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State of Maryland Medical Assistance Manual Revised April 2014

Request for Non-Covered Services Pre/Post-Eligibility Deductions

To: Office of Eligibility Services Department of Health & Mental Hygiene

201 West Preston Street, Room SS-10 Baltimore, Maryland 21201-2399

From: _______________________________Local Department of Social Services _______________________________ _______________________________ D.O. #_______________________________ Date Request Sent______________________ _________________________________________________________________________________________ Please complete the following information: New Request Resubmission Case Manager ______________________ Contact Number _________________________ Case Name _________________________ Client ID Number ________________________ Application Date ____________________ Current Certification Period ________________ Penalty Period (if applicable) From __________To__________

Retro Period ________________________ Has an eligibility determination been made for the retro period? Yes No (A determination must be made for the retro months requested before submitting this form*) Retro Eligibility Determination 1st Month _________________ Approved Denied 2nd Month _______________ Approved Denied 3rd Month ________________ Approved Denied Attach a copy of denial notices for all current and retro months. *This does not apply to Waiver cases. _______________________________________________________________________________________

Type of Expense (Place a check mark next to the appropriate type.)

Dental Bill

Hearing Aid Bill

Vision Bill

Podiatry Bill

Pharmacy Bill

Nursing Home Bill

Months being requested:

Other (Please Specify):

____________________

___________________

OES 001 (LTC) Revised 08/13 All other versions are obsolete. All information MUST be completed. Date Received by DHMH