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State of Maryland Medical Assistance Manual Revised April 2014

INSTRUCTIONS FOR COMLETING THE DHMH 257 (Rev. 4/2011) TO- Enter the name and address of the designated agency responsible for determining eligibility for benefits. For contact information or other detail, please contact the specific Program area.

FROM: Enter name, address, Medicaid Provider ID and CARES Vendor ID. Check appropriate provider type.

RECIPIENT INFORMATION: Enter full name (first, MI, last) recipient. Enter both Medicare and Medicaid numbers. If no Medicare, enter “none.” If approval for Medicaid eligibility is pending, enter “pending.”

IF THE RECIPIENT IS A COMMUNITY MEDICAL ASSISTANACE RECIPENT OR WAIVER PARTICIPANT and is expected to stay in the nursing facility or chronic/special hospital for less than 30 days (or up to 80 days Medicare coinsurance), check the “Community MA” or “Waiver” box at the top right of the form.

ACTION REQUESTED- Begin Payment-Enter data fields as instructed below. Enter all dates required on that line. If the column titled “UCA” is checked below, certification by the Department’s Utilization Control Agent (UCA) is required.

Nursing Facility (NF) or Chronic/Special Hospital (CSH) Activities UCA Initiate NF or CSH benefits, MA only Line A1 X Initiate NF or CSH benefits, start Medicare co- payment, convert to full MA Lines A1 and A2 (both begin and end dates for Medicare co-insurance must be entered) X Initiate NF or CSH benefits, Medicare co- payment only (no fill MA) Line A2 (both begin and end dates for Medicare co-insurance must be entered) X

Community MA recipient or Waiver participant for temporary NF or CSH placement less than 30 days Medicaid or up to 80 days coinsurance Check “Community” or Waiver” box at top right, Lines A1 and B1 (check “Community” as discharged destination). X Hospice recipient revoking Hospice care and returning to NF care Line A4 X Discharge from NF or CSH to another NF or CSH Line B1, check “Another Provider” box, write name of receiving NF or CSH

Discharge from NF or CSH to home, or to destination other than NF or CSH if not returning to facility Line B1, check “Community”

Died while in NF, CSH, or in acute hospital while on bedhold from NF Line B2

SIGNATURE- Sign and ate the form. The facility staff person completing the form should print his/her name and title.

SUBMISSION- If UCA certification is required, send the Agency and UCA copies to the UCA and retain the provider copy. Otherwise, send the Agency and UCA copies directly to the designated agency and retain the provider copy.

Medical Day Care (MDC) Center Activities Initiate MDC benefits Line A1, enter Begin Pay date and check “Initial” Continue MDC benefits Line A1, check “Continued” and enter Begin Pay date Discharge Line B1, check “Discharge” box and enter date of discharge Discharge-admitted to NF for long term care Line B1, check “Another Provider” box, write name of nursing facility if known (otherwise enter “NF”) Died while a participant Line B2, enter date of death DHMH 257 (Revised 04/11)