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State of Maryland Medical Assistance Manual Revised April 2014

MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE MEDICAID MANAGEMENT INFORMATION SYSTEM

206 – C I N T E R F A C E C O R R E C T I O N R E P O R T

SECTION: Skilled Chronic Intermediate

RECIPIENT ID: NAME:

----------------------------------------------------LONG TERM CARE SPANS ------------------------------------

BEGIN / EFFECTIVE CANCEL/DISCHARGE TRANSACTION MMIS TERM DATE DATE TYPE PROV-ID CD OASDI RESOURCE

1._____________________________________________________________________________________________ 2. _____________________________________________________________________________________________ 3. _____________________________________________________________________________________________ 4._____________________________________________________________________________________________ 5._____________________________________________________________________________________________ 6._____________________________________________________________________________________________

CASE MANAGER NAME:

________________ DIST. OFF: ________________ PHONE: ________________

NOTE TYPE - N IS BEGIN FULL MA, A IS MEDICARE CO-PAY PROVIDER # - 9 DIGIT MMIS FACILITY # OTHERWISE, LEAVE TYPE BLANK TERM CODE – EITHER 8 (DEATH) OR 4 (OTHER) OASDI - Gross Social Security Amount Resources - Available Income

____________ __/___/__________ Signature Date