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State of Maryland Medical Assistance Manual Revised April 2014

15. DES 2005 (LTC)- Consent for Release of Information (LTCF)

This form is signed by the applicant/recipient to authorize the LDSS to release information to the LTCF.

16. DHMH 257- Long-Term Care Patient Activity Report (SAMPLE)

The form is used to notify the LDSS of any action that is required regarding a Medical Assistance payment to the LTCF. The DHMH 257 is initiated by the LTCF and is approved by the UCA. The DHMH 257 form and the DHMH 3871B form to the UCA. The DHMH 257 and the DHMH 3871B forms are returned to the LTCF and the UCA sends the original DHMH 257 to the LDSS.

17. DHMH 259- Medical Care Transaction Form (SAMPLE)

This form is used to change the level of care between nursing facility services and chronic services. A change from one level of care to another is treated as a

discharge from one level and admission to another. The DHMH 259 discharging a person from one level of care does not require UCA approval; however, the

DHMH 259 to begin pay for the admission to another level of care does. Therefore, a change in the level of care to or from chronic care requires two DHMH 259 forms.

18. DHMH 3871B - Medical Eligibility Review Form (SAMPLE)

This form has multiple sections for completion. Part A of the form is completed by the representative or the long-term care facility (LTCF) and it is submitted to the attending physician. The physician completes Parts B-E and returns the 3871B to the LTCF. The LTCF completes the top half of DHMH 257 and sends both the DHMH 257 and the DHMH 3871B to the Utilization Control agent (UCA) for completion. The UCA completes part F of the DHMH 3871B. The UCA sends a copy of the DHMH 257 and the DHMH 3871B to the LTCF and sends the original DHMH 257 to the LDSS.

19. DHMH 1159D (LTC) -Worksheet for Institutionalized Persons- Cost of Care/Available Income This worksheet is used by the CM to calculate the cost of care, monthly income, deductions, and available income. This worksheet is used for difficult calculations that might not be calculated correctly by CARES, such as deductions for non-covered services over multiple months. The CM then enters the correct information on the appropriate CARES screens.

20. DHMH 4210 (LTC)- Notice of Ineligibility for Non-Financial Reasons

This notice is used when the applicant/recipient is not eligible for MA due to non-

financial reasons. It advises the applicant/recipient of the documents still outstanding and of the reactivation date. When needed, it may indicate that the applicant/recipient is within the income and resource limits but a DHMH 257 with the level of care certification has not been received by the LDSS.