14.3.1

Medi-Cal Eligibility Verification and Letter of Authorization

 

A.
General

Medi-Cal confidentiality regulations limit the amount of information, including eligibility information, that workers may give to medical providers.  Medical providers include:

 

·   Hospitals,

·   Primary Care Clinics (PCC),

·   Managed Care Plans,

·   Private providers, and

·   County Medical Services (CMS).

 

This section identifies how to provide information to medical providers.

 

B.
Available Eligibility Information On POS

Medical providers have access to Medi-Cal eligibility information for the twelve months immediately preceding the current month.  This information is available through the Point of Service (POS) system. 

 

C.
Allowable Conditions to Issue MC 180

Workers may only issue an original, numbered Eligibility Letter of Authorization (MC 180) (Appendix 14-3-A) and/or Eligibility Letter of Authorization-Share of Cost MC 180-2 (Appendix 14-3-B) when proof of eligibility is needed for services that occurred at least 12 months prior to the current month.  The following conditions must be met to issue the MC 180:

 

·   A court action requires that a MC 180 be issued,

 

·   An adopted State Hearing Decision or other administrative hearing decision requires a redetermination of eligibility which results in a beneficiary’s entitlement to Medi-Cal,

 

·   An adopted State Hearing Decision states that due to a county department or Department of Health Services (DHS) administrative error, a BIC was not received by the beneficiary or eligibility on MEDS was not established,

 

·   DHS requests that the MC 180 be issued, or

 

The county department has determined that an administrative error has occurred per D, below.

 

D.
Definition of Administrative Error

Administrative errors include, but are not limited to:

 

·   The applicant/beneficiary provided the county with the necessary information to determine eligibility and the county failed to issue the Medi-Cal BIC/benefits,

 

·   The beneficiary requested card issuance and the county failed to take appropriate action,

 

·   The applicant/beneficiary’s case had been erroneously denied or discontinued,

 

·   A computer failure resulted in the delay, non-issuance, or incorrect production of the Medi-Cal BIC.  This includes non-issuance of BICs due to county failure to take corrective action in response to MEDS error alerts.

 

·   The county issues a BIC within one year, but is coded incorrectly and cannot be used to bill for services rendered,

 

·   County Medical Services has retracted payment to a provider due to the granting of Medi-Cal, or

 

·   The SSI beneficiary requests an MC 180 within six months of the SSI decision or four months from the date of the SDX update.  Exceptions due to unusual circumstances should be referred to DHS for authorization.  See I, below.

 

·   Any other erroneous or required action not taken which resulted in the failure to provide a BIC within one year of the date of service.

 

E. 
MC 180 Requests for SSI/SSP Recipients Only

The period of SSI/SSP-based Medi-Cal eligibility begins with the month SSI/SSP cash assistance is effective.  However, DHS is unable to automatically establish Medi-Cal eligibility on MEDS for the period between the effective month of eligibility (if it is prior to the current month) and the month the SDX update is received.  Since the person was entitled to Medi-Cal, but DHS failed to establish eligibility, this is considered a state administrative error and the county can issue a MC 180.

 

The table below shows the steps to be taken to issue a MC 180 for these cases.

Step

Action

1

Ensure that the claimant was eligible for SSI in the month for which an MC 180 is being requested.

2

The burden of proof for eligibility will fall upon the claimant or the person requesting the MC 180 on behalf of the claimant since MEDS does not go back more than 15 months.  The proof must show that the SSI determination was delayed and that he/she is eligible for SSI in the month for which an MC 180 is requested.  A copy of one of the following (which includes the date the SSI decision was made) must be provided:

·   SSI award letter,

·   Form 07-94 HHSA, or

·   Form SD 1000, or

·   The appeals order.

3

If the claimant or person requesting the MC 180 is unable to provide verification, or the county finds that an administrative error does not exist, and there are extenuating circumstances beyond the control of the beneficiary or the county, see I, below for DHS authorization.

 

Note:  For SSI/SSP beneficiaries, if the cause of the administrative error is due to an SSI decision, the MC 180 must be completed with the third reason checked.  SSI decisions fall under “other administrative hearing decision.”

 

 

F.
Administrative Error Procedures

Usually, beneficiary requests for MC 180s create the need for an administrative error determination.  However, there are situations in which a request from an acute care hospital, Primary Care Clinic (PCC), or CMS can generate an administrative error determination. 

 

The table below shows the steps to be taken if the county determines that an administrative error has occurred.

 

 

Step

Action

 

1

Document and fully describe the error in the case file as soon as possible after the error has occurred.

 

2

Complete the MC 180 with the:

·   “Administrative error” line checked and a description of the administrative error given,

·   Appropriate case information provided (Medi-Cal 14-digit ID number, application date, worker’s name, phone, etc.), and

·   Original signature of the FRC Manager or FRC Assistant Manager.  Photocopies will not be accepted.

 

G.
Acute Care Hospital and Primary Care Clinic Definitions

The table below provides definitions for acute care hospital and primary care clinic.

 

Term

Definition

Acute Care Hospital

A medical institution that provides general acute care.  Long-Term Care facilities, Intermediate Care facilities, Skilled Nursing facilities and clinics are not considered hospitals.

Primary Care Clinic (PCC)

Non-profit clinics.  The worker will accept the clinic’s status as stated unless the request is questionable.  Questionable requests should be referred to the supervisor for clarification.

 

H. 
Requests for MC 180 from Acute Care Hospital or PCC

Hospitals/PCCs or authorized billing agents will send the request for MC 180s to Public Assistance Information on Form 14-6 HHSA.  MC 180s are to be provided to acute care hospitals and licensed PCCs upon request when all of the following conditions are met:

1)    Form 14-6 HHSA

Form 14-6 HHSA must:

·  Have the hospital/PCC letterhead overlaid on it, or

·  Be accompanied by cover letter on letterhead. 

2)    Billing Agent

If the hospital or PCC uses a billing agent, the letter must certify that the billing agent is empowered to act on behalf of the provider.  PAI will clear for an active case and forward to that worker if one is located.  PAI will handle the requests for closed cases.

3)    Welfare and Institution (W&I) Code Provisions

The request must contain a certification that the following provisions of W&I code, Section 14018.4 have been met:

·  The hospital or PCC unsuccessfully attempted to obtain verification of eligibility at the time the services were provided, and

·  The hospital or PCC made a subsequent attempt to obtain verification of eligibility.

·  The provider’s affirmation on 14-6 HHSA satisfies this requirement.

4)    Medi-Cal Eligibility

The beneficiary was eligible for Medi-Cal in the month for which the MC 180 is requested.

5)    Individual Request

The request is for an individual patient.  Multiple lists will not be processed.

6)    Timeliness

The request for the MC 180 must be completed within two months after eligibility was granted.

 

The table below provides an example of timeliness.

 

 

Date

Action

March 2004

·   Applicant applies for Medi-Cal.

·   Case pended by worker.

·   DAPD packet sent.

·   Applicant is approved for CMS.

February 2005

·   DAPD approval is received by worker.

March 2005

·   Worker approves Medi-Cal eligibility back to March 2004.

April 2005

·   Hospital requests MC 180 for March 2004.

·   This request is made more than one year after the month of service, but it is within two months of eligibility approval.  The request will be processed.

 

I. 
Requests for MC 180 from Private Providers

1)    MC 180s should not be issued to private providers except when:

·  The beneficiary is deceased, or

·  The provider is acting as a representative or authorized representative for a long-term care patient currently in residence at the provider’s facility.

 

2)    In all other situations, the worker must work through the beneficiary to provide MC 180s to private providers.

 

J.
DHS Authorization for Issuance

If…

Then…

The county finds that an administrative error does not exist but there are extenuating circumstances beyond the control of the beneficiary (e.g., a medical condition that severely impaired his/her functioning),

·   DHS must be contacted for authorization to issue a MC 180.

·   The beneficiary would need to describe how the impairment prevented him/her from giving the provider(s) the necessary documentation of his/her Medi-Cal eligibility.

 

 

 Step

Who

Action

 

1

Worker

Complete an MC 180 for each provider, with the applicant’s name, Medi-Cal ID number, and the month(s) eligibility is being verified.  In the event the one provider is billing for services for more than one month, one original MC 180 is sufficient.

 

2

 

Attach a gram (county letterhead) explaining that no administrative error exists.

 

3

 

List the sequence of events in processing the request and the extenuating circumstances.

 

4

 

Have the gram signed by the FRC manger/ assistant manager (photocopied signatures will not be accepted).

 

5

Worker

Forward to:

Department of Health Services

Medi-Cal Eligibility Branch

1501 Capitol Ave.  MS 4000

P.O. Box 997413

Sacramento, CA 95899-7413

 

6

DHS

Consider the request and if approved, authorize issuance of benefits by signing the MC 180 and returning it to the county.

The table below shows the steps to be taken to obtain DHS authorization.

 

K.
Issuance Procedures

The table below shows the procedures to be used when either issuing a MC 180, or denying issuance of an MC 180.

 

If…

Then…

 

A MC 180 cannot be issued,

Send the beneficiary or person requesting the MC 180 a 14-52 HHSA MC 180 Determination Notice (Appendix 14-3-C).  The notice must indicate the billing month(s) and the reason(s) the MC 180 cannot be issued by the county.  The worker will file the yellow copy of the 14-52 HHSA in the case file.  A 14-52 HHSA is not required if a provider requests an MC 180 directly from the worker.

 

There is no share of cost,

Issue form MC 180 to the beneficiary/provider to authorize billing beyond the one-year limit.  The worker will file the yellow copy in the case folder.

 

There is a share of cost,

Follow the steps below:

 

 

 

 

 

 

Step

Action

 

 

 

 

1

Issue form MC 180-2 by completing the top four boxes on the form:

·   Month/year,

·   Share of cost,

·   County district, and

·   EW file number (CDS case number).

 

 

 

 

2

Complete the names of the persons in the same MFBU as the person for whom the form is being issued.  This information must be typed.

 

 

 

 

3

Give the form to the beneficiary or directly to the provider.  The provider completes the lower part of the form with the billing information.  Instructions are located on the form itself.

 

 

 

 

4

The beneficiary signs the bottom of the form and returns it to the worker.

 

 

 

 

5

Copy the completed form and file in the case.

 

 

 

 

6

Return the MC 180-2 to the beneficiary.  The beneficiary must give the MC 180-2 to only one provider to meet the SOC.

 

 

 

 

7

The MC 180 can be issued to the beneficiary once the share of cost has been met.

 

 

 

 

 

L. 
MC 180 Retention

ACWDL 07-18

 

 

Active Cases

 

When the MC 180 is for a beneficiary in an active case, a case copy and supporting eligibility documentation must be in the case file.

 

Closed Cases

 

When the MC 180 is for a beneficiary whose Medi-Cal case has been closed prior to the month of the MC 180, the MC 180 and supporting documents must be retained in a central file that is accessible for audit purposes.  This action prevents the forms and documents from being purged too early based on case closure date. 

 

Case records are purged from record room 3.5 years after the last budget unit closes.  Workers use the MC 180 when proof of eligibility is needed for services that occurred at least 12 months prior to the current month.  If this is done on a closed case, 3.5 years from the issue date of the MC 180 could be a later date than the 3.5 years from the closure of the Medi-Cal case.  This could lead to the MC 180 and supporting documentation being destroyed prior to the required 3.5 years from the MC180 issuance date.  Cases may be purged from the central file after 3.5 years from the MC 180 issuance date.  Former beneficiaries may request an MC 180 form no matter how long their case has been closed.  After 3.5 years from the discontinuance date, the burden of proof of eligibility rests with the former beneficiary.

 

SSI/SSP only

 

A central file must be retained for possible future review that includes a copy of the MC 180 and documentation that supports the issuance of the MC 180.  Cases may be purged from the central file after 3.5 years from the MC 180 issuance date.


 

M. 
MC 180 Log

The State requires that counties maintain a central log that identifies all issued MC 180s.  When a worker completes an MC 180, they must enter the following information into the MC 180 log:

 

·      MC 180 document number

·      Issuance date of MC 180

·      First and last name of MC 180 beneficiary

·      CIN of MC 180 beneficiary

·      Month/Year of requested Medi-Cal Billing

·      Filing location of MC 180 – include the case number if filed in an active case or indicate that it was filed in a central MC 180 file.

 

Cases may be purged from the log after 3.5 years from MC 180 issuance date.  This log may be found on the  County’s S drive at:

S:\ENTERPRISE\Medi-Cal Spreadsheets and Forms\MC 180 Log.

 


Appendix A MC 180 Example

THE MULTI-TONE AREA OF THE DOCUMENT CHANGES COLOR GRADUALLY AND EVENLY FROM DARK TO LIGHT WITH DARKER AREAS BOTH TOP AND BOTTOM.

STATE OF CALIFORNIA – HEALTH AND WELFARE AGENCY

DEPARTMENT OF HEALTH SERVICES

 

ELIGIBILITY LETTER OF AUTHORIZATION

Document

Number

123456

Issuing County:

 

SSN / Pseudo No.:

 

 

Issuance Date

of MC-180: __________________

                                 Date

 

** Provider Name:                                                                                                                            

 

** Provider No.:                                                       

                   Beneficiary’s Name, Address, City, State and Zip

 

 

 

 


County I.D.:

 

Date of Approval (SSI only):

 

* Worker’s Name:

 

* Worker’s Number:

 

* Worker’s Telephone #:

 

Other Health Coverage (Code):

 

MEDI-CAL BILLING FOR:

 

             /        

    Mo.           Yr.

 

             /        

    Mo.           Yr.

 

             /        

    Mo.           Yr.

 

             /        

    Mo.           Yr.

 

 

             /        

    Mo.           Yr.

 

             /        

    Mo.           Yr.

 

             /        

    Mo.           Yr.

 

             /        

    Mo.           Yr.

 

 

             /        

    Mo.           Yr.

 

             /        

    Mo.           Yr.

 

             /        

    Mo.           Yr.

 

             /        

    Mo.           Yr.

This original numbered MC-180 is approval for Medi-Cal providers to bill services provided to you during the above referenced months. An MC-180 is being issued in accordance with Title 22, California Code of Regulations (CCR) Section 50746. This regulation permits county welfare departments to issue documentation of eligibility which can be used by beneficiaries for periods more than one year after the month of service as a result of one of the following reasons:

1.

SSI/SSP eligibility was approved for a retroactive period but cards were not issued by the State Department of Health Services.

2.

A court order requires that Medi-Cal be issued.

3.

A State Hearing or other administrative hearing decision requires that Medi-Cal be provided.

4.

The State Department of Health Services requests that Medi-Cal be issued. (Original signature of an authorized DHS staff person:                                                                                                                              ).

5.

An Administrative Error has occurred.

(Description)                                                                                                                                                

                                                                                                                                                                   

                                                                                                                                                                   

Please immediately give your doctor or other medical provider this form for the applicable month(s)/year(s) of service. Providers do not need to submit a Medi-Cal proof of eligibility label with their claims when using this MC-180.

If you were provided services by more than one doctor or provider, please contact your local welfare office immediately to obtain additional original form(s).

 

 

INSTRUCTIONS TO PROVIDER

Submit this form, along with the claim(s), to:

EDS Federal Corporation

Attention:  Over-One-Year-Unit

P.O. Box 13029

Sacramento, CA 95813-4029

 

 

 

 

 

                                                                                                                         

(Original Signature of Authorized County Administrative Staff)

MC-180 (1/97)

 *   This information is not needed when eligibility is established by the Social Security Administration.

**   Optional                                        

THE ORIGINAL DOCUMENT HAS A REFLECTIVE WATERMARK ON THE BACK.    HOLD AT AN ANGLE TO VIEW WHEN CHECKING THE ENDORSEMENT.

 


Appendix B MC 180-2 Example

 

ELIGIBILITY LETTER OF AUTHORIZATION  l  SHARE OF COST  l  RECORD OF HEALTH COST

 

STATE OF CALIFORNIA  l  HEALTH AND WELFARE AGENCY  l  DEPARTMENT OF HEALTH SERVICES

SHARE OF COST  l  RECORD OF HEALTH COST  l  MEDI-CAL OR COUNTY MEDICAL SERVICES PROGRAM

MONTH OF ELIGIBILITY

 

MONTH                           YEAR

SHARE OF COST

THE AMOUNT YOU MUST

PAY OR OBLIGATE IS           $

COUNTY DISTRICT

EW FILE NO.

PLEASE READ THE DECLARATION BELOW:

PROVIDER INSTRUCTIONS AND DECLARATION:  EACH SERVICE LISTED BELOW BY ME HAS BEEN PROVIDED BY ME TO THE PERSON LISTED ON THE DATE SPECIFIED. I HEREBY DECLARE THAT I RECEIVED PAYMENT OR WILL SEEK PAYMENT FROM THE PATIENT FOR THE AMOUNT IN THE “AMOUNT BILLED PATIENT” COLUMN AND THAT I WILL NOT SEEK OR ACCEPT PAYMENT FROM THE MEDI-CAL PROGRAM FOR THAT AMOUNT. I UNDERSTAND THAT THE AMOUNT REIMBURSED BY INSURANCE, MEDICARE OR ANY OTHER THIRD PARTY FOR THE SERVICE RENDERED CANNOT BE LISTED ON THIS FORM. I CERTIFY UNDER PENALTY OF PERJURY THAT THE INFORMATION I HAVE LISTED ON THIS FORM IS TRUE AND CORRECT. I UNDERSTAND THE LETTER OF AUTHORIZATION (MC-180) CANNOT BE ISSUED UNTIL THE SHARE OF COST FOR THIS MONTH IS PAID OR OBLIGATED BY THE BENEFICIARY.

MEDICAL/DENTAL EXPENSES OF FAMILY MEMBERS LISTED BELOW MAY BE USED TO MEET SHARE OF COST.

 

14 DIGIT COUNTY ID NUMBER       [A]

 

NAME - LAST, FIRST

BIRTHDATE

MO.        DAY       YR.

SEX

OTHER

SOCIAL

SECURITY NO.

HIC OR RR NO.

 

CNTY

AID

7 DIGIT SERIAL NO.

FBU

PERS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  E

  X

  A

  M

  P

  L

  E

PROVIDER MEDICAL NUMBER

14 DIGIT COUNTY ID NUMBER (SEE [A] ABOVE)

SERVICE DATES

PROCEDURE/DRUG CODE

90050

SERVICE DESCRIPTION

 OFFICE VISIT

 

FROM

01/05/88

    TO

01/05/88

0

2

6

7

0

2

3

4

5

6

7

0

5

0

PROVIDER NAME

        Dr. Anne Smith

 PROVIDER SIGNATURE (SEE DECLARATION ABOVE)

u                 Dr. Anne Smith

DATE

01/30/88

AMOUNT BILLED PATIENT

$      15.00

UNREIMBURSED AMOUNT

$      15.00

1

PROVIDER MEDICAL NUMBER

14 DIGIT COUNTY ID NUMBER (SEE [A] ABOVE)

SERVICE DATES

PROCEDURE/DRUG CODE

 

SERVICE DESCRIPTION

 

 

FROM

MM/DD/YY

   TO

MM/DD/YY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROVIDER NAME

       

 PROVIDER SIGNATURE (SEE DECLARATION ABOVE)

u                

DATE

     /     /

AMOUNT BILLED PATIENT

$          

UNREIMBURSED AMOUNT

$          

2

PROVIDER MEDICAL NUMBER

14 DIGIT COUNTY ID NUMBER (SEE [A] ABOVE)

SERVICE DATES

PROCEDURE/DRUG CODE

 

SERVICE DESCRIPTION

 

 

FROM

MM/DD/YY

   TO

MM/DD/YY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROVIDER NAME

       

 PROVIDER SIGNATURE (SEE DECLARATION ABOVE)

u                

DATE

     /     /

AMOUNT BILLED PATIENT

$          

UNREIMBURSED AMOUNT

$          

3

PROVIDER MEDICAL NUMBER

14 DIGIT COUNTY ID NUMBER (SEE [A] ABOVE)

SERVICE DATES

PROCEDURE/DRUG CODE

 

SERVICE DESCRIPTION

 

 

FROM

MM/DD/YY

   TO

MM/DD/YY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROVIDER NAME

       

 PROVIDER SIGNATURE (SEE DECLARATION ABOVE)

u                

DATE

     /     /

AMOUNT BILLED PATIENT

$          

UNREIMBURSED AMOUNT

$          

4

PROVIDER MEDICAL NUMBER

14 DIGIT COUNTY ID NUMBER (SEE [A] ABOVE)

SERVICE DATES

PROCEDURE/DRUG CODE

 

SERVICE DESCRIPTION

 

 

FROM

MM/DD/YY

   TO

MM/DD/YY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROVIDER NAME

       

 PROVIDER SIGNATURE (SEE DECLARATION ABOVE)

u                

DATE

     /     /

AMOUNT BILLED PATIENT

$          

UNREIMBURSED AMOUNT

$          

5

PROVIDER MEDICAL NUMBER

14 DIGIT COUNTY ID NUMBER (SEE [A] ABOVE)

SERVICE DATES

PROCEDURE/DRUG CODE

 

SERVICE DESCRIPTION

 

 

FROM

MM/DD/YY

   TO

MM/DD/YY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROVIDER NAME

       

 PROVIDER SIGNATURE (SEE DECLARATION ABOVE)

u                

DATE

     /     /

AMOUNT BILLED PATIENT

$          

UNREIMBURSED AMOUNT

$          

6

PROVIDER MEDICAL NUMBER

14 DIGIT COUNTY ID NUMBER (SEE [A] ABOVE)

SERVICE DATES

PROCEDURE/DRUG CODE

 

SERVICE DESCRIPTION

 

 

FROM

MM/DD/YY

   TO

MM/DD/YY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROVIDER NAME

       

 PROVIDER SIGNATURE (SEE DECLARATION ABOVE)

u                

DATE

     /     /

AMOUNT BILLED PATIENT

$          

UNREIMBURSED AMOUNT

$          

7

PROVIDER MEDICAL NUMBER

14 DIGIT COUNTY ID NUMBER (SEE [A] ABOVE)

SERVICE DATES

PROCEDURE/DRUG CODE

 

SERVICE DESCRIPTION

 

 

FROM

MM/DD/YY

   TO

MM/DD/YY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROVIDER NAME

       

 PROVIDER SIGNATURE (SEE DECLARATION ABOVE)

u                

DATE

     /     /

AMOUNT BILLED PATIENT

$          

UNREIMBURSED AMOUNT

$          

 

I AGREE TO ASSUME FULL RESPONSIBILITY FOR THE AMOUNTS LISTED IN THE “AMOUNT BILLED PATIENT” COLUMN.

TITLE

Signature of Beneficiary:    x                                                                                              Date Signed:              /               /              

MC-180-2 (8/98)

                PLY ONE TITLE -

                                                                                                                        F.I. COPY


Appendix C 14-52 HHSA Example

 

County of San Diego

Department of Social Services

 

Letter of Authorization MC 180

Determination Notice

Date:                                                                                             

 

Client Name:                                                                               

Medi-Cal I.D. No.:                                                                     

Worker’s Name:                                                                         

Worker’s Telephone No.:                                                          

 

 

 

 

 


 

Dear_____________________________

 

RE:  Medi-Cal Billing for month(s) _______________________

 

A Letter of Authorization (LOA) form MC 180 to verify Medi-Cal eligibility for above month(s) cannot be issued by the County.

 

A Letter of Authorization (LOA) form MC 180 is needed to verify Medi-Cal eligibility more than one year after a medical service was provided. A Medi-Cal provider cannot bill Medi-Cal for these services without the Letter of Authorization. The State Department of Health Services allows the county welfare department to issue a LOA MC 180 only if one of the following conditions exist:

 

1)           A court action requires that a Letter of Authorization be issued.

 

2)           A State Hearing Decision or administrative hearing decision requires a redetermination of eligibility which results in a beneficiary’s entitlement to Medi-Cal benefits.

 

3)           A State Hearing Decision states that due to a county department or State administrative error, a Medi-Cal Benefits Identification Card (BIC) was not received and/or the Medi- Cal Eligibility Data System (MEDS) eligibility was not correctly established.

 

4)           The State Department of Health Services requests the Letter of Authorization be issued.

 

5)           The county welfare department determines that an administrative error has occurred.

 

(   )       Your circumstances do not meet any of the above requirements.

 

(   ) Before the county welfare department can determine if an administrative error occurred, SSI recipients must provide verification from Social Security of:

 

                     (    )        when their SSI was granted; and

                     (    )        SSI eligibility for the month the LOA is being requested.

 

            The above checked verification(s) was not provided.

 

The regulation which requires this action is:  California Code of Regulations, Title 22, Section 50746.

 

14-52 HHSA (3/95)


Appendix D 14-6 HHSA Example

 

COUNTY OF SAN DIEGO

HEALTH AND HUMAN SERVICES AGENCY

REQUEST FOR A LETTER OF AUTHORIZATION (MC 180)

 

Health and Human Services Agency

Public Assistance Information

4990 Viewridge Ave.

San Diego, CA 92123

 

PROVIDER INFORMATION

q  Hospital*

q  Licensed Primary Care Clinic*

        Address:                                                                                           

                                                                                                                                   

                                                                                                                       

            Phone number:                                                                               

 

* Please include hospital or clinic letterhead or cover letter.

 

I certify that the above provider information is correct.

___________________________     ________________                        _____________

                               Signature                                                                       Title                                                        Date

 

PATIENT INFORMATION

Name:                                                                                                                                               

Address:                                                                                                                                           

                                                                                                                                                           

Date of Birth:  _______________                  Gender:  ______         SSN:  ____________________           

Mother’s Full Name (if patient is a minor):  ____________________________________

A Form MC 180 is needed for the month(s) of:

_____/_____      _____/_____     _____/_____     _____/_____     _____/_____     _____/_____

    Mo.       Yr.                  Mo.       Yr.               Mo.       Yr.              Mo.       Yr.              Mo.       Yr.              Mo.       Yr.  

 

COUNTY RESPONSE

q  Letter of Authorization (MC 180) attached

q  No eligibility for the months of:                                                                                        

q  Unable to verify eligibility

q  Request submitted more than 60 days from date of approval (except SSI)

q  Comments:                                                                                                                          

                                                                                                                                                     

______________________________________________           ________________

                                                       HSS Signature                                                                                          Date

14-6 HHSA (11/04) Request for MC 180