 02111

Do you still work at this job? ( )Yes

( )No

 

If yes, number of hours per week? ____ Weekly pay before deductions: $ ______

Is health insurance offered that would cover doctors’ visits and hospitalizations? ( )Yes ( )No

If you answered no to the above question, was health insurance offered in the last six months? ( )Yes ( )No

D. Current Nonworking Income (including rental income):

Current Nonworking Income

Please review the current nonworking income we have on file and answer the

questions (Yes

or No). Send proof of this income if

you still get this income. You

do not have to

send proof of social security or SSI

income.

1.

Name of person: REVIEW, JOHN

Type

of income: PENSION

 

Monthly amount: $400.00

Do you still get this income? ( )Yes

( )No

 

If amount has changed, monthly

amount before taxes: $__________

 

2.

Name of person: REVIEW, WIFE

Type of income: PENSION

 

Monthly amount: $300.00

Do you still get this income? ( )Yes

( )No

 

If amount has changed, monthly

amount before taxes: $__________

 

3.

Name of person: REVIEW, WIFE

Type of income: RENTAL

 

 

Property address: 1100 MAIN ST BOSTON MA 02111

 

 

 

Net monthly amount: $300.00

Do you still get this income? ( )Yes

( )No

 

If amount has changed, net monthly amount: $__________

 

EOM 09-05

April 1, 2009

Attachment

Page 3

E. Proof Current Health Insurance:

Current Health Insurance

Please review the current health-insurance information we have on file and answer the questions (Yes or No).

1. Policyholder name: REVIEW, JOHN

 

Policy number: 1235453456

Insurance company name: BLUE CROSS BLUE SHIELD

 

 

 

Policyholder contribution to premium: $100.00

Frequency: MONTHLY

Names of covered family members:

 

 

 

 

REVIEW, JOHN

 

REVIEW, WIFE

 

 

 

REVIEW, DAUGHTER

 

REVIEW, SON

 

 

 

Are you or any of your family members still covered under this health

insurance? ( )Yes ( )No

If no, what date did it end? / /

 

 

 

 

 

 

F. Injury, Illness, or Disability:

Injury, Illness, or Disability

Our records indicate that the following members have already been determined

disabled:

 

REVIEW, JOHN

XXX-XX-1234

REVIEW, WIFE

XXX-XX-3456

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