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STEP 7: Request for Additional Info.

Note: if this customer just got a 120-day certification in order to provide missing verifications, then proceed to Step 8. Otherwise: Check areas for which the customer may not have provided sufficient info: D Earnings D Unearned income D Resources (MC and SR customers only) D New Medical Form (not for customers 65+) D Verifications for other reported changes D Other (specify):

If you checked any of the above, speak with your supervisor before requesting additional info. With your supervisor’s approval (noted with their signature below), you should: (1) contact the customer by telephone to request the missing info.; and (2) issue a General Communication (C617) requesting verifications marked above; and (3) approve eligibility with a 4 month cert period.

Supervisor’s Authorization:

D Yes, issue the notice and approve eligibility with 4- month cert period. Make sure that the recert is registered.

Signature

Date:

For SSR:

Customer’s telephone:

Date of telephone contact:

Date General Communication (C617) sent: STEP 8: Terminations

You may initiate a termination if: D The customer did not respond to the prior General Communication requesting additional info; D AR/AX-customer has exhausted Transitional MA period (6 mos. for earnings, 4 mos. for child support) and continues to report earnings above the scale; D MC customer did not return Medical Form after four months as requested in a General Communication or MC Approval-Short Cert A822); D MC customer did not provide Alien ID # after 4 months, as requested in an A822; D 21 year old MC customer did not apply for continued benefits after 4 months as requested in an A822; D MC or SR-customer is over-income; or D MC or SR-customer is over-resourced.

If you checked any of the above, speak with your supervisor about initiating a termination. If your supervisor agrees that the customer’s Medicaid should be terminated (denoted by their signature below), then please ensure that:

(1) you send a notice before terminating benefits in ACEDS; and (2) you terminate benefits at the end of the certification period (or thereafter in order to comply with adequate and timely notice requirements).*

Supervisor’s Authorization:

D Yes, issue a denial notice to the customer and then terminate eligibility in ACEDS.

Signature

Date:

* Note: you may terminate benefits prior to the end of the certification period in the event that the customer dies, moves outside of the District, or loses contact with IMA (i.e., mail is returned.)

Income Maintenance Administration Original: Case Record Page 2 D.C. Department of Human Services DHS Form 1210 (10/06)