Form Dma-5020 - North Carolina Division Of Medical Assistance Notice Of Case Status Page 2
Download a blank fillable Form Dma-5020 - North Carolina Division Of Medical Assistance Notice Of Case Status in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Dma-5020 - North Carolina Division Of Medical Assistance Notice Of Case Status with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2(County completes)
North Carolina Division of Medical Assistance
Notice of Case Status
_____________________________County Department of Social Services
Enter name and Address of Provider
_____________________________________________
_____________________________________________
_____________________________________________
1. Name: (First, MI, Last)
2. Individual ID Number
3. Aid Program/Category
4. Classification Code
5. This response acknowledges receipt of your referral and informs you of the status:
a.
Medicaid authorization begins on:
Patient payment due hospital: $
b.
An application has been filed and is being processed. You will be notified when the decision is made.
c.
We are waiting for the applicant/recipient to return necessary information to make a determination of eligibility.
d.
Medical information required to establish incapacity has not been returned from the patient’s doctor.
Form DMA-5006 is attached for completion. Please return to this office when completed.
e.
The individual was notified on __________________________to come to the agency to file an application for
Medicaid.
f.
Patient is not eligible for Medicaid.
6. Carolina ACCESS
Yes
No
Primary Care Provider is__________________________________________
(Name)
County Director Signature /Designee
Date
Instructions: County Department of Social Services
A. Within 15 workdays after receipt, complete status information. Return original to the provider and retain a copy
for your file.
1. If the patient is eligible, enter the Medicaid ID number in block 2.
2. If the individual is eligible for dates of hospitalization, check block 5.a. and enter authorization from date.
3. If the case has a deductible, enter in block 5.a., the amount of the deductible balance applied to the
hospital charges on date of authorization. This amount must agree with the deductible balance amount
entered in EIS.
B. If block 5. b. c. d. or e. is checked, you must notify the provider of the final disposition. Note the final disposition
on the file copy and send a copy to the provider.
C. Use this form to notify the hospital of the deductible amount due the hospital for any hospitalized
recipient whether or not hospital has initiated referral.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dl-79 - Removal Request Form - Medical Review Program - North Carolina Division Of Motor Vehicles
Legal
Form Dss-5268 - Responsible Individuals List (ril) Information Request - North Carolina Division Of Social Services
Legal
Related Categories
Parent category: Legal