Form DMA 285

If a TPL exists a Form DMA 285, Health Insurance Information Questionnaire, must be signed and placed in the case record or scanned into DIS. A copy of the front and back of the Medical Insurance card, if available, should also be scanned into DIS. The reported TPL must be entered into Gateway on corresponding page as this is electronically transmitted to HMS. Do not submit Form DMA 285 if Medicare is the only TPL.

Form DMA 285 is not needed if the AU reported their TPL while using one of the following:

Form 94A Medicaid Streamlined application

Federal Single Streamlined application

Gateway Online Medicaid application or renewal

The pre-paid dental services do not need a DMA 285 completed. For example: Onsite Dental Services does not require a DMA 285.

If an AU has no TPL, completion of the DMA 285 is not required if application for Medicaid is made with the following forms that include the assignment of TPL rights:

Form 94 (rev. 12/03 or later)

Form 508

Form 297M (rev. 11/07 or later) This must be completed with the Form 297 (Obsolete as of 12/2021)

Form 700 (rev. 11/07 or later)

Gateway Online Medicaid Application and Renewal

PeachCare for Kids® Application (Obsolete as of 09/2017)

Form 94A Medicaid Streamlined Application

Form 632 Presumptive Eligible (PE) Pregnancy Medicaid (rev. 4/1/10 or later)

Form 632W Presumptive Eligible (PE) Women’s Health Medicaid (rev. 1/1/13 or later)

Form DMA 285 can be accessed by the below link: mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/FORMS/10232006_285_Rev-Jan06_RVSD%2013-02-2012%20212123.pdf

The assignment of TPL rights must be done at each application and renewal. If a renewal is completed by phone, a renewal form must be sent to the A/R for signature, and the form must be returned to prevent penalization/loss of coverage.

For MAGI Family Medicaid COAs a separate DMA 285 is not required if the Form 94A Medicaid streamlined application, or pre-populated renewal (web services) has the TPL information included, and the form is signed.

For Q-Track applications, a DMA 285 is not required to be completed even when the AU has TPL. A copy of the application may be submitted in lieu of the DMA 285 with a copy of the insurance card attached, if possible.

Mail, fax, or email Form DMA 285 to:

Health Management Systems 100 Crescent Centre Pkwy, Suite 1000 Tucker, Georgia 30084 Phone 678-564-1162, Press 3 Email: gatpl@gainwelltechnologies.com

or

fax # 770-937-0180

It is not necessary to mail or fax Form DMA 285 if the Case Worker was able to input the required information on the assigned Gateway page. Prior to sending form DMA 285 to HMS please consult with your local Medicaid Field Program Specialist.