Responsibilities of a Qualified Provider or Qualified Hospital

The QP or QH determines eligibility for PE Medical Assistance based on the applicant’s pregnancy statement (Pregnant Women), certificate of diagnosis (Women’s Health), the net income of the budget group (BG), citizenship or immigrations status and residency. The QP or QH conducts a face-to-face (FTF) interview with the applicant and performs the following functions:

Screens the applicant in GAMMIS to see if he/she is already active on Medical Assistance. If a woman is already active on Medical Assistance (except Planning for Health Babies®(P4HB)) DO NOT complete a PE application. (See Note below.)

Accepts the applicant’s statement of net income and obtains adequate information from the applicant to complete the following forms: (See Note below.) Form 632, Pregnant Women Presumptive Eligibility application Form 632H Qualified Hospital Presumptive Eligibility application Form 632W, Women’s Health Presumptive Eligibility application Form 216, Declaration of Citizenship/Immigration Status Form 5460, HIPPA Notice of Privacy Practices Form 94A, Single Streamlined Medical Assistance application Form 94, Medical Assistance application (Women’s Health only)

Determines if the applicant meets eligibility criteria for PE Medicaid.

QP forwards the PE Packet to DFCS within five business days of the PE application date.

QH forward the PE Packet to DCH within five business days of the PE application date.

If the QP or QH determines that the applicant is eligible for PE Medicaid, the QP or QH completes the determination process as follows:

provides the applicant with a Temporary Medical Assistance Certificate and form 634, 634H, 634W – Notice of Action (Approval)

provides the applicant with the Quick Guide on Presumptive Eligibility Medical Assistance, Quick Guide on Presumptive Eligibility for Pregnant Women or Quick Guide on Women’s Health Medical Assistance

informs the applicant of the PE Medical Assistance period and covered services

informs the applicant about P4HB

QP forwards the PE Packet to DFCS within five business days of the PE application date

QH forwards the PE Packet to DCH within five business days of the PE application date

If the QP or QH determines that the applicant is ineligible for PE Medical Assistance, the QP or QH completes the determination process as follows:

informs the applicant that he/she is not eligible and provides him/her with the form 634, 634H or 634W – Notice of Action (Denial)

advises the applicant that if his/her circumstances change, he/she may have another determination of PE Medical Assistance completed by a QP or QH

informs the applicant that his/her application for ongoing and/or retroactive Medical Assistance will be forwarded to DFCS for a formal determination of eligibility

A PE application cannot be completed on an already active Medical Assistance member. Qualified Providers and Qualified Hospitals are unable to update pregnancy information in GAMMIS on active Medical Assistance members. If the applicant is pregnant and actively receiving Women’s Health, inform member to report pregnancy to their caseworker. If the applicant is actively SSI, QH/QP should complete the SSI Pregnant Women Update form and send to DCH by email at pecorrections@dch.ga.gov . All other active members need to contact DFCS at 1-877- 423-4746 or submit a Change Report via Gateway “Report My Change” to report their pregnancy.

Form 216 is not required when Forms 632, 632H, or 632W are used as the language is included.

For Women’s Health, a certificate of diagnosis is required at the time of application.

The Temporary Medical Assistance Certificate and the Notice of Action-Approval will serve as proof of eligibility.

The PE Packet being sent to DFCS consists of the following:

PE Application (Form 632, 632H, or 632W)

Notice of Action (Form 634, 634H or 634W) and Temporary Medical Assistance Certificate

Third Party Liability Questionnaire (DMA 285)

Single Streamlined Medical Assistance application (94A) or Medical Assistance application (94 - Women’s Health Only)

Certificate of Diagnosis (Women’s Health only)

Any documentation the applicant provides

To ensure that applications for pregnant women are processed within the 10-day standard of promptness, the local QP(s) should contact DFCS to discuss procedure for forwarding PE Packets to DFCS daily. All other COAs processed as Hospital Presumptive are subject to a 45-day standard of promptness.