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UPDATED: JUNE 2010

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OTHER ELIGIBILITY REQUIREMENTS CITIZENSHIP AND IMMIGRATION STATUS UNDOCUMENTED/ILLEGAL ALIENS

TREATMENT OF AN EMERGENCY MEDICAL CONDITION

The DOH-4471 certification form must be signed by the A/R. If the A/R is unable to sign, his or her authorized representative may sign on the behalf of the A/R. The form is not valid without the required signature of the A/R or his/her authorized representative. Signing the form authorizes the local department of social services to request information regarding the emergency medical treatment. It also gives the physician or facility permission to provide such information.

The treating physician must complete the DOH-4471 and sign and date the form. The physician must, in all cases, make the decision as to whether or not the medical treatment is for an emergency medical condition. The physician must complete the entire form, sign and date the certification and return it to the local department of social services.

The local district maintains this certification form in the applicant’s case record, the local district notifies the provider of the acceptance/denial of the application, and furnishes the provider with the individual’s CIN number when appropriate.

The DOH-4471 has space to accommodate up to four coverage periods (“FROM_____TO_____ Date(s)” of Treatment/Hospital Stay) that may be entered by the provider. A new DOH-4471 certification form must be completed, dated and signed by the A/R, or the A/R’s authorized representative, and by the treating physician and submitted for subsequent or continuing treatment of an emergency medical condition.

Each person’s “emergency” is unique and the coverage period under the definition of emergency medical condition is limited and date specific. Therefore, Medicaid coverage for the emergency care must be a specific period of time in the past (i.e., at least one day prior to the initial Medicaid application date or one day prior to the Transaction Date for recipients in need of continuing care for the treatment of the emergency medical condition).

Medicaid payment for emergency services is limited to the day treatment was initiated and the following period of time in which the necessity for emergency services exists (e.g., the date of admission through the date of discharge from the hospital).

MRG