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State of Maryland Medical Assistance Manual Revised April 2014

INSTRUCTIONS Facility: 1. Complete Part I and II for all Medical Assistance recipients admitted to your facility. 2. Follow the instructions in section III, IV and V to determine when to complete and submit this form for each recipient. 3. The facility’s authorized representative must sign and date the form. 4. Submit the entire, completed, signed form to the Administrative Services Organization (ASO) for their signature. 5. When the ASO returns the signed form to you: a. Send original to the Medical Assistance CM b. Send the second copy to the DHMH HealthChoice Enrollment Section c. Retain the last copy for your files. Administrative Services Organization: 1. Review form to determine that the period from the date of admission through the effective dates specified in the certification (Part III, IV, or V) is an authorized inpatient stay at this facility. 2. If the period is fully authorized, sign the form, retain the last copy for your files, and return the original and all other copies to the facility. 3. If any portion of the period from admission to date specified in the certification section is not authorized by your organization, do not sign the form, but return it to the facility, noting the discrepancy. CM: 1. Check the date specified in Part III, IV, V against the admission date in Part I. 2. Redetermine eligibility based on the recipient’s institutionalized status. a) For recipients younger than 21 or 65 or older, redetermine eligibility in a long-term care b) coverage group (T track or L track) effective the date specified in the certification (Part III or V). For medically needy recipients aged 21 through 64, cancel eligibility with timely notice due to residency in an institution for mental disease. 3. Retain the original form in the case record. 4. Take no action for recipients of SSI or TANF. HealthChoice Enrollment Section: 1. Disenroll the recipient from HealthChoice effective the date specified in the certification section (Part III, IV or V). a. For Part III or V, use disenrollment code C8. b. For Part IV, use disenrollment code B2 or B1, as appropriate. 2. Retain form for your files. Discharge Notification - To Be Completed By the Facility: 1. Complete Parts I and II. Indicate the date of discharge and destination in Part VI. 2. The facility’s authorized representative must sign and date the form. 3. For recipients under 21 years old, send the original to:

Division of Eligibility Waiver Services (DEWS) 6 St. Paul Street, Room 400 Baltimore, Maryland 21202

4. For recipients over 65 years old, send the original to the Financial Agent or respective local department of social services. 5. Send the second copy to the DHMH HealthChoice Enrollment Section. 6. Retain the last copy for your files.