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State of Maryland Medical Assistance Manual Revised July 2012 Appendix A: Medical Assistance Forms and Notices
The following forms and notices are used in activities associated with liens, adjustments and recoveries. Some of the notices are used only for institutional (LTC) cases and are identified by the abbreviation- “LTC” following the form number. Others are used for both institutional and non institutional cases.
For the purpose of explaining the usage of these forms, the term “recipient” includes persons who have been determined eligible but the card has not yet been authorized.
(a)Notice of Potential MA Payment Recovery- DHMH 1169 This form is completed by the LDSS to report to MACA, Division of Recoveries, all potential third party recoveries for recipients in areas including:
Liability (e.g., an automobile accident, malpractice suit, or an accidental injury sustained on the premises of another individual); Workmen‟s Compensation; Assault; Recoverable Resources; Paternity; Child Support; Estates; and Improper payments due to LDSS error.
(b)Referral for Investigation-DHMH 4243 This form is completed by the LDSS to refer to MACA, Division of Field Investigation, for investigation of all cases involving client or representative error associated with not reporting, delayed reporting, or erroneous reporting of information that may have resulted in improper Program payments.
(c)Explanation of Lien-DHMH 4244 (LTC) The LDSS completes and provides this notice to all institutionalized recipients who own home property. It explains the meaning of a lien and the circumstances under which the Program will impose a lien on the home and other real property.
(d)Physician Report- DHMH 4245 (LTC) This is a two purpose form which is used to request medical information required for a Medical Review to determine an institutionalized person‟s ability to resume living in his/her home property. The CM completes Part I and gives the form to the representative to have Part II completed by the person‟s attending physician. The representative must return this form to the LDSS. Upon receipt, the LDSS forwards the original to the UCA for a Medical Review.