Provider Update: March 5, 2019
To: All ADvantage Case Management Providers
Subject:Policy Update OAC 317:35-17-16:Member Annual Level of Care Re-evaluation and Annual Service Plan Reauthorization
Recent policy update to OAC 317:35-17-16 includes the following: (c) When medical eligibility redetermination is not made prior to the current medical eligibility expiration, the existing medical eligibility certification is automatically extended.
(1) For members who are not receiving inpatient; acute care, long term acute care, rehab or skilled nursing services, the existing medical eligibility certification is extended for a maximum of sixty (60) calendar days from the date the previous medical eligibility expiration date.
(2) For members who are receiving inpatient; acute care, long term acute care, rehab or skilled nursing services, the existing medical eligibility certification is extended for thirty (30) calendar days from the date of discharge from the facility or the sixty (60)calendar days from the date of the previous medical eligibility date, whichever is longer.
(3) When the medical eligibility redetermination is not made by the applicable extended deadline, the member is determined to no longer meet medical eligibility. The area nurse or nurse designee updates the system's medical eligibility end date and simultaneously notifies AA electronically.
The UCAT III completed by the Case Manager is required for DHS to make the annual level of care eligibility determination. The above policy becomes applicable when the required UCAT III is not completed by the Case Manager prior to the end of the service plan year, the date that corresponds with the current program eligibility end date.
To comply with this policy and negative action deadlines* it is necessary for the Medicaid Services Unit – Eligibility Team to initiate the process for closures within 30 days of the original eligibility end date.
*The negative action deadline is the date by which a computer generated notice must be sent to a Member advising of a decrease in benefits.When a negative action requiring a 10-calendar day notice to the Member occurs, staff must process the change by an established date to be effective on the first day of the next month.
Please send any questions regarding the information above through the Harmony PQ chapter.