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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