Pa 162 Rm Form PDF Details

The PA 162 RM form serves as a crucial notice to applicants regarding the determination of their eligibility for Retroactive Medical Assistance. This document outlines the decision made after reviewing an individual's application, detailing whether they have been deemed eligible for assistance, including for which months an individual or family members are covered. Additionally, it breaks down the financial aspects under consideration, such as income levels, resources, and incurred medical expenses, which play a pivotal role in determining eligibility and the potential requirement of a patient pay liability. It also specifies the consequences for both the applicant and the providers regarding billing and payments, emphasizing legal boundaries to prevent misuse of funds. Importantly, the form provides guidance on how to appeal the decision if the applicant disagrees with the eligibility determination, offering a pathway to request a fair hearing and stressing the availability of free legal help. This ensures that applicants are informed of their rights and understand the steps they can take to challenge decisions they believe are incorrect. The form underscores the importance of clear communication between the applicants and the Department, facilitating a process where concerns and queries can be addressed effectively.

QuestionAnswer
Form NamePa 162 Rm Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespa 162 form notice of eligibility, pa form 162, pa fs 162 pa 162 notice to applicant of retroactive medical assistance eligibility, pa fs162c

Form Preview Example

NOTICE TO APPLICANT

Your application of ________________________ for RETROACTIVE MEDICAL

ASSISTANCE has been reviewed.

The decision regarding eligibility for RETROACTIVE MEDICAL ASSISTANCE is shown below.

A

LINE

NO.

THE FOLLOWING PERSONS ARE INCLUDED FOR THE MONTH(S) SHOWN

NAME

MONTH

MONTH

MONTH

MONTH

LINE

NAME

MONTH

MONTH

MONTH

MONTH

& YEAR

& YEAR

& YEAR

& YEAR

NO.

& YEAR

& YEAR

& YEAR

& YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

B

RETROACTIVE MEDICAL ASSISTANCE

MONTH & YEAR

MONTH & YEAR

MONTH & YEAR

MONTH & YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CATEGORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTROL DIGIT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RESOURCES

 

$

 

 

 

$

 

 

 

$

 

 

 

$

 

 

RESOURCE LIMITATION

 

$

 

 

 

$

 

 

 

$

 

 

 

$

 

 

GROSS MONTHLY INCOME

 

$

 

 

 

$

 

 

 

$

 

 

 

$

 

 

NET MONTHLY INCOME

 

$

 

 

 

$

 

 

 

$

 

 

 

$

 

 

INCURRED MEDICAL EXPENSES

 

$

 

 

 

$

 

 

 

$

 

 

 

$

 

 

ELIGIBLE FOR RETROACTIVE MEDICAL ASSISTANCE

 

 

 

YES

 

 

 

YES

 

 

YES

 

 

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ELIGIBLE WITH A PATIENT PAY LIABILITY OF

$

 

 

 

$

 

 

 

$

 

 

 

$

 

 

INELIGIBLE DUE TO EXCESS RESOURCES

 

 

REGULATION

 

 

REGULATION

 

REGULATION

 

REGULATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INELIGIBLE DUE TO EXCESS INCOME

 

 

REGULATION

 

 

REGULATION

 

REGULATION

 

REGULATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

You are responsible under your PATIENT PAY LIABILITY for payment to the following in the amount(s) shown below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AMOUNT

 

PROVIDER NAME

 

 

PROVIDER NUMBER

 

DATE SERVICE PROVIDED

LINE NO.

CATEGORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IT IS ILLEGAL FOR THE ABOVE PROVIDER (S) TO BILL THE DEPARTMENT FOR THIS AMOUNT.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D

The following unpaid medical bills were used as income deductions to make you eligible for Retroactive Medical Assistance:

AMOUNT

PROVIDER NAME

TYPE OF SERVICE

DATE SERVICE PROVIDED

$

$

$

$

IT IS ILLEGAL FOR YOU TO USE YOUR MEDICAL CARD TO PAY FOR ANY OF THESE MEDICAL BILLS!

If

you

have

other

medical

bills

for the

month(s)

for

which

you

were determined eligible, the provider(s)

may submit

invoices

for

payment

by

using

the

case information

contained

in

this notice

if

they

are

willing

to

accept

the

payment

made by

the

Department for the type of service rendered.

CO

RECORD NUMBER

CAT

CTR DIG

DIST

 

 

 

 

 

Worker

Telephone

Mailing Date

LEGAL HELP IS AVAILABLE AT

If you do not understand our decision or have any questions,

contact your worker.

CLIENT

CASE RECORD COPY

PROVIDER COPY

OMA COPY

APPEAL COPY

PA 162-RM 9/08

YOUR RIGHT TO APPEAL AND TO A FAIR HEARING

You have the right to appeal any Departmental action or failure to act and to have a hearing if you are dissatisfied with the decision regarding your eligibility for RETROACTIVE MEDICAL ASSISTANCE.

At the hearing you Office is incorrect and have anyone represent you.

can present to

the

Hearing Officer

the

reasons why

you

think

the

decision

of the County Assistance

present evidence

or

witnesses in

your

own behalf.

You

have

the

right to

represent yourself or to

A staff member of the County Assistance Office will refer you for free legal help upon request.

 

If you need an interpreter at the hearing because you do not speak English or you have limited understanding of English, or you have a hearing impairment, the Department will arrange for an official interpreter at no cost to you. You may bring a friend or relative to assist you at the hearing, but

the interpreter provided by the Department will

be

the

official

interpreter.

The Department

will provide reasonable or special accommodations

for

you

if you

have a hearing impairment or

other

disability.

You must make

the request for

an

interpreter or

other accommodation

in advance of the hearing.

 

 

 

 

 

 

 

 

 

 

 

 

 

If

you and your representative would

like

to

meet

with

the

County Assistance

Office staff to discuss the matter informally

or

to

present

information which might

change

the

decision

regarding

your

eligibility

for

retroactive

medical

assistance,

please call your worker. This will not delay or replace your hearing.

 

 

 

 

 

 

 

 

 

 

You must request a hearing within 30 days of

the mailing date of this notice.

If your

request is not postmarked

or received

within the 30-day time limit, your appeal will be dismissed without a hearing.

 

 

 

 

 

 

 

HOW TO REQUEST A FAIR HEARING:

To appeal and request a hearing for ASSISTANCE CHECKS, MEDICAL ASSISTANCE or SOCIAL SERVICES, you may call your worker; but, you must also put the appeal in writing as follows: (1) Fill out and sign one copy of this form. Give the reason for your appeal; and Give your telephone number; and Give your exact address; and (2) Mail or take this form to the CAO at the address on the front side of this form. To appeal and request a hearing for FOOD STAMPS, you may call your worker; or put the appeal in writing; or do both. If you put the appeal in writing, follow the instructions above.

PLEASE CHECK THE BOX NEXT TO THE TYPE OF HEARING YOU WANT:

I want a Telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: _______________________________.

I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO).

I want a Face-to-Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff.

I want a Face-to-Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO.

PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR A DISABILITY OR YOU NEED AN INTERPRETER:

I have a hearing impairment or a disability. Describe accommodations needed _____________________________________________________.

I need an interpreter. There will be no cost to me. What language? _______________________________.

I WANT TO REQUEST A HEARING BECAUSE:

DATE

CLIENT REPRESENTATIVE SIGNATURE

TELEPHONE #

DATE

CLIENT SIGNATURE

TELEPHONE #

CLIENT ADDRESS

 

 

HEARING LOCATIONS

 

 

 

 

 

PHILADELPHIA FOR:

Bucks, Chester, Delaware, Montgomery, Philadelphia.

PITTSBURGH FOR:

Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette,

 

Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington, Westmoreland.

HARRISBURG FOR:

Adams, Berks, Centre, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lancaster, Lebanon, Lycoming, Mifflin,

 

Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Union, York, Lehigh.

PLYMOUTH FOR:

Bradford, Clinton, Lackawanna, Monroe, Sullivan, Tioga, Wyoming, Carbon, Columbia, Luzerne, Pike, Susquehanna, Wayne.

CLIENT

CASE RECORD COPY

PROVIDER COPY

OMA COPY

APPEAL COPY

PA 162-RM 9/08

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How one can complete pa fs162c stage 1

2. After filling in this part, head on to the next stage and fill in the essential details in all these blank fields - INCURRED MEDICAL EXPENSES ELIGIBLE, INELIGIBLE DUE TO EXCESS RESOURCES, INELIGIBLE DUE TO EXCESS INCOME, REGULATION, REGULATION, REGULATION, REGULATION, REGULATION, REGULATION, REGULATION, REGULATION, You are responsible under your, AMOUNT, PROVIDER NAME, and PROVIDER NUMBER.

REGULATION, INCURRED MEDICAL EXPENSES ELIGIBLE, and REGULATION inside pa fs162c

3. This subsequent segment is considered quite straightforward, If you have other medical bills, are willing, the case, accept, they, invoices, for which you for this notice the, the, payment made, for, the months, the providers may submit, information contained, RECORD NUMBER, and CAT - all of these form fields has to be filled in here.

Stage number 3 in filling in pa fs162c

Lots of people often make mistakes when completing invoices in this section. Ensure that you read twice whatever you type in here.

4. This next section requires some additional information. Ensure you complete all the necessary fields - PLEASE CHECK THE BOX NEXT TO THE, will be on the phone from the CAO, PLEASE CHECK BELOW IF YOU NEED, I WANT TO REQUEST A HEARING BECAUSE, DATE, CLIENT REPRESENTATIVE SIGNATURE, TELEPHONE, DATE, CLIENT SIGNATURE, TELEPHONE, CLIENT ADDRESS, and HEARING LOCATIONS - to proceed further in your process!

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