INSTRUCTIONS FOR COMPLETING THE COMPREHENSIVE MEDICAID ...

INSTRUCTIONS FOR COMPLETING THE COMPREHENSIVE MEDICAID CASE MANAGEMENT (CMCM) ENROLLMENT REQUEST FORM INSTRUCTIONS FOR CMCM AGENCY PROVIDERS: This form is used to enroll clients in your CMCM.

CMCM Client Enrollment Form
INSTRUCTIONS FOR COMPLETING THE COMPREHENSIVE MEDICAID CASE MANAGEMENT (CMCM) ENROLLMENT REQUEST FORM
INSTRUCTIONS FOR CMCM AGENCY PROVIDERS: This form is used to enroll clients in your CMCM. Providers must fill the shaded areas of the form.
ELIGIBILITY VERIFICATION PLEASE BE SURE THAT YOU HAVE CHECKED THE CLIENT'S MEDICAID ELIGIBILITY. YOU MAY CALL THE EMEDNY CALL CENTER AT 1-800-343-9000 TO GET HELP ENROLLING IN ePACES.
1. CASE MANAGEMENT SERVICE GIVEN TO CLIENTS WITHOUT MEDICAID ELIGIBILITY WILL NOT BE REIMBURSED.
2. Fill in the required information for your CMCM agency and also for each client. Include:
 FROM DATE: Enter the specific date of initial service provided by your agency. Do NOT enter a Thru Date or End Date. This date will be system generated. If the client is no longer being serviced by your agency, send a disenrollment form to the Local Department of Social Services (LDSS).
 AUTHORIZED PROVIDER SIGNATURE: The authorized representative of your agency must sign and date this form. By signing s/he certifies the accuracy of the data submitted.
3 Mail the completed Enrollment Form to the representative of the LDSS responsible for the client. Include a self-addressed stamped return envelope with your enrollment form(s). Be sure to keep a copy for your files.
 Periodically, check to insure that the requested enrollments you sent to the LDSS have been returned and show successful enrollment to your CMCM from the correct "begin date". You may bill one day from the WMS Transaction Date of Successful enrollment listed on the enrollment request returned from the Local DSS. If you have not received the returned form within 30 days, or if there is a question concerning a CMCM enrollment, contact your Local Social Service District worker.
INSTRUCTIONS FOR LDSS: Fill in non-shaded areas on the Enrollment Form:
1. When the information submitted is successfully stored in the WMS R/E Subsystem, "Successful Data Entry Transaction Date" should be recorded on the Enrollment Form. The data should be entered from the requested "From Date". The Exception Thru Date will be system generated to 99/99/99. Let the system generated date stand, do not enter a Thru Date.
2. If the information supplied could not be entered into WMS, circle the number corresponding to the "Unable To Process" reason listed at the bottom of the form. If the reason is something other than the available choices, fill in an explanation in the space called "Other" on the Enrollment Form.
3. If the client is already enrolled in another CMCM program, LDSS staff should circle reason "1" and provide the name and address of the other CMCM agency on the "Other" line provided.
4. Mail the completed signed and dated form(s) back to the CMCM agency in the provided SASE. Retain a copy of the Enrollment Form for your records.

CASE MANAGEMENT (CMCM) ENROLLMENT REQUEST

LDSS RESPONSIBLE FOR CLIENTS LISTED (County Name)_______________________________

CMCM AGENCY NAME_______________________________________________PROVIDER NUMBER____________________ ADDRESS___________________________________________________________ZIP CODE________________________________ CONTACT PERSON__________________________________________________PHONE NUMBER ( __ )__________________

CASE MANAGEMENT AGENCY DATA

.

CLIENT NAME (Last, First)

CLIENT ID (CIN)

SSN

DOB (optional)

ENROLLMENT FROM DATE MM/DD/YY

1.

LDSS CLIENT 1 SUCCESSFUL WMS DATA ENTRY TRANSACTION DATE_______________________________________________________ REASON UNABLE TO PROCESS (CIRCLE ONE ­ SEE BELOW) 1 2 3 4 5 OTHER______________________________________________________________________________________________________

CLIENT NAME (Last, First)
2.

CLIENT ID (CIN)

SSN

DOB (optional)

ENROLLMENT FROM DATE MM/DD/YY

LDSS CLIENT 2 SUCCESSFUL WMS DATA ENTRY TRANSACTION DATE_______________________________________________________ REASON UNABLE TO PROCESS (CIRCLE ONE ­ SEE BELOW) 1 2 3 4 5 OTHER______________________________________________________________________________________________________

CLIENT NAME (Last, First)
3.

CLIENT ID (CIN)

SSN

DOB

ENROLLMENT FROM DATE

(optional) MM/DD/YY

LDSS CLIENT 3 SUCCESSFUL WMS DATA ENTRY TRANSACTION DATE______________________________________________________ REASON UNABLE TO PROCESS (CIRCLE ONE ­ SEE BELOW) 1 2 3 4 5 OTHER______________________________________________________________________________________________________

Provider certification: In signing this form, the CMCM agency attests to the following for each individual listed to enroll in CMCM services: Each client is part of the targeted population and documentation verifying this is in the case record; each client understands the voluntary nature of CMCM and freely accepts services from this agency; and the client's signed statement is in the case record. The agency has asked the client if s/he is enrolled in another CMCM and this agency believes that they are the sole provider of CMCM services.
PROVIDER SIGNATURE__________________________________________________________________________________DATE________________________________

UNABLE TO PROCESS REASONS

1. CURRENT RESTRICTION WITH ANOTHER PROVIDER ALREADY EXISTS (LIST PROVIDER ID , NAME & ADDRESS UNDER "OTHER")
2. INDIVIDUAL HAS NO MA COVERAGE FOR ENROLLMENT REQUEST PERIOD 3. NO NEW ENROLLMENT REQUIRED (Client is already enrolled ­ put "Begin date" under "other".) 4. CLIENT NOT FOUND IN THE WELFARE MANAGEMENT SYSTEM (WMS) DATABASE 5. OTHER (EXPLAIN)
LDSS Representative Signature____________________________________________Date___________Phone(____)______________


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