Add New Record to MMIS Eligibility File for SPED or Ex-SPED, SFN 676 525-05-60-30

(Revised 2/1/17 ML #3490)

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Purpose:  In order for an individual to be enrolled in the benefit plans of SPED or Ex-SPED and to receive a 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 Aging Services Division along with the SPED Program Pool Data, SFN 1820 or Ex-SPED Program Pool Data SFN 56. This form is used to identify active SPED & Ex-SPED program recipients in the payment system.  When billings are received from providers, the claim is checked against the SPED or Ex-SPED eligibility MMIS file.

 

For changes to service fees, statistical information, or re-entry into the SPED or Ex-SPED Pool:

 

An "Add New Record to MMIS Eligibility File SPED or Ex-SPED", 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 SPED service fee (percentage), this form must be completed and forwarded to the Aging 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.

 

   

ITEM

 

COUNTY NUMBER

Enter the county number where the client resides.

CASE MANAGERS NAME

Enter the case managers first and last name.

SPED/EX-SPED:

Check the box to indicate if the applicant is applying for SPED or Ex-SPED.

RECIPIENT ID:

Enter the clients ND number if known. If not known leave it blank.

NAME:

Print the individual's last name, first name and middle initial in spaces provided.

ADDRESS:

Enter mailing address of client.

ZIP CODE:

Enter the remainder of the zip code. The "58" is preprinted because all zip codes in North Dakota begin with those numbers.

RACE:

Check the appropriate box to indicate the applicant's race:

White

Black or African American

American Indian or Alaskan Native

Native Hawaiian or Other Pacific Islander

Other

Asian

SEX:

Check the correct box

Male

Female

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, 1915, is entered as 09071915.

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, 1915, is entered as 09071915.

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.

APPR. DATE:

SPED & Ex-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 or Ex-SPED Pool approval date.

SPED LIABILITY %:

Enter the percentage of SPED costs 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.

SPED 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 Aging Services/HCBS at the same time SPED or Ex-SPED Program Pool Data form is submitted.

 

The form is available electronically through the state e-forms system.