7.2.5 INSTRUCTIONS

Agency Denial

If the client identified on this Good Faith form was neither eligible nor possessed a valid ID card for the dates of service indicated in field six, place an “X” in this box.  If you check “Yes” here, you must also check the reason in the field below.

Recipient Did Not Have ID Card After Date of Service

Place an “X “in this box if you are certain that the client did not possess a valid MA ID card for the date of service.  In the blank provided, enter the closing date of eligibility.

Recipient Not Eligible

Place an “X” in this box if the client was not eligible for any of the dates of service shown.  If the client was eligible for some of the dates of service, follow the instructions for completing the Partial Deny box.

Record Not Found

Place an “X” in this box if the client has never been eligible for MA in your agency.

Dates of Services

EDS enters the dates of service for the claim.

Partial Deny

Use this field only if the client had eligibility for some of the dates of service.  Enter the “from” and “to” dates which cover the portion of the dates of service for which the client did not have eligibility.

Type of Certification

EDS will check one of these boxes:

1. Initial Certification
   EDS will place an “X” in this box when the client and MA number submitted on the claim cannot be found on the eligibility master file.
    

2. Amended Certification
   EDS will place an “X” in this box when the client is on MMIS, but no eligibility exists for the claimed dates of service.

Agency Number

EDS will enter the three-digit code of the agency they believe may have certified the client during the dates in question.

Casehead ID Number

EDS will enter the known or suspected MMIS case number (primary person’s SSN + tie-breaker) of the client listed on the provider’s claim.  

Action Date

EDS enters the date they completed the Good Faith form.

Medical Status Code

When EDS receives the provider’s claim along with a photocopy of an ID card, a hard copy response received through EVS or a transaction log number from the Automated Voice Response ( AVR ).  EDS compares the dates of service with the dates on the card.  If the dates of service fall within the dates of eligibility for the ID number on the card, EDS enters a “71” medical status code and pays the claim immediately.  EDS then enters the eligibility dates for the entire month in which services were provided.

If the client was eligible for the entire period of certification shown on the Good Faith form ( HCF 10111 ) , remove the “71” medical status code and write in the correct code.  Attach a HCF 10110 (formerly DES 3070) to add the certification period and appropriate medical status code for the time when the client was eligible for MA.

Period of Certification

If EDS has entered the suspected period of certification to be added to the recipient master file, check it for accuracy.  Then complete a HCF 10110 (formerly DES 3070) and enter the period of certification if the client file does not show eligibility for the time when the client was eligible or for the time covered by an ID card issued to the client.

Control Name Year of Birth

EDS will enter the suspected control name and year of birth (YOB) for the client.  This control name must be the first four letters of the client’s last name.  The YOB is the last two digits in the client’s year of birth.  Both of these items must match the information currently in the client’s EDS file.

Current ID Number

EDS will enter the client’s current MA ID number.

Date of Birth

EDS completes this field only for initial certifications.  Change this birth date if the date entered is incorrect.  Indicate birthdate as MM/DD/CCYY.

Signature of Agency Director

Good Faith forms must have an authorized signature for initial certifications.

Worker ID

On initial certifications, enter the six-digit worker code of the certifying IM worker.

This page last updated in Release Number : 02-03

Release Date:07/01/02

Effective Date: 07/01/02