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healthCare Eligibility Findings Page

ma_findings4-01-08.jpg

 

 

  1. Name, PIN, Healthcare Category:

 

These fields display each individual in the MA/BC case, his/her PIN, and the Healthcare category as recorded in CARES.
 

  1. Correct Category:
     

If the review determines that the benefit category is incorrect for any individual, select the correct benefit category from the "correct category” drop down box.  All CARES category codes are listed in the drop down box as well as an option to choose "ineligible."  If there is no change in category, leave this field blank.    

 

  1. Responsibility Amount:
     

This field displays the recipient cost share responsibility from CARES including but not limited to: BadgerCare Plus premium, patient liability, or MAPP premium.  

 

  1. Correct Amount:
     

If the review reveals a change in the cost share amount for a recipient indicate the correct cost share amount here.  If the individual should not have a cost share but an amount was displayed in the previous field, enter "0” here.  If the individual was found ineligible and had a cost share associated with his/her benefit, also enter "0” here.

 

  1. Responsibility Amount Difference:

 

This field displays the difference (if any) between the client responsibility amount which is recorded in CARES and the corrected client responsibility if entered in (4) "Correct Amount” field.

 

  1. Over or Under Payment:
     

This field displays  the "over" or "under" payment amount that resulted from an incorrect "Responsibility Amount"(3).  This field displays either "over” or "under” depending on the outcome of any change in the responsibility amount.

 

  1. Eligibility Findings:
     

This field displays six options for the reviewer to choose from  that describes the overall finding for the Healthcare case.  The option chosen summarizes the post-review eligibility outcome as compared to the original eligibility on the case before review.  Below are the options and the description of each of the choices.

 

 

Drop Down Option

Description

Correct

No errors

Ineligible

No eligible members for any type of Healthcare.

Technical error only

Error, but did not cause a change in eligibility

Eligible with cost share error

Remains Healthcare eligible, but the cost share/premium/patient liability amount was incorrect

Eligibility error

Healthcare eligibility continues, but the error caused a change in the eligibility. (e.g. an individual incorrectly included/excluded from benefits).

Benefit error

Change from full benefit to limited benefit Healthcare or vice-versa.

 

 

  1. Over/Under Payment for Month Under Review:
     

In this section the reviewer needs to determine whether there is an over or under payment on the Healthcare case as a whole and what the amount is.  This section of the page is different from the over and under payment field in the top section of the page.  Here,it is necessary to look at the case as a whole not just the cost share portion of the case.  The reviewer will need to look at MMIS to determine what claims were paid on the case to determine the actual overpayment amount.  

 

  1. Comments:

    Provide any unique details of the case which affect conclusions reached in the Healthcare Eligibility Findings.
     

 

This page last updated in Release Number: 08-02

Release Date: 04/03/08

Effective Date: 02/01/08