Page 1

COMBINED MEDICAID 304-3 Trauma Questionnaires Supersedes: FMA 307-3 (07/01/05); MA 305-3 (07/01/05) Reference: 42 CFR 433.136, .137-.140, .145-.148; ARM 37.82.101, 37.85.407 Overview: As a condition of the adult’s eligibility, all Medicaid households must cooperate with the TPL Unit by completing and returning all trauma questionnaires for any family member receiving Medicaid. Certain injury diagnosis codes trigger a trauma questionnaire to be sent to Medicaid households. The requested information from the questionnaire must be submitted as directed on the questionnaire within the specified time frame. If not provided within the time frame, the TPL Unit will enter the appropriate system non-compliance. An adult Medicaid recipient loses or is denied Medicaid eligibility until such time as the requested information is received. If the Medicaid recipient is a child, the responsible adult(s)/specified caretaker relative will lose Medicaid eligibility until such time as the required information is provided. Children will not lose Medicaid eligibility because the responsible adult failed to comply with these requirements. Effective Date: July 01, 2016