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