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(Revised 7/1/11 ML #3273)
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Purpose: In order for an individual to receive a SPED client identification number, to change the service fee, to update client statistical information, or to begin applicant client eligibility for payment purposes.
For new applicants:
An "Add New Record to MMIS Eligibility File,” SFN 676 must be submitted to the Medical Services Division along with the SPED Program Pool Data, SFN 1820. This form is used to identify active SPED program recipients in the payment system. When billings are received from providers, the claim is checked against the SPED eligibility MMIS file.
For changes to service fees, statistical information, or re-entry into the SPED Pool:
An "Add New Record to MMIS Eligibility File,” SFN 676, must be completed if there is a change in the statistical information such as address or corrections to the Social Security Number or birthdate. In addition if there is a change to the service fee (percentage), this form must be completed and forwarded to the Medical Services Division (HCBS) along with the date of the change.
If this form is not submitted when a SPED service fee changes and it results in an over payment or underpayment to the provider the case manager must file an adjustment to correct the payment error.
Note: for changes to the SPED service fee, changes occur the first of the following month of the change. Dates should not include partial months.
Below are the instructions for completing those items on SFN 676, "Add New Record to MMIS Eligibility File” (E101), that have not been preprinted.
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ITEM |
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ORIG. BY: |
In the first 2 boxes enter the initials of the person completing the form; in the last 2 boxes enter the county number. (This information will be used in contacting the county regarding questions about the information on the form.) |
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BASE ID: |
This number is assigned and provided to the county by Medical Services/HCBS. The number will begin with 560; IT WILL BE UNIQUE TO SPED PROGRAM RECIPIENTS. BILLING UNDER THE SPED PROGRAM WILL REQUIRE THE USE OF THIS NUMBER.
If the person was previously assigned a SPED Program ID number, the county social service office should enter that number OR advise Medical Services/HCBS that a number was previously issued. Only one MMIS record is to be established per person. |
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NAME: |
Print the individual's last name, first name and middle initial in spaces provided. |
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ADDRESS: |
Mailing address of client. |
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ZIP CODE: |
Enter the remainder of the zip code. The "58" is preprinted because all zip codes in North Dakota begin with those numbers. |
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RACE: |
Enter the correct code: 1 = White 2 = Native American 3 = Black 4 = Asian 5 = Hispanic 6 = Southeast Asian |
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SEX: |
Enter the correct code: 1 = Male 2 = Female |
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BIRTH DATE: |
The first 2 boxes (mm) are for the month, the second 2 boxes are for the day (dd), the next two boxes are for the century (cc), and the last 2 boxes are for the year (yy). September 7, 1909, is entered as 09071909; October 1, 1989, is entered as 10011989. |
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APPL. DATE: |
Enter the date the most recent assessment (or level-of-care screening, if a child) was completed. The date is two digits for month, two for day, two for the century, and two for year: September 7, 1909 is entered as 09071909; May 9, 1990 is entered as 05091990. |
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CASE NO.: |
Same as BASE ID.
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SSN: (NUMERIC ONLY) |
Enter the client's social security number. Do NOT use dummy numbers. If the client does NOT have a social security number of their own, leave blank. |
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AID CATEG: |
Enter applicable code: 01 = Aged (65 years of age or older) 04 = Disabled (under age 65) |
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PHY. CNTY.: |
Enter code for county of physical residence. |
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MEDICAL APPR. DATE: |
SPED Program approval date is completed by the Medical Services/HCBS. This field would be completed by the Case Manager only when there is an exception to the SPED Pool approval date. |
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DIAG: |
Enter the two-digit code if the client has any of the following. If the client has more than the maximum of three conditions, enter those that most affect his/her need for services.
10 = AIDS/HIV Positive 11 = Alzheimer’s/Dementia 12 = Arthritis/Rheumatism/Degenerative 13 = Cancer, NOT TERMINAL 14 = Closed Head Injured 15 = Diabetes, INSULIN DEPENDENT 16 = Discharged from Hospital (Receiving 17 = Discharged from Nursing Home 18 = Heart (Receiving treatment/ 19 = Incontinence 20 = Lung or respiratory disease 21 = Paralysis: Paraplegic,
Quadriplegic, 22 = Stroke (may or not have paralysis) 23 = Terminally Ill (NOT expected to live 24 = Multiple Sclerosis 25 = Congenitally Disabled 26 = Diabetes, Non-Insulin Dependent 27 = Parkinsons 28 = Legally Blind 29 = Deaf 30 = Osteoporosis 31 = Neuromuscular diseases other 32 = Intellectual disability 33 = Mental Illness (SMI/CMI) 34 = Chronic Alcoholism 35 = Kidney Dialysis 36 = Liver disease (e.g. Cancer of; |
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LIABILITY %: |
Enter the percentage of cost that is the client's responsibility. If the client does not have a fee, enter zero. If there is no entry in this section, it will be returned for completion. |
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LIABILITY DATE: |
Effective date of the percentage of "liability." If the client does NOT share in the cost of the services, leave blank. After the opening of a new case, a change in liability is effective the first of the month following the month of action. |
For new clients, this completed form is to be mailed or faxed to the Medical Services/HCBS at the same time SPED Program Pool Data form is submitted.
County social service boards are to reproduce sufficient copies for their use. The form is available electronically through the state e-forms system.