Page 94

State of Maryland Medical Assistance Manual Revised April 2014

MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE MEDICAID MANAGEMENT INFORMATION SYSTEM

CERTIFICATION / TURNAROUND DOCUMENT

Action Code:

TYPE OF CHANGE ADD INDIVIDUAL REISSUE TAD CANCEL RECERTIFY

CHANGE REISSUE CARD REOPEN COVERAGE

ORIG-ID: *HOH/CASE-NUM: *CURR-ID: CARES-IRN: *NAME SSN: MEDICARE –NUM:

*HOH NAME: *APPL DATE: *ADDR: ADDR: *DEC-DT: *CITY: *BIRTH: *STATE: MD *ZIP: *RACE: *SEX: PHONE: HOSP-NUM: *RES-CNTY: DT-OF-ENTRY: CITZ-IDEN: DIST-OFF: UNIT: DEATH: VCN: ISSUE-DT:

*REQUIRED FOR ADD REQUIRED FOR QMB

ELIGIBILITY SPAN BEGIN DATE END DATE COV GROUP COV TYPE CAT SCP SPLIT AMT CIT CN-RSN

REASON FOR DOCUMENT: MARYLAND KIDS COUNT TRANSACTION NOT PASSED TO MMIS-II OUTSIDE OF CARES

MESSAGE: SEE ATTACHED CARES PRINTS.

SIGNATURE:______________________PHONE:_______________________DATE:_________________________