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Model Application Template for the State Children‟s Health Insurance Program

Effective Date:

Approval Date: 65

Attachment 2 Referral Process Enrollment Process for hawk-i Application is received by the Third Party Administrator (TPA)

Steps Yes No Unknown 1. Is the application signed? Application is date stamped, logged into the TPA‟s system and screened for Medicaid eligibility within 24 hours of receipt. Return application for signature within 24 hours.

2. Does Medicaid eligibility appear to exist? Send referral to co-located Income Maintenance Workers (IMW) for Medicaid eligibility determination using Medicaid policies and procedures. Determine eligibility for hawk-i within 10 working days of receiving a complete application. If hawk-i eligibility does not exist then deny application. If hawk-i eligibility does exist then notify family of plan choices and cost sharing obligation if applicable. Insufficient information to make determination. Request additional information. If requested information is not received timely, deny application. If requested information is received then determine if Medicaid eligibility exists and follow Yes and NO section of step 2. 3. Are the children eligible for Medicaid? Children are enrolled in Medicaid. Go to Step. 4. If no action has been taken on the application within 30 days, the TPA will follow-up with the co- located IMW for status. 4. Was the application denied because of failure to cooperate with Medicaid? Deny application for hawk-i coverage. Go to Step. 5

5. Was the application over income for Medicaid? Determine eligibility for hawk-i within 10 working days of receiving the Medicaid decision. if hawk-i eligibility does exist then notify family of plan choices and cost sharing if applicable. if hawk-i eligibility does not exist, deny application.

Referral Process from DHS to hawk-i

When Medicaid Application is Denied 1. Family applies for Medicaid at DHS office 2. The application is denied due to excess income.