Article 9 Section 03 Indicators and ProgramRecovery Member Alerts
Table of Contents
TITLE PG CITE
Indicator Process 090301
General 090301A
Exercise Caution Indicator 090301B
ExplanationClarification Needed Indicator 090301C
Affects Eligibility Indicator 090301D
ProgramRecovery Member Alert Process 090302
General 090302A
Do Not Recert and Call Before Recert Member Alerts 090302B
CMSPG LTR 25 0513
090301 Indicator Process
090301A Indicators are designed to inform staff of the need to act upon reported
General information received for the applicantbeneficiary SHSS HSS and ProgramRecovery staff will have access to select or remove the appropriate Indicator
Indicators Refer to Appendix 0901C have been added to AuthMed to record information that
Advises staff to exercise caution
Needs an explanationclarification or
Affects eligibility
CMSPG LTR 25 0513
090301B Exercise Caution Indicator
Hostile Threatening or Abusive ApplicantBeneficiary Indicator
This Indicator is designed to inform staff that have facetoface contact with an applicantbeneficiary to exercise caution The Indicator may be initiated by either ASO or County staff and is reviewed at each new application The information contained in the Indicator is for CMS staff only and is not to be shared with the applicantbeneficiary
Criteria
This Indicator includes but is not limited to the following situations
Applicantbeneficiary identified as a drug seeker
Applicantbeneficiary made threats directed at clinic County or ASO staff
Applicantbeneficiary was verbally abusive andor disruptive at a clinic or worker office operations
A new Indicator is created for each subsequent County or ASO
referral
Referral Procedure
When the applicantbeneficiary meets this Indicator criteria
The worker emails their supervisor explaining the situation The email must contain the applicantsbeneficiarys name SSN and the clinic or office which the incident occurred
The supervisor will either place or advise the worker whether to place or not to place the Indicator in AuthMed
The worker scans a copy of the email with the supervisors response in the case record
The above procedure is followed each time the need for a subsequent Indicator is identified
Mandatory Supervisor Reviews The supervisor reviews all Indicator referrals to ensure that it is an appropriate referral The supervisor will either place or advise the worker whether to place or not to place the Indicator in AuthMed
Status Review The worker will review the Indicator at each new application To remove the Indicator the worker will
Email their supervisor requesting the supervisor to remove the Indicator or approval to remove the Indicator
Scan a copy of the email response in the case record
Remove the Indicator if request to remove the Indicator was approved by the supervisor
CMSPG LTR 25 0513
090301C This Indicator in AuthMed is designed to inform staff to act upon Explanation reported information that needs an explanationclarification Example Clarification Returned Mail wo forwarding address
Needed Indicator
CMSPG LTR 25 0513
090301D This Indicator in AuthMed is designed to inform staff of individuals who
Affects may not be eligible for CMS Example Referred to CMS Fraud
Eligibility
Indicator CMSPG LTR 25 0513
090302 ProgramRecovery Member Alert Process
090302A CMS ProgramRecovery staff member use these Member Alerts to
General identify applicantsbeneficiaries who are no longer eligible to be certifiedrecertified for CMS or if there are issues that must be resolved before certifyingrecertifying for CMS Only designated ProgramRecovery staff have access to addupdate Member Alerts HSS and SHSS staff will only have viewing access to Member Alerts placed by ProgramRecovery staff or the ASO
Then workers must
Not certifyrecertify any case with a Do Not Recert or Call Before Recert alert without first contacting CMS ProgramHCPA Recovery staff member via email for instructions on what actions the applicantbeneficiary must take before the issuance of benefits
Confirm with CMS ProgramHCPA Recovery staff member that all issues have been resolved and for staff member to update the DNR Member Alert before the issuance of benefits and
Document action taken in case comments
Note Historical IDX DNR Member Alerts will remain in the historical alert section in AuthMed
CMSPG LTR 25 0513
090302B Do Not Recert and Call Before Recert Alerts
A Do Not Recert DNR Alert
This Member Alert is used when an applicantbeneficiary is determined not eligible for CMS or the applicantbeneficiary must comply with a program requirement The DNR alert includes the reason date and ProgramRecovery staff member who placed the alert
B Call Before Recert Alert
This Member Alert is used when there is a need for the applicantbeneficiary to resolve certain issues before certifyingrecertifying for CMS The alert includes the reason date and Program staff member who is to be contacted
Below are some examples when these alerts are used
Third Party Liability TPL When a beneficiary does not cooperate in providing information about injuries caused by a third party or in reimbursing CMS from a third party payment CMS Program staff will place the alert to prevent recertification until the beneficiary contracts CMS Program staff to provide the information or payment
Fraud When the beneficiary does not cooperate with the investigation into allegations of fraud CMS Program staff will place an alert to prevent certificationrecertification until the applicantbeneficiary cooperates or the investigation is complete
Overpayment Collections When the beneficiary does not cooperate in reimbursing CMS for overpayment of benefits CMS Program staff will place the alert to prevent certificationrecertification until the applicantbeneficiary contacts the CMS Program staff to discuss payment arrangements
CMSPG LTR 25 0513