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Client Notice System Manual

(CNS)

Office of Temporary & Disability Assistance Center for Employment & Economic Supports

Foreword The material contained in this manual provides assistance to local district staff by introducing the information necessary for issuing client notices on the Client Notice System (CNS) and by serving as an instructional guide for workers. This manual is the product of many individual’s work. Direction and coordination of the text is the responsibility of Bob Markham and Kelly Whitney. It is the hope of all those involved in issuing this manual that you, the reader, will find it useful.

Contacts PA and FS Questions can be directed to the following individuals: Bob Markham @ 1-800-343-8859, extension 4-2166 Jim Dormond @ 1-800-343-8859, extension 4-9286 MA Questions can be directed to the following individuals: Cindy Kreuger-Farley @ (518) 402-6663 Jeremy Strickland @ (518) 408-0826 Susan Wolski @ (518) 408-0115 Catherine Martel @ (518) 408-0109 Rachel Demars @(518) 408-0566

CLIENT NOTICES SYSTEM MANUAL CNS Section: Table of Contents

Last Revised 3-25-08 Page i

Section Description A Background B General System Design C Notice Production Method Definitions D Menu and Screen Selections E Notice Entry F Notice Inquiry G Notice Update H Pending Notice Inquiry I Supervisory Review Print J Notice Authorization/Release K Batch Notice Entry L Batch Notice Inquiry and Update M Notice History Inquiry N CNS Control Information Maintenance O NYC/Upstate Inquiry P Specialized CNS Input Screens (TA, FS, HEAP) R Supervisory Review Report S PA/FS Indicator T CNS Reports U Fair Hearing Interface V MA Openings W MA Denials X MA Discontinuances Y MA Undercare Z MA Chronic Care AA MA MTCP BB MA Insert Language - Matrices

CLIENT NOTICES SYSTEM MANUAL CNS Section: A - Background

Last Revised 3-25-08 Page A-1

The Client Notices System (CNS) was developed to relieve local district examiners of the time-consuming task of manually preparing and sending client notices for actions taken on a case. CNS produces notices using case and individual information contained in WMS. When an examiner performs a WMS transaction without an “N” (Manual Notice Required) in the CNS Notice Indicator, the required notice is automatically produced. Entry of reason codes are used in combination to produce notices which explain all of the actions taken on a case. Each CNS notice contains a series of explanatory paragraphs and WMS data. Whenever possible, CNS will produce a notice without further examiner input. However, if a notice cannot be completely system-filled, further language can be added either directly by the examiner or by a data-entry operator based on the examiner's instructions. Once the notice is reviewed/approved and the transaction that it is associated with is processed without errors, it is printed and mailed directly from Albany to the client. All required enclosures are included with the notice. CNS not only assists the examiner, but also helps to guarantee that program policies are applied in a consistent manner across the state. CNS also assures that the same types and amounts of information are contained in each district's notices. This consistency and thoroughness helps to reduce the number of fair hearings which are requested and the number of fair hearings which are lost due to problems with notices. Beyond the savings resulting from fewer requested fair hearings or adverse decisions, substantial savings are realized from reduced examiner time spent preparing manual notices, from reduced postage costs and from reduced printing costs.

CLIENT NOTICES SYSTEM MANUAL CNS Section: B – General System Design

Last Revised 3-25-08 Page B - 1

The Client Notices System (CNS) of the Welfare Management System (WMS) is designed to automatically produce notices which are sent to social services clients to inform them of actions taken on their cases. Notices for approvals, denials, changes, recertifications and closings to PA, MA, FS and HEAP case types are produced by the system and include required Fair Hearing Language. CNS notices use data extracted from the WMS database. Notices are generated and printed in the Department's Albany data center and are mailed directly from Albany to each affected client and provider (if appropriate). All necessary attachments to the notice (e.g., child/teen health letter, FS recertification application) are included in the same mailing as the notice. Custom notices for each case circumstance are composed by combining a series of narrative paragraphs and WMS data. The number and contents of the paragraphs depends on the case type and the CNS reason codes used to create the notice. Notices can be printed in both English and Spanish featuring plain language paragraphs. Case budget information is included in the notice when appropriate. GENERAL SYSTEM FEATURES

1. Reason code entry and WMS case and individual data are used to produce client notices.

2. CNS creates notices without additional worker input whenever possible. Workers are prompted or use specialized CNS screens to provide necessary notice details not collectible from WMS. A CNS supervisory review report containing the added variable information is generated for review in conjunction with the case's Turnaround Document (TAD).

3. Copies of notices may be mailed to up to four appropriate associated names and providers.

4. Worker names, local district addresses and telephone numbers are printed on notices based on

locally maintained district tables.

5. CNS provides the Fair Hearings Information System (FHIS) with the data required by Fair Hearing staff to verify case actions and make "aid continuing" determinations.

6. Notices are retained and may be retrieved in their entirety. Also available, is cross-district

inquiry of the Upstate and NYC CNS database. Notices are also sent to the COLD (Computer Output to Laser Disk) system on the day they are mailed to the client. COLD is available through the OTDA Intranet as WEBCOINS. Local district staff can access and reprint client notices on-line in the same format as they are mailed to clients.

7. CNS is designed to allow rapid modification to the text of the notices as dictated by legislation,

regulations changes or litigation.

CLIENT NOTICES SYSTEM MANUAL CNS Section: C – Definition of Notice Production Methods

Last Revised 3-25-08 Page C - 1

Most CNS notices are produced as the result of a WMS transaction. Some, like Recertification Call-in notices, have no corresponding WMS transaction and require special worker-initiated CNS action to produce the notice. There are three categories of CNS reason codes: No-Fill, Limited Fill and Extensive Fill. No-Fill – these reason codes can be directly entered into WMS and do not require any worker input into

CNS. Limited Fill - these reason codes require 1-2 items of worker-provided information. These items are

entered into CNS data collection screens. Extensive Fill - these reason codes require 3 or more items of worker-provided information. These items

are entered into CNS data collection screens. The first letter of the CNS reason code can generally be used to determine its category. The chart below indicates the categories by transaction type:

Degree of Worker Involvement

Transaction

No Fill

Limited (1-2 Fills)

Extensive (3+ Fills) Openings

A

K

Q

Undercare Maintenance

B, C, J

L

R, S, X

Closing/Denials

E, F, G, H (MA Only)

M, N, P

U, V, W, X (MA Only)

In addition to the above chart the following letters are also used: Z = Non-WMS Transaction based Y = Reason codes that result in no notice being sent I = Individual Reason Code Required T = Denial Code Required 9 = System Generated and Special Circumstance



1. NO FILL DEFINITION: No-Fill notices do not require worker entry of information on CNS to support the

notice. All of the information necessary to produce the notice already exists on the WMS database and is contained in the transaction undergoing batch update.

PRODUCTION: No-Fill notices require no additional supervisory review other than what is

performed on the Turnaround Document (TAD). Users need only complete the TAD; submit the TAD for supervisory review; and after supervisory approval, complete (submit the TAD for) data entry on WMS. A notice will be automatically generated after error-free data entry and nightly WMS Batch Update.

*Please note: users may optionally go to CNS to create a no-fill notice, and then enter the notice

number created and the reason codes used during WMS data entry. NOTE: For case transactions with multiple no fill reason codes, the Limited Fill method of notice

production must be used prior to completion of the TAD (see below). 2. LIMITED FILL DEFINITION: Limited-Fill notices are those that require additional worker entry of 1-2 pieces of

information on CNS to support the notice. It is defined by any combination (up to 3) of no fill and limited fill codes at both the Case and Individual reason code levels. The limited fill method of production is not available for MA cases or in New York City.

PRODUCTION: Users select CNS from the WMS main menu (WMSMNU) by choosing selection

number 11 or depressing Special Function key 11 (SF-11). Users may also optionally select CNS when scheduling screens on the WMS data entry menu (WDXMNU). Please see the CNS reason code and data entry screens and their respective explanations in CNS Manual Section E. A CNS Supervisory Review Report (CNS Manual Section R) is automatically produced.

3. EXTENSIVE FILL DEFINITION: Similar in nature to limited-fill notices, Extensive Fill notices are those that require

additional worker entry of 3 or more data variables. Additionally, some CNS Extensive Fill reason codes require worker entry on specific, specialized extensive-fill screens.

PRODUCTION: Users must select CNS from the WMS main menu (WMSMNU) by choosing

selection number 11 or depressing Special Function key 11 (SF-11). Please see the CNS reason code and data entry screens and their respective explanations in CNS Manual Sections E & P. The Notice Number created and the reason codes used must be entered on WMS during data entry. A CNS Supervisory Review Report (CNS Manual Section R) is automatically produced.



4. NON-TRANSACTION BASED NOTICES DEFINITION: Non-Transaction based notices are those that are produced for reasons other than a

benefit-related change. PRODUCTION: For information on the production of Non-Transaction Based Notices see CNS

Manual Section G. EXAMPLES - For PA, such notices include those regarding:

1. The need to recertify 2. Repayment of over-issuances 3. Certain restored benefit situations.

For FS, such notices include those regarding:

1. The need to recertify 2. Repayment of over-issuances 3. Certain restored benefit situations 4. Request for contact.

For MA, such notices include those regarding:

1. They need to recertify. 5. BATCH NOTICES DEFINITION: Batch Notices are those sent to multiple cases with the same non-transaction based

reason code, for example, the "Continuing Your Food Stamps" call-in recertification letter. PRODUCTION: For information on producing Batch Notices see CNS Manual Sections K & L.

CLIENT NOTICES SYSTEM MANUAL CNS Section: D – Menu & Screen Selections

Last Revised 3-25-08 Page D - 1

To access the Client Notices Menu, workers must either hit SF-11 or enter selection number 11 (for NYC hit F-12 or select number 12) from the main WMS Menu. The Client Notices Subsystem Menu, screen WCN000 is displayed (see below).

‐WCN000 Department of Social Services Date / / WMS/Client Notice Subsystem Menu Time : : CASE NUMBER __________ SUFFIX __ REGISTRY NUMBER ______ NOTICE NUMBER __________ DISTRICT ____ BATCH NUMBER ______ INDICATE SELECTION NUMBER __ Xmit _ 01 NOTICE ENTRY (CASE/REGISTRY NUMBER REQUIRED) 02 NOTICE INQUIRY (NOTICE NUMBER REQUIRED) 03 NOTICE UPDATE (NOTICE NUMBER REQUIRED) 04 PENDING NOTICE INQUIRY (CASE/REGISTRY NUMBER REQUIRED) 05 SUPERVISORY REVIEW PRINT (NOTICE NUMBER REQUIRED) 06 SIGNOFF 07 NOTICE AUTHORIZATION/RELEASE 08 BATCH NOTICE ENTRY 09 BATCH NOTICE INQUIRY (BATCH NUMBER REQUIRED) 10 BATCH NOTICE UPDATE (BATCH NUMBER REQUIRED) 11 NOTICE HISTORY INQUIRY (CASE/REGISTRY/NOTICE NO REQUIRED) 12 NOTICE HISTORY REPRINT (NOTICE NUMBER REQUIRED) 13 14 CNS CONTROL INFO MAINTENANCE 15 NYC/UPSTATE INQUIRY F16 WMSMNU (MENU KEY)

Screen explanations follow: DATE - Today's date is computer-generated. TIME - The current time is computer generated. CASE NUMBER - Worker enters the case number, if appropriate. This field is left justified. SUFFIX - NYC only (masked for rest of state). Entry into this field is optional for NPA/FS cases. If

no entry is made, the system defaults to "01". For PA/FS cases, worker enters the suffix number. For Upstate districts, this field is blank.

REGISTRY NUMBER - Worker enters the registry number, if appropriate. NOTICE NUMBER - Worker enters the notice number, if appropriate. DISTRICT - Worker enters the local district code, if appropriate. BATCH NUMBER - If appropriate, the batch number is entered. INDICATE SELECTION NUMBER - Worker enters selection number of function to be used. XMIT – Transmit location.



On the CNS menu (WCN000) workers indicate one of the following selections: CNS Menu Selection 01 - NOTICE ENTRY Users must enter either CASE or REGISTRY number and transmit. The CNS WCN011 Reason

Code Entry screen is displayed. Workers then enter CASE and/or INDIVIDUAL reason codes as appropriate, move cursor to the "XMIT" position and transmit. If necessary, other CNS screens are presented to collect variable information needed for the notice. (See CNS Manual Section E)

CNS Menu Selection 02 - NOTICE INQUIRY Users can view pending notices that have been created by entering the Notice Number they wish to

inquire. Screen WCN011 appears with the reason codes that were used to create the notice number entered. (See CNS Manual Section F)

CNS Menu Selection 03 - NOTICE UPDATE Users can update pending notices that have been created by entering the Notice Number they wish to

modify. The CNS Reason Code screen (WCN011) is displayed with the reason codes previously entered. Users may Change; Add or Remove reason codes as well as Modify the worker fill associated with any reason code. (See CNS Manual Section G)

CNS Menu Selection 04 – PENDING NOTICE INQUIRY Users can view a list of all pending notices that have been created by entering the Case Number or

Application Registry Number they wish to inquire. CNS Screen WCN019 appears with a list of the pending notices associated with the Case Number/Application Registry Number entered. (See CNS Manual Section H)

CNS Menu Selection 05 - SUPERVISORY REVIEW PRINT Users can generate another Supervisory Review Report for any pending notice by entering the Notice

Number and CNS Menu Selection number 05. (See CNS Manual Section I) CNS Menu Selection 06 - SIGNOFF This selection ends a worker's session (signs off the terminal). CNS Menu Selection 07 - NOTICE AUTHORIZATION/RELEASE For a select set of reason codes, users can introduce notices to the nightly notice production process

by entering CNS Menu Selection number 07. (See CNS Manual Section J) CNS Menu Selection 08 - BATCH NOTICE ENTRY For a select set of reason codes, users can create notices for up to 15 cases at one time. (See CNS

Manual Section K) CNS Menu Selection 09 - BATCH NOTICE INQUIRY Users can view a previously created batch by entering the Batch Number they wish to inquire and

CNS Menu Selection number 09. (See CNS Manual Section L) CNS Menu Selection 10 - BATCH NOTICE UPDATE Users can update a previously created batch by entering the Batch Number they wish to modify and

CNS Menu Selection number 10. (See CNS Manual Section L)



CNS Menu Selection 11 - NOTICE HISTORY INQUIRY Workers enter a CASE, REGISTRY or NOTICE number to view either ALL notices or a specific

notice that has been sent to a particular case. (See CNS Manual Section M) CNS Menu Selection 12 – NOTICE HISTORY REPRINT This function has been disabled. All notice re-prints are now achieved using COLD software. CNS Menu Selection 14 – CNS CONTROL INFO MAINTENANCE This function is used to view and/or change the local district addresses and telephone numbers and/or

the names and telephone numbers of the offices, units and workers from which notices originate. Access to this function is restricted to a designated local district staff person. (See CNS Manual Section N)

CNS Menu Selection 15 – NYC/UPSTATE INQUIRY This selection allows Upstate workers to inquire about previously sent NYC notices and NYC

workers to inquire about previously sent Upstate notices. (See CNS Manual Section O) CNS Menu Selection 16 (F16) - WMSMNU (MENU KEY) This selection returns the user to the WMS Menu.

CLIENT NOTICES SYSTEM MANUAL CNS Section: E – Notice Entry

Last Revised 3-25-08 Page E - 1

CNS Menu Selection 01 Users must enter either a CASE or REGISTRY number and transmit. The CNS Reason Code Entry screen (WCN011) is displayed. WCN011 allows entry of up to three Case reason codes per category and up to three Individual reason codes per individual per category. Users must enter Transaction Type, the appropriate Case and/or Individual reason codes and the PA/FS Indicator if required. Users may optionally enter values in the Office-Unit-Worker fields. If entered, these values will be used to print the worker contact name and phone number on the notice. Users then move the cursor to the "XMIT" position and transmit. If necessary, CNS screen WCN012 (Notice Entry) or specialized CNS screens are presented to collect variable information needed for the notice. Immediately following the final successful transmit, CNS screen WCN000 is returned with the following message at the bottom of the screen:

“CASE xxxxxxxxxx - NOTICE NO xxxxxxxxxx CREATED”. A CNS Supervisory Review Report (CNS Manual Section R) is automatically produced.

CNS Reason Code Screen - WCN011

‐WCN011 WMS/Client Notice Subsystem Date / / Reason Code Screen Time : : CASE NO TRANS TYPE __ OFFICE ___ UNIT _____ WORKER _____ PA/FS IND __ CASE REASONS: PA ___ ___ ___ FS ___ ___ ___ MA ___ ___ ___ INDIVIDUAL REASONS: LN PA FS MA __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ Xmit _



CNS Notice Entry Screen - WCN012 CNS screen WCN012 is used to collect necessary notice data from the user. The screen is assembled dynamically... its appearance will vary according to the requirements of the reason code entered. Screen WCN012 (or another specialized screen) will appear for each entered reason code requiring user data. Prompts appear at the bottom of the screen to provide users with field entry instruction. A CNS screen WCN012 example (Food Stamp case reason code X01 - Issue Restored Benefits) follows below:

‐WCN012 WMS/Client Notice Subsystem Date 11/09/06 Notice Entry Screen Time 11:05:00 CASE NAME Z001F CASE NO Z001F CASE REASON X01 : ISS RSTRD FS DATE 1 ______ DATE 2 ______ DATE 3 ______ AMT 1 ________ FF 1: ________________________________________________________________________ FF 2: ________________________________________________________________________ FF 3: ________________________________________________________________________ FF 4: ________________________________________________________________________ FF 5: ________________________________________________________________________ ENTER DATE 1: RESTORED BENEFIT FROM DT ENTER DATE 2: RESTORED BENEFIT TO DT ENTER DATE 3: EBT BEN AVAILBLTY DATE ENTER AMT 1: RESTORED BENEFIT AMOUNT ENTER FF 1‐5: MISTAKE WE MADE WAS Xmit _



CNS Access from WMS Data Entry - WDXMNU The WMS Non-Services Data Entry Menu (WDXMNU) also allows the scheduling of the CNS Reason Code Entry screen WCN011. Only those reason codes that are defined as “no-fill” or “limited-fill” may be entered using this method of access. The CNS notice entry screen (WCN012) appears automatically if necessary.

‐WDXMNU Non‐Services Data Entry and Case Disposition Menu Date / / Function _ Reg/Ver OR Case# __________ Auth# ________ Screen# _ Screens: _ 01 _ 02 _ 03 _ 04 _ 05 _ 06 _ 07 _ 08 _ 09 _ CNS A ‐ Initial Full Data Entry B ‐ Full Data Entry Error Correction/Change Pend C ‐ Undercare Maintenance/Error Correction/Change Pend D ‐ Full Data Entry Withdrawal E ‐ Authorization Report Request F ‐ Closed Case Maintenance G ‐ Case Reactivation ^ XMT ** The bottom of the WDXMNU screen is not shown here in order to illustrate the CNS option during data entry.

For all WMS transaction types, the first Case reason code (by category), the Transaction Type, and Notice Number are carried forward from CNS to WMS screen 1. For Approval and Denial transactions (02, 10 and 03) only, the PA/FS Indicator and the first Individual reason code (by category) are also carried forward to WMS. *Please note - for TA case closings and recertification closings (transaction types 07 and 08), the Case

reason code that is carried forward to WMS will also be the reason code that determines continued MA and TBA-FS eligibility.

CNS WRAP-AROUND TEXT PROCESSING CNS utilizes a wrap-around feature when data is entered in multiple-line free-form data fields.

Examples of these include the FF1-FF5 fields (Notice Entry and Inquiry/Update screens WCN012 and WCN014), the INFO field (PA/FS Employment Worker Entry screen WCN151) and the ACTION EXPL & REPAYMENT CONDITIONS fields (FS Claim Data Collection screen WCN013).

The guidelines for these entries are as follows:

• If backslashes ( \ ) are not keyed in, the notice text will print exactly as entered on a line-by-line basis. Punctuation should be data entered as necessary.

• Entries following a backslash (up to the next backslash) will be print on the next line.



• Entries that split words from one line to the next will print as whole sentences with all words intact ONLY if the entry is followed by a backslash. *Please note that when using multiple backslashes, you must begin a line with a blank space if the previous line completed a word in the last possible entry space. Without doing so, the text processor will assume the last word of a previous line and the first words of a succeeding line are to be concatenated.

• Data entered as a block of text with multiple spaces ending a line or words split across lines, will

print as a paragraph with correct spacing and all words intact ONLY if the final character or punctuation mark is followed by a backslash.

CLIENT NOTICES SYSTEM MANUAL CNS Section: F – Notice Inquiry

Last Revised 3-25-08 Page F - 1

CNS Menu Selection 02 Users can view pending notices that have been created by entering the Notice Number they wish to inquire. Screen WCN011 appears with the reason codes that were used to create the notice number entered. Reason Codes that required worker fill will have an inquiry indicator “_“ appear next to them. Entry of an ‘X’ in the inquiry indicator next to any “fill” reason code will display the previous worker fill entries associated with that reason code. A transmit without the entry of any “X-es” will display, in sequence, the previous worker entries for ALL reason codes requiring worker fill. An example of this screen sequence follows below:

‐WCN000 Department of Social Services Date 11/15/06 WMS/Client Notice Subsystem Menu Time 14:37:16 CASE NUMBER __________ REGISTRY NUMBER ______ NOTICE NUMBER U5300S5484 DISTRICT ____ BATCH NUMBER ______ INDICATE SELECTION NUMBER 02 Xmit _ 01 NOTICE ENTRY (CASE/REGISTRY NUMBER REQUIRED) 02 NOTICE INQUIRY (NOTICE NUMBER REQUIRED) 03 NOTICE UPDATE (NOTICE NUMBER REQUIRED) 04 PENDING NOTICE INQUIRY (CASE/REGISTRY NUMBER REQUIRED) 05 SUPERVISORY REVIEW PRINT (NOTICE NUMBER REQUIRED) 06 SIGNOFF 07 NOTICE AUTHORIZATION/RELEASE 08 BATCH NOTICE ENTRY 09 BATCH NOTICE INQUIRY (BATCH NUMBER REQUIRED) 10 BATCH NOTICE UPDATE (BATCH NUMBER REQUIRED) 11 NOTICE HISTORY INQUIRY (CASE/REGISTRY/NOTICE NO REQUIRED) 12 NOTICE HISTORY REPRINT (NOTICE NUMBER REQUIRED) 13 14 CNS CONTROL INFO MAINTENANCE 15 NYC/UPSTATE INQUIRY F16 WMSMNU (MENU KEY)

(*transmitting delivers the next screen)

CLIENT NOTICES SYSTEM MANUAL CNS Section: F – Notice Inquiry

Last Revised 3-25-08 Page F - 2

‐WCN011 WMS/Client Notice Subsystem Date 11/15/06 Reason Code Screen Time 14:44:17 CASE NO Z001F NOTICE NO U5300S5484 TRANS TYPE 07 OFFICE UNIT WORKER Z CASE REASONS: PA FS E30 L99 _ MA Xmit _

(*transmitting with or without an ‘X’ next to the L99 r/c delivers the next screen)

‐WCN012 WMS/Client Notice Subsystem Date 11/15/06 Notice Entry Screen Time 14:46:00 CASE NAME Z001F CASE NO Z001F NOTICE NO U5300S5484 CASE REASON L99 : RCP/CLM BAL AMT 1 00032100 AMT 2 00002500 ENTER AMT 1: TOTAL CURR CLAIM BALANCE ENTER AMT 2: 1ST MONTH PAYMENT AMT Xmit _

CLIENT NOTICES SYSTEM MANUAL CNS Section: G – Notice Update

Last Revised 3-25-08 Page G - 1

CNS Menu Selection 03 Users can update pending notices that have been created by entering the Notice Number they wish to modify. The CNS Reason Code screen (WCN011) is displayed with the reason codes previously entered. Users may Change, Add or Remove reason codes as well as Modify the worker fill associated with any reason code. Like Inquiry, reason codes that required worker fill will have an inquiry indicator “_” appear next to them. Entry of an ‘X’ in the inquiry indicator next to any “fill” reason code will display the previous worker fill entries associated with that reason code. All edits associated with initial CNS entry screens are enforced. After transmitting the final time, an alert is printed on the bottom of the final entry screen:

NO MORE REASON CODES – ENTER SF-13 TO STORE NOTICE To enforce the modifications made, users must depress Special Function key SF-13. This creates a new Notice Number and automatically DELETES the Notice Number that was modified. A new Supervisory Review Report is also generated. Users are returned to the CNS Menu screen (WCN000) with two messages displayed:

CASE xxxxxxxxxx - NOTICE NO xxxxxxxxxx CREATED

NOTICE NUMBER CHANGED - PLEASE UPDATE THE TAD This last message serves as an alert to users that if data entry had already been completed using the old (just modified) notice number, it must be replaced with the NEW notice number created in order to properly notice the client. *Note – Due to system limitations, some notices containing certain reason codes, such as Employment

Sanction or Food Stamp Claims cannot be updated. Notice Update screen sequence examples appear on the following pages.



‐WCN000 Department of Social Services Date 11/17/06 WMS/Client Notice Subsystem Menu Time 11:31:38 CASE NUMBER __________ REGISTRY NUMBER ______ NOTICE NUMBER U5300S5521 DISTRICT ____ BATCH NUMBER ______ INDICATE SELECTION NUMBER 03 Xmit _ 01 NOTICE ENTRY (CASE/REGISTRY NUMBER REQUIRED) 02 NOTICE INQUIRY (NOTICE NUMBER REQUIRED) 03 NOTICE UPDATE (NOTICE NUMBER REQUIRED) 04 PENDING NOTICE INQUIRY (CASE/REGISTRY NUMBER REQUIRED) 05 SUPERVISORY REVIEW PRINT (NOTICE NUMBER REQUIRED) 06 SIGNOFF 07 NOTICE AUTHORIZATION/RELEASE 08 BATCH NOTICE ENTRY 09 BATCH NOTICE INQUIRY (BATCH NUMBER REQUIRED) 10 BATCH NOTICE UPDATE (BATCH NUMBER REQUIRED) 11 NOTICE HISTORY INQUIRY (CASE/REGISTRY/NOTICE NO REQUIRED) 12 NOTICE HISTORY REPRINT (NOTICE NUMBER REQUIRED) 13 14 CNS CONTROL INFO MAINTENANCE 15 NYC/UPSTATE INQUIRY F16 WMSMNU (MENU KEY)

(*transmitting delivers the next screen)

‐WCN011 WMS/Client Notice Subsystem Date 11/17/06 Reason Code Screen Time 11:33:01 CASE NO Z001F NOTICE NO U5300S5521 TRANS TYPE 07 OFFICE ___ UNIT _____ WORKER Z____ CASE REASONS: PA ___ ___ ___ FS E30 L99 _ ___ MA ___ ___ ___ INDIVIDUAL REASONS: LN PA FS MA __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ Xmit _



*An ‘X’ is entered next to the L99 reason code. Transmitting delivers the following WCN012 screen with the originally entered data.

‐WCN012 WMS/Client Notice Subsystem Date 11/17/06 Notice Entry Screen Time 11:36:51 CASE NAME Z001F CASE NO Z001F NOTICE NO U5300S5521 CASE REASON L99 : RCP/CLM BAL AMT 1 00032100 AMT 2 00002500 ENTER AMT 1: TOTAL CURR CLAIM BALANCE ENTER AMT 2: 1ST MONTH PAYMENT AMT Xmit _

(*AMT 2 is CHANGED to $33.00 before transmitting; see the next screen)

‐WCN012 WMS/Client Notice Subsystem Date 11/17/06 Notice Entry Screen Time 11:36:51 CASE NAME Z001F CASE NO Z001F NOTICE NO U5300S5521 CASE REASON L99 : RCP/CLM BAL AMT 1 00032100 AMT 2 00003300 ENTER AMT 1: TOTAL CURR CLAIM BALANCE ENTER AMT 2: 1ST MONTH PAYMENT AMT Xmit _ NO MORE REASON CODES ‐ ENTER SF ‐ 13 TO STORE NOTICE



A reminder appears at the bottom of screen to alert workers that SF-13 must be depressed to store the updated notice... see below for the screen delivered after depressing SF-13.

‐WCN000 Department of Social Services Date 11/17/06 WMS/Client Notice Subsystem Menu Time 11:42:00 CASE NUMBER __________ REGISTRY NUMBER ______ NOTICE NUMBER __________ DISTRICT ____ BATCH NUMBER ______ INDICATE SELECTION NUMBER __ Xmit _ 01 NOTICE ENTRY (CASE/REGISTRY NUMBER REQUIRED) 02 NOTICE INQUIRY (NOTICE NUMBER REQUIRED) 03 NOTICE UPDATE (NOTICE NUMBER REQUIRED) 04 PENDING NOTICE INQUIRY (CASE/REGISTRY NUMBER REQUIRED) 05 SUPERVISORY REVIEW PRINT (NOTICE NUMBER REQUIRED) 06 SIGNOFF 07 NOTICE AUTHORIZATION/RELEASE 08 BATCH NOTICE ENTRY 09 BATCH NOTICE INQUIRY (BATCH NUMBER REQUIRED) 10 BATCH NOTICE UPDATE (BATCH NUMBER REQUIRED) 11 NOTICE HISTORY INQUIRY (CASE/REGISTRY/NOTICE NO REQUIRED) 12 NOTICE HISTORY REPRINT (NOTICE NUMBER REQUIRED) 13 14 CNS CONTROL INFO MAINTENANCE 15 NYC/UPSTATE INQUIRY F16 WMSMNU (MENU KEY) CASE Z001F ‐ NOTICE NO U5300S5534 CREATED NOTICE NUMBER CHANGED ‐ PLEASE UPDATE THE TAD

CLIENT NOTICES SYSTEM MANUAL CNS Section: H – Pending Notice Inquiry

Last Revised 3-25-08 Page H - 1

CNS Menu Selection 04 Users can view a list of ALL pending notices that have been created by entering the Case Number or Application Registry Number they wish to inquire. CNS screen WCN019 appears with a list of all the pending notices associated with the Case Number/Application Registry Number entered. The WCN019 screen list provides the Notice Number, Date Created, the Transaction Type and the Notice Status for all pending notices. Workers are presented with three (3) options for each notice listed: 1) SUP REV (Supervisory Review) Placing an ‘X’ in this option allows a user to generate another supervisory review report for the

associated notice number. 2) NTC UPD (Notice Update) See the previous notice update section (G). 3) NTC DEL (Notice Delete) Placing a ‘D’ in this option deletes the associated notice number from pending notice history.

Screen WCN019 re-appears with the notice STATUS now equal to DELETED. This notice number will NOT appear on future pending notice inquiries.

NOTE: If there are no pending notices, the following message appears: "No Pending Notices for this Case/Registry Number" If an invalid case number is entered, the following message appears: “Case Number not Found” Please see the following pages for sample screens.



‐WCN000 Department of Social Services Date 11/01/06 WMS/Client Notice Subsystem Menu Time 13:26:47 CASE NUMBER Z003F_____ REGISTRY NUMBER ______ NOTICE NUMBER __________ DISTRICT ____ BATCH NUMBER ______ INDICATE SELECTION NUMBER 04 Xmit _ 01 NOTICE ENTRY (CASE/REGISTRY NUMBER REQUIRED) 02 NOTICE INQUIRY (NOTICE NUMBER REQUIRED) 03 NOTICE UPDATE (NOTICE NUMBER REQUIRED) 04 PENDING NOTICE INQUIRY (CASE/REGISTRY NUMBER REQUIRED) 05 SUPERVISORY REVIEW PRINT (NOTICE NUMBER REQUIRED) 06 SIGNOFF 07 NOTICE AUTHORIZATION/RELEASE 08 BATCH NOTICE ENTRY 09 BATCH NOTICE INQUIRY (BATCH NUMBER REQUIRED) 10 BATCH NOTICE UPDATE (BATCH NUMBER REQUIRED) 11 NOTICE HISTORY INQUIRY (CASE/REGISTRY/NOTICE NO REQUIRED) 12 NOTICE HISTORY REPRINT (NOTICE NUMBER REQUIRED) 13 14 CNS CONTROL INFO MAINTENANCE 15 NYC/UPSTATE INQUIRY F16 WMSMNU (MENU KEY)

Transmitting the screen above delivers the following WCN019 screen:

‐WCN019 WMS/Client Notice Subsystem Date 11/01/06 Pending Notice List Time 13:28:12 REG/CASE NO Z003F_____ DIST WASH NAME Z003F SUP NTC NTC DATE TRANS REV UPD DEL NOTICE NUM CREATED TYPE STATUS _ _ _ U5300S5077 10/19/06 05 AWAITING AUTHORIZATION _ _ _ U5300S5014 10/17/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3820 09/01/06 05 AWAITING AUTHORIZATION _ _ _ U5300S3299 08/22/06 00 AWAITING SYSTEM VARIABLES _ _ _ U5300S3287 08/22/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3275 08/22/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3248 08/22/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3224 08/22/06 00 AWAITING AUTHORIZATION Xmit _



The following screens show examples of each option:

‐WCN019 WMS/Client Notice Subsystem Date 11/01/06 Pending Notice List Time 13:28:12 REG/CASE NO Z003F_____ DIST WASH NAME Z003F SUP NTC NTC DATE TRANS REV UPD DEL NOTICE NUM CREATED TYPE STATUS X _ _ U5300S5077 10/19/06 05 AWAITING AUTHORIZATION _ _ _ U5300S5014 10/17/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3820 09/08/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3299 08/22/06 00 AWAITING SYSTEM VARIABLES _ _ _ U5300S3287 08/22/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3275 08/22/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3248 08/22/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3224 08/22/06 00 AWAITING AUTHORIZATION Xmit _

Transmitting the screen above delivers the following screen:

‐WCN000 Department of Social Services Date 11/01/06 WMS/Client Notice Subsystem Menu Time 13:33:15 CASE NUMBER __________ REGISTRY NUMBER ______ NOTICE NUMBER __________ DISTRICT ____ BATCH NUMBER ______ INDICATE SELECTION NUMBER __ Xmit _ 01 NOTICE ENTRY (CASE/REGISTRY NUMBER REQUIRED) 02 NOTICE INQUIRY (NOTICE NUMBER REQUIRED) 03 NOTICE UPDATE (NOTICE NUMBER REQUIRED) 04 PENDING NOTICE INQUIRY (CASE/REGISTRY NUMBER REQUIRED) 05 SUPERVISORY REVIEW PRINT (NOTICE NUMBER REQUIRED) 06 SIGNOFF 07 NOTICE AUTHORIZATION/RELEASE 08 BATCH NOTICE ENTRY 09 BATCH NOTICE INQUIRY (BATCH NUMBER REQUIRED) 10 BATCH NOTICE UPDATE (BATCH NUMBER REQUIRED) 11 NOTICE HISTORY INQUIRY (CASE/REGISTRY/NOTICE NO REQUIRED) 12 NOTICE HISTORY REPRINT (NOTICE NUMBER REQUIRED) 13 14 CNS CONTROL INFO MAINTENANCE 15 NYC/UPSTATE INQUIRY F16 WMSMNU (MENU KEY) NOTICE NUMBER ‐ U5300S5077 HAS BEEN PRINTED



‐WCN019 WMS/Client Notice Subsystem Date 11/01/06 Pending Notice List Time 13:34:55 REG/CASE NO Z003F_____ DIST WASH NAME Z003F SUP NTC NTC DATE TRANS REV UPD DEL NOTICE NUM CREATED TYPE STATUS _ _ _ U5300S5077 10/19/06 05 AWAITING AUTHORIZATION _ X _ U5300S5014 10/17/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3820 09/08/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3299 08/22/06 00 AWAITING SYSTEM VARIABLES _ _ _ U5300S3287 08/22/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3275 08/22/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3248 08/22/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3224 08/22/06 00 AWAITING AUTHORIZATION Xmit _


‐WCN011 WMS/Client Notice Subsystem Date 11/01/06 Reason Code Screen Time 14:09:52 CASE NO Z003F NOTICE NO U5300S5014 TRANS TYPE 00 OFFICE ___ UNIT _____ WORKER Z____ CASE REASONS: PA ___ ___ ___ FS Z95 _ ___ ___ MA ___ ___ ___ INDIVIDUAL REASONS: LN PA FS MA __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ Xmit _




‐WCN012 WMS/Client Notice Subsystem Date 11/01/06 Notice Entry Screen Time 14:12:04 CASE NAME Z003F CASE NO Z003F NOTICE NO U5300S5014 CASE REASON Z95 : C/I: PHONE DATE 1 112206 TIME HHMM 1100 ENTER DATE 1: INTERVIEW DATE (MMDDYY) ENTER TIME HHMM: INTERVIEW TIME (HHMM) Xmit _

Change DATE 1 to 11/27/06 and TIME HHMM to 0930...

‐WCN012 WMS/Client Notice Subsystem Date 11/01/06 Notice Entry Screen Time 14:12:04 CASE NAME Z003F CASE NO Z003F NOTICE NO U5300S5014 CASE REASON Z95 : C/I: PHONE DATE 1 112706 TIME HHMM 0930 ENTER DATE 1: INTERVIEW DATE (MMDDYY) ENTER TIME HHMM: INTERVIEW TIME (HHMM) Xmit _




‐WCN012 WMS/Client Notice Subsystem Date 11/01/06 Notice Entry Screen Time 14:30:24 CASE NAME Z003F CASE NO Z003F NOTICE NO U5300S5014 CASE REASON Z95 : C/I: PHONE DATE 1 112706 TIME HHMM 0930 ENTER DATE 1: INTERVIEW DATE (MMDDYY) ENTER TIME HHMM: INTERVIEW TIME (HHMM) Xmit _ NO MORE REASON CODES ‐ ENTER SF ‐ 13 TO STORE NOTICE

Hitting the SF-13 key yields the following screen:

‐WCN000 Department of Social Services Date 11/01/06 WMS/Client Notice Subsystem Menu Time 14:33:02 CASE NUMBER __________ REGISTRY NUMBER ______ NOTICE NUMBER __________ DISTRICT ____ BATCH NUMBER ______ INDICATE SELECTION NUMBER __ Xmit _ 01 NOTICE ENTRY (CASE/REGISTRY NUMBER REQUIRED) 02 NOTICE INQUIRY (NOTICE NUMBER REQUIRED) 03 NOTICE UPDATE (NOTICE NUMBER REQUIRED) 04 PENDING NOTICE INQUIRY (CASE/REGISTRY NUMBER REQUIRED) 05 SUPERVISORY REVIEW PRINT (NOTICE NUMBER REQUIRED) 06 SIGNOFF 07 NOTICE AUTHORIZATION/RELEASE 08 BATCH NOTICE ENTRY 09 BATCH NOTICE INQUIRY (BATCH NUMBER REQUIRED) 10 BATCH NOTICE UPDATE (BATCH NUMBER REQUIRED) 11 NOTICE HISTORY INQUIRY (CASE/REGISTRY/NOTICE NO REQUIRED) 12 NOTICE HISTORY REPRINT (NOTICE NUMBER REQUIRED) 13 14 CNS CONTROL INFO MAINTENANCE 15 NYC/UPSTATE INQUIRY F16 WMSMNU (MENU KEY) CASE Z003F ‐ NOTICE NO U5300S5597 CREATED NOTICE NUMBER CHANGED ‐ PLEASE UPDATE THE TAD



‐WCN019 WMS/Client Notice Subsystem Date 11/01/06 Pending Notice List Time 13:34:55 REG/CASE NO Z003F_____ DIST WASH NAME Z003F SUP NTC NTC DATE TRANS REV UPD DEL NOTICE NUM CREATED TYPE STATUS _ _ D U5300S5077 10/19/06 05 AWAITING AUTHORIZATION _ _ _ U5300S5014 10/17/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3820 09/08/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3299 08/22/06 00 AWAITING SYSTEM VARIABLES _ _ _ U5300S3287 08/22/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3275 08/22/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3248 08/22/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3224 08/22/06 00 AWAITING AUTHORIZATION Xmit _


‐WCN019 WMS/Client Notice Subsystem Date 11/01/06 Pending Notice List Time 13:35:15 REG/CASE NO Z003F_____ DIST WASH NAME Z003F SUP NTC NTC DATE TRANS REV UPD DEL NOTICE NUM CREATED TYPE STATUS U5300S5077 10/19/06 05 DELETED _ _ _ U5300S5014 10/17/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3820 09/08/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3299 08/22/06 00 AWAITING SYSTEM VARIABLES _ _ _ U5300S3287 08/22/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3275 08/22/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3248 08/22/06 00 AWAITING AUTHORIZATION _ _ _ U5300S3224 08/22/06 00 AWAITING AUTHORIZATION Xmit _

Notice U5300S5077 status is changed to DELETED... this notice can no longer be accessed for inquiry, update or WMS transaction.

CLIENT NOTICES SYSTEM MANUAL CNS Section: I – Supervisory Review Print

Last Revised 3-25-08 Page I - 1

CNS Menu Selection 05 Supervisory Review Reports are automatically generated after transmitting the final CNS input screen. Users can generate another Supervisory Review Report for any pending notice by entering the Notice Number and CNS Menu Selection number 05. The following message is returned on CNS screen WCN000:

NOTICE NUMBER - xxxxxxxxxx HAS BEEN PRINTED See the next page for a Supervisory Review Report mock-up. Field explanations are provided.



99/99/99 CLIENT NOTICES SUBSYSTEM PAGE 1 SUPERVISORY REVIEW REPORT CURRENT CASE DATA: CASE NAME xxxxxxxxxx CASE NO xxxxxxxxxx SUFFIX CASE STATUS 99 xxxxxx CASE TYPE 99 xxxxxxx OFFICE UNIT WORKER FS IND NOTICE NUMBER xxxxxxxxxx TRANS TYPE 07 CLOS OFFICE UNIT WORKER FS IND CASE REASON CODES: PA REASONS 999 XXXXXXXXXXXX USER VARIABLES XXXXXXXXXXXXXXXXXXXX 999999 XXXXXXXXXXXXXXXXXXXX 999999 FS REASONS 999 XXXXXXXXXXXX USER VARIABLES XXXXXXXXXXXXXXXXXXXX 999999 XXXXXXXXXXXXXXXXXXXX 999999 MA REASONS 999 XXXXXXXXXXXX USER VARIABLES XXXXXXXXXXXXXXXXXXXX 999999 XXXXXXXXXXXXXXXXXXXX 999999 INDIVIDUAL REASON CODES: PA REASONS 999 XXXXXXXXXXXX USER VARIABLES XXXXXXXXXXXXXXXXXXXX 999999 XXXXXXXXXXXXXXXXXXXX 999999 FS REASONS 999 XXXXXXXXXXXX USER VARIABLES XXXXXXXXXXXXXXXXXXXX 999999 XXXXXXXXXXXXXXXXXXXX 999999 MA REASONS 999 XXXXXXXXXXXX USER VARIABLES XXXXXXXXXXXXXXXXXXXX 999999 XXXXXXXXXXXXXXXXXXXX 999999



The Supervisory Review Report provides the following information: CASE NAME Appears as entered on WMS CASE NO. Appears as entered on CNS Menu screen (WCN000) SUFFIX NYC only. Appears as entered on CNS Menu screen (WCN000) CASE STATUS The current WMS case status and its mnemonic appears CASE TYPE Appears as entered on WMS OFFICE/UNIT/WORKER Appear as entered on WMS. NOTICE NUMBER This is the unique number automatically assigned by the system to the pending notice TRANS TYPE Appears as entered on CNS reason code entry screen (WCN011) OFFICE/UNIT/WORKER (2ND occurrence) Appears as entered on CNS reason code entry screen (WCN011) FS IND Upstate only. Appears as entered on CNS reason code entry screen (WCN011) CASE REASON CODES For each of the program areas, these appear as entered on the CNS reason code entry screen

(WCN011). USER VARIABLES For each reason code that required worker variable entry, this data appears as entered on CNS

under its corresponding reason code. The prompt originally displayed on the input screen is printed to the left of the value previously entered.

INDIVIDUAL REASON CODES For each of the program areas, these appear as entered on the CNS reason code entry screen

(WCN011). USER VARIABLES For each reason code that required worker variable entry, this data appears as entered on CNS

under its corresponding reason code. The prompt originally displayed on the input screen is printed to the left of the value previously entered.

CLIENT NOTICES SYSTEM MANUAL CNS Section: J – Notice Authorization/Release

Last Revised 3-25-08 Page J - 1

CNS Menu Selection 07 For a select set of reason codes, users can introduce notices to the nightly production process by entering CNS Menu Selection number 07. The CNS Notice Authorization/Release Screen (WCN021) is presented (see example below). It allows the entry of up to thirty-two (32) case numbers/notices per screen for that night’s notice production. Users enter the Case Number(s) and the corresponding Notice Number(s) that they wish to have sent as part of that night’s notice production. This function is reserved for Non-Transaction reason codes (those allowed for Transaction Type 00) like Recertification Call-in and FS Application/Recertification Appointment Reminders. These notices do not require a WMS transaction in order to be produced.

WCN021 WMS/Client Notice Subsystem Date 11/21/06 Notice Authorization/Release Screen Time 08:41:15 Office ___ Unit _____ Worker _____ Case # Notice # Case # Notice # Z001F_____ U5300S5787 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ More to Authorize (Y) N Xmit _

If desired, users may over-ride the Office-Unit-Worker values associated with the case/notice numbers entered by making entries in the corresponding fields at the top of the WCN021 screen. ALL notices released will print with the worker name and phone number associated with these WCN021 values. If the “More to Authorize” Indicator value remains as an “N”, the CNS Menu (WCN000) is returned when transmitting. If the user has more notices to release, they may change this indicator to a “Y” and a blank WCN021 will be returned for additional entry.

CLIENT NOTICES SYSTEM MANUAL CNS Section: K – Batch Notice Entry

Last Revised 3-25-08 Page K - 1

CNS Menu Selection 08 For a select set of reason codes, users can create notices for up to 15 cases at one time. This function is reserved for Non-Transaction reason codes (those allowed for Transaction Type 00) like Recertification Call-in and FS Application/Recertification Appointment Reminders. After entering CNS Menu Selection number 08 and transmitting, the CNS Batch Notice Entry screen (WCN022) appears.

‐WCN022 WMS/CLIENT NOTICE SUBSYSTEM Date 11/21/06 Batch notice entry screen Time 11:42:58 BENEFIT CATEGORY __ REASON CODE ___ PROCESS DATE 112106 OFFICE ___ UNIT _____ WORKER _____ CASE # USER VARIABLE # 1 USER VARIABLE # 2 USER VARIABLE # 3 __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ Xmit _

Users are required to enter: BENEFIT CATEGORY This is the category associated with the reason code (PA, FS, MA or HP). REASON CODE These are the allowable Transaction Type 00 (or HEAP Approval) reason codes for the notice to

be sent. Users may optionally enter: PROCESS DATE This is the date that the notices will be produced. This field is automatically filled with the

current date. Users are reminded to change this to a valid future date if necessary. OFFICE, UNIT and WORKER These fields are provided to allow the notices to be printed with the name/phone number

associated with these values rather than those associated with each case.



Four entry columns are provided with the headings: CASE #, USER VARIABLE # 1, USER VARIABLE # 2 and USER VARIABLE # 3. CASE # Users enter the case numbers that require noticing for the reason code entered. USER VARIABLE # 1, 2 & 3 These are the data entry fields that correspond to the required entry fields that would be seen on

screen WCN012 if the regular notice creation process was used. For example, if the Food Stamp Recertification Call-in reason code Z10 had been entered, users would be required to fill VARIABLE # 1 with the Interview Date and VARIABLE # 2 with the Interview Time. These variable information fields are edited for correctness according to the reason code entered. Please see the example below:

‐WCN022 WMS/CLIENT NOTICE SUBSYSTEM Date 11/21/06 Batch notice entry screen Time 13:26:19 BENEFIT CATEGORY FS REASON CODE Z10 PROCESS DATE 120106 OFFICE ___ UNIT _____ WORKER _____ CASE # USER VARIABLE # 1 USER VARIABLE # 2 USER VARIABLE # 3 Z001F_____ 121706______________ 0930________________ ____________________ Z002F_____ ____________________ 1015________________ ____________________ Z003F_____ ____________________ 0130________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ Xmit _

In the example screen above, FS (Food Stamps) is entered in the Benefit Category, Z10 (Continuing Your Food Stamps – ON/AT) is entered in the Reason Code and the Process Date has been changed from “today’s” date (11/21/06) to 12/01/06. Please Note: If required by the reason code, entries must be made at least for the first occurrence(s) of variable

information. For ease of entry, variable information for Case Numbers 2-15 ONLY needs to be entered when it differs from the entry above it.

In the example above, three (3) cases need to be called in on the same date (12/17/06) for food stamp

recertification interviews, although each case was to be interviewed at different times, therefore, each case listed requires an interview time entry in VARIABLE # 2.



When the screen above is transmitted the following screen is displayed:

‐WCN022 WMS/CLIENT NOTICE SUBSYSTEM Date 11/21/06 Batch notice entry screen Time 13:29:41 BENEFIT CATEGORY FS REASON CODE Z10 PROCESS DATE 120106 OFFICE UNIT WORKER CASE # USER VARIABLE # 1 USER VARIABLE # 2 USER VARIABLE # 3 Z001F 121706 0930 Z003F 121706 1015 Z004F 121706 0130 More notices to create (Y/N) N Xmit _ BATCH NOTICE RECORD 00891 CREATED

Please notice that when screen WCN022 is returned, any formerly blank required field is now filled by the value that preceded it. Two messages also appear at the bottom of the WCN022 screen: More notices to create (Y/N) N This feature is used when another batch needs to be created using the same Category and Reason

Code. If a “Y” is entered over the pre-filled “N” prior to transmitting, screen WCN022 is returned with

the Benefit Category and Reason Code fields pre-filled with the same values as previously transmitted. The Process Date, however, again appears as the current date and the Case # and User Variables 1-3 are blank.

If an “N” remains in the “More notices to create” Indicator when transmitting, the CNS Menu

screen (WCN000) is returned. BATCH NOTICE RECORD xxxxx CREATED *Please note that this Batch Number is extremely important... it will be necessary to use this

number for future Batch Notice inquiry or update. *A print of this screen is automatically generated when the Xmit key is hit.

CLIENT NOTICES SYSTEM MANUAL CNS Section: L – Batch Notice Inquiry & Update

Last Revised 3-25-08 Page L - 1

BATCH NOTICE INQUIRY (CNS Menu Selection 09) and... BATCH NOTICE UPDATE (& Delete) (CNS Menu Selection 10) INQUIRY Users can view a previously created batch by entering the Batch Number they wish to inquire and CNS Menu Selection number 09. CNS screen WCN022 is presented for review with the previously entered information.

‐WCN022 WMS/CLIENT NOTICE SUBSYSTEM Date 11/21/06 BATCH NUMBER 000891 Batch notice entry screen Time 14:31:00 BENEFIT CATEGORY FS REASON CODE Z10 PROCESS DATE 120106 OFFICE UNIT WORKER CASE # USER VARIABLE # 1 USER VARIABLE # 2 USER VARIABLE # 3 Z001F 121606 0930 Z003F 121606 1015 Z004F 121606 0130 Xmit _

*Please note: batches are available for review only through the Process Date; once a batch has been

processed, it is no longer available for review. *Please see the next page for a Batch Update explanation.



UPDATE (& DELETE) Users can update a previously created batch by entering the Batch Number they wish to modify and CNS Menu Selection number 10. CNS screen WCN022 is presented with the previously entered information. Users may Add or Delete Case Numbers as well as Modify previously entered User Variables (see the example screens below). On the CNS Menu, Batch Number 891 is entered with Selection Number 10... the following screen is displayed:

‐WCN022 WMS/CLIENT NOTICE SUBSYSTEM Date 11/21/06 BATCH NUMBER 000891 Batch notice entry screen Time 14:35:43 BENEFIT CATEGORY FS REASON CODE Z10 PROCESS DATE 120106 OFFICE ___ UNIT _____ WORKER _____ CASE # USER VARIABLE # 1 USER VARIABLE # 2 USER VARIABLE # 3 Z001F_____ 121606______________ 0930________________ ____________________ Z003F_____ 121606______________ 1015________________ ____________________ Z004F_____ 121606______________ 0130________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ Xmit _

The entries are modified...

• Process Date is Changed to 12/02/06 • The Interview Time for case Z003F is Changed from 10:15 to 11:00 • Case Z004F is removed • Cases Z005F and Z007F have been added with their Interview Dates/Times

(see modified screen on next page)



‐WCN022 WMS/CLIENT NOTICE SUBSYSTEM Date 11/21/06 BATCH NUMBER 000891 Batch notice entry screen Time 14:35:43 BENEFIT CATEGORY FS REASON CODE Z10 PROCESS DATE 120206 OFFICE ___ UNIT _____ WORKER _____ CASE # USER VARIABLE # 1 USER VARIABLE # 2 USER VARIABLE # 3 Z001F_____ 121606______________ 0930________________ ____________________ Z003F_____ 121606______________ 1100________________ ____________________ Z005F_____ 121606______________ 0215________________ ____________________ Z007F_____ 121706______________ 0130________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ Xmit _

The modified screen is then transmitted...

‐WCN022 WMS/CLIENT NOTICE SUBSYSTEM Date 11/21/06 BATCH NUMBER 000891 Batch notice entry screen Time 14:51:01 BENEFIT CATEGORY FS REASON CODE Z10 PROCESS DATE 120206 OFFICE UNIT WORKER CASE # USER VARIABLE # 1 USER VARIABLE # 2 USER VARIABLE # 3 Z001F 121606 0930 Z003F 121606 1100 Z005F 121606 0215 Z007F 121706 0130 Xmit _ BATCH NOTICE RECORD 00891 HAS BEEN MODIFIED

*Please note: like Inquiry above, batches are available for update only through the Process Date.



Batch DELETE Users can delete a previously created batch by entering the Batch Number they wish to delete on the CNS Menu screen (WCN000) and transmitting with CNS Selection Number 10. CNS screen WCN022 is presented with the previously entered information. In order to delete the batch, users must then depress Special Function Key 14 (SF-14). Users are returned to the CNS Menu (WCN000) with the following bottom-line message:

BATCH NOTICE RECORD xxxxx HAS BEEN DELETED

‐WCN022 WMS/CLIENT NOTICE SUBSYSTEM Date 11/21/06 BATCH NUMBER 000894 Batch notice entry screen Time 15:01:54 BENEFIT CATEGORY FS REASON CODE Z10 PROCESS DATE 112106 OFFICE ___ UNIT _____ WORKER _____ CASE # USER VARIABLE # 1 USER VARIABLE # 2 USER VARIABLE # 3 Z001F_____ 121106______________ 1100________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ __________ ____________________ ____________________ ____________________ Xmit _

Depress Special Function Key 14 (SF-14)...

‐WCN000 Department of Social Services Date 11/21/06 WMS/Client Notice Subsystem Menu Time 15:03:14 CASE NUMBER __________ REGISTRY NUMBER ______ NOTICE NUMBER __________ DISTRICT ____ BATCH NUMBER ______ INDICATE SELECTION NUMBER __ Xmit _ 01 NOTICE ENTRY (CASE/REGISTRY NUMBER REQUIRED) 02 NOTICE INQUIRY (NOTICE NUMBER REQUIRED) 03 NOTICE UPDATE (NOTICE NUMBER REQUIRED) 04 PENDING NOTICE INQUIRY (CASE/REGISTRY NUMBER REQUIRED) 05 SUPERVISORY REVIEW PRINT (NOTICE NUMBER REQUIRED) 06 SIGNOFF 07 NOTICE AUTHORIZATION/RELEASE 08 BATCH NOTICE ENTRY 09 BATCH NOTICE INQUIRY (BATCH NUMBER REQUIRED) 10 BATCH NOTICE UPDATE (BATCH NUMBER REQUIRED) 11 NOTICE HISTORY INQUIRY (CASE/REGISTRY/NOTICE NO REQUIRED) 12 NOTICE HISTORY REPRINT (NOTICE NUMBER REQUIRED) 13 14 CNS CONTROL INFO MAINTENANCE 15 NYC/UPSTATE INQUIRY F16 WMSMNU (MENU KEY) BATCH NOTICE RECORD 00894 HAS BEEN DELETED

CLIENT NOTICES SYSTEM MANUAL CNS Section: M – Notice History Inquiry

Last Revised 3-25-08 Page M - 1

CNS Selection 11 Users can view information about a specific notice or a complete list of notices that have been sent to a case by entering the Case Number or Notice Number they wish to inquire and CNS Menu Selection number 11. If a Case Number is entered, the CNS Client Notice List screen (WCN051) appears with a complete list (in reverse chronological order) of the notices that have been sent to that Case Number. If a Notice Number is entered, the CNS Client Notice Detail screen (WCN052) appears with the details associated with that Notice Number. If there are no authorized notices, the message "No Notice History for this Case/Registry Number" appears. If an invalid case number is entered, the message "Case/Registry Number Not Found" appears. Samples of both screens and explanations follow below: WCN051:

‐WCN051 WMS/Client Notice Subsystem Date 11/22/06 Client Notice List Screen Time 09:07:46 CASE # Z003F_____ DIST WASH Page 01 of 04 next? __ NAME Z003F TYPE NPA‐FS STATUS ACTIVE OFFICE UNIT WORKER Z R D NOTICE # FAIR HEAR # MAIL DT TRANS TYPE AUTH # AFFECTED IND P T PA ACTION EFF DT FS ACTION EFF DT MA ACTION EFF DT _ _ U5300S5077 10/20/06 05‐CHANGE 00137134 AX75278D CHANGE 10/20/06 _ _ U5300S4835 10/12/06 06‐RECERT 00137077 AX75278D RECERT 10/01/06 _ _ U5300S4354 09/28/06 05‐CHANGE 00136989 AX75278D + CHANGE 10/01/06 _ _ U5300S4075 09/23/06 05‐CHANGE 00136922 AX75278D CHANGE 10/01/06 _ _ U5300S2564 07/26/06 05‐CHANGE 00136465 AX75278D CHANGE 07/01/06 Xmit _

Screen WCN051 field explanations: DATE/TIME: The current Date and Time are displayed. CASE # The case number as entered on the CNS menu (WCN000). SUFX The suffix appears as entered on the CNS menu (WCN000) (NYC only).

DIST The first 4 characters of the local district name are displayed.



Page 01 of __ The current history page number and the total number of history pages are displayed. next? __ This is a history page navigator. Users may enter the number of the page they wish displayed and

hit Xmit to display a preferred history page. Users may also navigate within notice history by using Special Function keys 01, 02 and 03:

SF-01 – returns the user to the FIRST PAGE of notice history SF-02 - advances the user to the NEXT (higher) PAGE of notice history SF-03 - returns the user to the PRIOR (lower) PAGE of notice history

NAME The case name from the WMS record is displayed. TYPE The current case type (mnemonic) is displayed. STATUS The current WMS case status (mnemonic) is displayed. OFFICE, UNIT, WORKER The current values from the WMS record are displayed.

**The following items associated with each notice appear in two (2) rows. Notice information is stacked one item over the other and corresponds to the screen column headings above. R P The former reprint request indicator. This function has been disabled because COLD software is

now used for notice reprints. D T Entry of an "X" in this column allows users to view the details associated with the notice number

to its right. CNS screen WCN052 is displayed after transmitting. NOTICE # The notice number, as assigned by CNS. FAIR HEARING # If the client has requested a fair hearing, the fair hearing number appears. MAIL DT The date the notice was mailed. TRANS TYPE The transaction type associated with the notice appears.



AUTH # The authorization number of the WMS transaction that authorized the notice is displayed. AFFECTED IND The CIN of the affected individual is displayed. A plus sign ("+") indicates that more than one

individual was affected. PA ACTION The mnemonic for the PA category action is displayed. FS ACTION The mnemonic for the FS category action is displayed. MA ACTION The mnemonic for the MA category action is displayed. EFF DT (occurs three times corresponding to each of the program categories) The effective date of the action is displayed.

*In the following screen example, notice U5300S5077 is selected for detail display by placing an “X” in the DT column and transmitting:

‐WCN051 WMS/Client Notice Subsystem Date 11/22/06 Client Notice List Screen Time 09:41:52 CASE # Z003F_____ DIST WASH Page 01 of 04 next? __ NAME Z003F TYPE NPA‐FS STATUS ACTIVE OFFICE UNIT WORKER Z R D NOTICE # FAIR HEAR # MAIL DT TRANS TYPE AUTH # AFFECTED IND P T PA ACTION EFF DT FS ACTION EFF DT MA ACTION EFF DT _ X U5300S5077 10/20/06 05‐CHANGE 00137134 AX75278D CHANGE 10/20/06 _ _ U5300S4835 10/12/06 06‐RECERT 00137077 AX75278D RECERT 10/01/06 _ _ U5300S4354 09/28/06 05‐CHANGE 00136989 AX75278D + CHANGE 10/01/06 _ _ U5300S4075 09/23/06 05‐CHANGE 00136922 AX75278D CHANGE 10/01/06 _ _ U5300S2564 07/26/06 05‐CHANGE 00136465 AX75278D CHANGE 07/01/06 Xmit _



When the screen above is transmitted, the following CNS Notice Detail screen (WCN052) is displayed:

‐WCN052 WMS/Client Notice Subsystem Date 11/22/06 Client Notice Detail Screen Time 09:45:16 Notice # U5300S5077 CASE # Z003F DIST WASH TRANS CH STATUS CHANGE NAME Z003F OFF/UNIT/WRKR TST/WRAP /NO \ MAIL 10/20/06 ADDR XX AUTH NO 00137134 HEARING # CITY XX ST NY ZIP 21365‐0000 ASSC 1 ASSC 3 ASSC 2 ASSC 4 AID STATUS ENG/SPN S NOT IND ONLINE N PUBLIC ASSISTANCE FOOD STAMPS MEDICAL ASSISTANCE CASE ACTION CH REASON CODES X01‐ISS UPAY ADJ EFFECTIVE DATE 10/20/06 BUDGET VERSION IND CIN AX75278D IND CIN IND CIN IND CIN EFF DATE EFF DATE EFF DATE EFF DATE PA PA PA PA FS FS FS FS MA MA MA MA Print _ Xmit _

Screen WCN052 field descriptions: DATE/TIME: The current Date and Time are displayed. NOTICE # The Notice Number, as entered on WCN000 or indicated on WCN051. CASE # The Case Number associated with the Notice Number. SUFX The suffix associated with the Notice Number (NYC only). DIST The first 4 characters of the local district name. TRANS The mnemonic for the transaction type associated with the notice. STATUS The mnemonic for the current WMS case status is displayed.

NAME The Case Name associated with the Notice Number. OFFICE, UNIT, WORKER The Office, Unit and Worker values associated with the Notice Number.



MAIL The notice mail date is displayed. ADDR The client Street Address as printed on the notice. AUTH NO The authorization number of the WMS transaction associated with the Notice Number. HEARING # The fair hearing number associated with the Notice Number. CITY The City as printed on the notice. ST The State as printed on the notice. ZIP The Zip Code as printed on the notice. ASSC 1-4 Any Associated Name(s) that received a copy of the notice appear here. AID STATUS The case aid continuing status.

1 = Automatic Aid to Continue 2 = Aid Continuing 3 = Non-Aid Continuing 4 = Conditional Aid Continuing

NOTE: The only code that will appear in NYC is "2". ENG/SPN The language indicator as entered on WMS at the time the notice was sent (E = English Only, S =

English and Spanish). NOTICE IND The notice indicator as entered on WMS at the time the notice was sent. ONLINE Formerly used for re-prints, this field is no longer used.



For each of the Benefit Categories (PUBLIC ASSISTANCE, FOOD STAMPS, MEDICAL ASSISTANCE and HEAP), two fields are listed: CASE ACTION This is the 2-character mnemonic of the action associated with the notice. The values are:

UPSTATE NYC OP – Opening AC - Accept DN – Denial RJ – Reject CH – Change CH – Change RT – Recertification RT – Recertification CL – Close CL – Close RC – Recert/Close RC – Recert/Close RO – Reopening RO – Reopening RA – Reactivation RA – Reactivation FC – Forced Close FC – Forced Close

REASON CODES The Case reason codes (and their mnemonics) associated with the notice are listed. EFFECTIVE DATE The effective date of the notice is displayed. BUDGET VERSION This field is no longer used. IND CIN (occurs 4 times per screen) The Client Identification Number of each individual in the case is listed. Four individuals at a

time are displayed on the screen. For cases with more than four (4) individuals, users should depress Special Function Key 2 (SF-2) as many times as necessary to page forward for a view all individuals in the case. Special Function Key 3 (SF-3) is used to page backward one (1) page at a time. Special Function Key 1 (SF-1) returns the user to page 1 (the original WCN052 page displayed).

EFF DATE This is the effective date of the action associated with the individual reason code(s) displayed. PA, FS, MA The Individual reason codes associated with the notice are listed by individual and category. Print Formerly used for re-prints, this field is no longer used. CLKDWN – MM/DD/YY or CLOCK STOPPED messages These messages appear in the lower LEFT hand corner of the screen if the case is in “clockdown”

status or if the “clockdown” clock had been stopped. Note: These messages only appear if the WCN052 screen is displayed due to a request for details (DT)

about a particular notice on the Client Notice List (WCN051). Entry of a Notice Number and Selection 11 on the Client Notice Menu (WCN000) will NOT display these messages.



RETURN TO THE LIST: Returning to the CNS Client Notice List screen (WCN051) is accomplished by depressing

Special Function Key 15 (SF-15).

CLIENT NOTICES SYSTEM MANUAL CNS Section: N – CNS Control Information Maintenance

Last Revised 3-25-08 Page N - 1

CNS Menu Selection 14 Contact data for each local district is maintained in three (3) tables:

1. District Data Table - this table contains the local district return address and agency telephone numbers that are printed on each district’s notices. District contact data records may be created for the District, each Program Area, and any Office-Unit combination the district deems appropriate. Each local district maintains their agency’s table entries.

2. Office-Unit-Worker Table - this table contains the Names and Telephone Numbers associated

with all the Office-Unit-Worker combinations as well as each Program Area in the local district. These Names and Telephone Numbers are printed on each notice. Contact data records may be created for the District, each Program Area, and any Office-Unit-Worker combination the district deems appropriate. Each local district maintains their agency’s table entries.

3. Advocate Table - this table contains the Names and Telephone Numbers associated with all the

Advocate organizations in each local district. The NYS OTDA Office of Administrative Hearings maintains this table.

*Note – In order for any notice to be produced, both the District and O-U-W data tables must have either

a record that corresponds exactly to the District-Office-Unit/Program Area and the Office-Unit-Worker associated with the case or district default record(s) must exist.

Districts are strongly encouraged to establish district default records in both tables. Creation of default records is discussed in the WCN062/WCN064 entry screen explanations under the title: DEFAULT RECORDS. WCN060 – Contact Data Maintenance Menu This is the screen displayed when users choose Selection Number 14 from the CNS Menu (WCN000).

‐WCN060 WMS/Client Notice Subsystem Date 11/02/06 Contact Data Maintenance Menu Time 14:37:19 INDICATE SELECTION NUMBER _ ACTION (I/U) _ DISTRICT XXXX PROGRAM AREA (PA,FS,MA,HP) __ OFFICE ID ___ UNIT ID _____ WORKER ID _____ ADVOCATE NUMBER _____ MASS CHANGE KEY _____ ‐ ________ Xmit _ DISTRICT REQUIRED FOR SELECTIONS 1, 2, 3, AND 4 1 DISTRICT MAINTENANCE (PROGRAM AREA,OFFICE,UNIT ID OPTIONAL) 2 OFFICE/UNIT/WORKER MAINTENANCE (PROGRAM AREA OR OFFICE,UNIT,WORKER OPTIONAL) 3 OFFICE/UNIT/WORKER DATA ENTRY (OFFICE,UNIT,WORKER OPTIONAL) 5 ADVOCATE MAINTENANCE (ADVOCATE NUMBER REQUIRED)



Screen WCN060 field explanations: DATE/TIME: The current Date and Time are displayed. INDICATE SELECTION NUMBER: Users enter one of the available functions displayed on the menu. ACTION (I/U): In this required field, users must enter either I (Inquiry) or U (Update). DISTRICT: The first 4 characters of the local district name are system-filled. PROGRAM AREA (PA, FS, MA, HP): If appropriate, users enter one of four program categories: PA – Public Assistance, FS – Food Stamps,

MA – Medical Assistance or HP – HEAP. OFFICE ID: If appropriate, users enter Office value for the record to be inquired or updated. UNIT ID: If appropriate, users enter Unit value for the record to be inquired or updated. WORKER ID: If appropriate, users enter Worker value for the record to be inquired or updated. ADVOCATE NUMBER: If appropriate, users enter Advocate Number value for the record to be inquired or updated. *See the following pages for explanations of each WCN060 menu selection.



WCN060 Menu Selection Descriptions/Instructions: 1) DISTRICT MAINTENANCE This function allows users to Inquire, Add, Change or Delete district-level contact data records.

Users may also enter Program Area, Office or Unit ID values. CNS screen WCN062 is displayed. Screen results, according to the ACTION field value entered, follow below:

‐WCN062 WMS/Client Notice Subsystem Date 11/02/06 DISTRICT MAINTENANCE SCREEN Time 14:46:16 DISTRICT WASH PROGRAM AREA OFFICE UNIT ACTION (A,C,D) NAME ____________________________ ADDRESS ___________________________________ ___________________________________ CITY _______________ STATE NY ZIP _____ DISTRICT Phone Numbers GENERAL ___ ___ ____ EXT. ____ CONFERENCE ___ ___ ____ EXT. ____ FAIR HEARINGS ___ ___ ____ EXT. ____ RECORD ACCESS ___ ___ ____ EXT. ____ CHILD/TEEN HEALTH ___ ___ ____ EXT. ____ FS RECERTIFICATION ___ ___ ____ EXT. ____ EMPLOYMENT ___ ___ ____ EXT. ____ FS REPAYMENT ___ ___ ____ EXT. ____ MA RECERTIFICATION ___ ___ ____ EXT. ____ Xmit _

WCN060 ACTION field = I: If the record exists, screen WCN062 is displayed with the name, address and phone number

information that corresponds to the entries made on WCN060. When the Menu key (SF-16) is depressed, screen WCN060 is returned with the bottom-screen message:

‘DISTRICT RECORD HAS BEEN SUCCESSFULLY INQUIRED’ If the record does not exist, the message “District record NOT found” is displayed on the

bottom of screen WCN060. WCN060 ACTION field = U: If the record does NOT already exist, a blank WCN062 screen is displayed with the

corresponding Program Area, Office-Unit entries made on screen WCN060. Required data fields Name, Address, City, Zip and Phone Number(s) are blank. The WCN062 ACTION field will be system-filled with an ‘A’ (ADD).

Users must enter the NAME, ADDRESS, CITY, ZIP and the GENERAL through CHILD/TEEN

HEALTH PHONE NUMBERS. If any of these entries are left blank, the field will blink and users will receive a “Required field missing” message at the bottom of screen WCN062.

After an error-free transmission, screen WCN064 (Office/Unit/Worker Data Entry) is returned

with the OFC (Office) field system-filled with the value entered on WCN060. The message: “DISTRICT RECORD HAS BEEN SUCCESSFULLY ENTERED” appears at the bottom of screen WCN064.



If the record does already exist, screen WCN062 is displayed with the Name, Address, City, Zip and Phone Numbers previously entered. The ACTION field is initially blank-filled and requires an entry of ‘C’ (Change) or ‘D’ (Delete); the menu key (SF-16) may also be depressed.

If the Menu key (SF-16) is depressed, the user is returned to the WCN060 menu screen with the

following bottom-screen message: ‘UPDATE OF DISTRICT RECORD HAS BEEN ABORTED’.

If a ‘C’ (Change) is entered into the Action field, any modifications the user makes to the district

record will be effective immediately after transmitting. Users are returned to the WCN060 menu screen with the following bottom-screen message:

‘DISTRICT RECORD HAS BEEN SUCCESSFULLY CHANGED’. If a ‘D’ (Delete) is entered into the Action field, users are returned to the WCN060 menu screen

with the following bottom-screen message: ‘DISTRICT RECORD HAS BEEN SUCCESSFULLY DELETED’.

After this action, this district record is no longer available for inquiry or modification. 2) OFFICE/UNIT/WORKER MAINTENANCE This function allows users to Inquire, Add, Change or Delete worker-level contact data records.

Users may optionally enter Program Area, Office, Unit or Worker ID values. CNS screen WCN063 is displayed. Screen results, according to the ACTION field value entered, follow below:

‐WCN063 WMS/Client Notice Subsystem Date / / Office/Unit/Worker Maintenance Screen Time : : DISTRICT PROGRAM AREA OFFICE ID UNIT ID WORKER ID ACTION (A,C,D) PHONE NUMBER ___ ___ ____ EXT. ____ NAME ____________________________ Xmit _

WCN060 ACTION field = I: If the record exists, screen WCN063 is displayed with the name and phone number information

that corresponds to the entries made on WCN060. When the Menu key (SF-16) is depressed, screen WCN060 is returned with the bottom-screen message: ‘OFFICE/UNIT/WORKER RECORD HAS BEEN SUCCESSFULLY INQUIRED’

If the record does not exist, the message ‘OFFICE/UNIT/WORKER record NOT found’ is

displayed on the bottom of screen WCN060.



WCN060 ACTION field = U: If the record does NOT already exist, a blank screen WCN063 is displayed with the

corresponding Program Area, Office-Unit-Worker entries made on screen WCN060. Required data fields Name, and Phone Number(s) are blank. The WCN063 ACTION field will be system-filled with an ‘A’ (ADD).

Users must enter the NAME and the PHONE NUMBER. If either of these entries is left blank,

the field will blink and users will receive a ‘Required field missing’ message at the bottom of screen WCN063. The Phone Extension field (EXT.) is an optional entry.

After an error-free transmission, screen WCN060 (Data Maintenance Menu) is returned with the

bottom-screen message: ‘OFFICE/UNIT/WORKER RECORD HAS BEEN SUCCESSFULLY ENTERED’.

If the record does already exist, screen WCN063 is displayed with the Name and Phone Number

previously entered. The ACTION field is initially blank-filled and requires an entry of ‘C’ (Change) or ‘D’ (Delete); the menu key (SF-16) may also be depressed.


following bottom-screen message: ‘UPDATE OF OFFICE/UNIT/WORKER RECORD HAS BEEN ABORTED’.

If a ‘C’ (Change) is entered into the Action field, any modifications the user makes to the Office-

Unit-Worker record will be effective immediately after transmitting. Users are returned to the WCN060 menu screen with the following bottom-screen message: ‘OFFICE/UNIT/WORKER RECORD HAS BEEN SUCCESSFULLY CHANGED’.

If a ‘D’ (Delete) is entered into the Action field, users are returned to the WCN060 menu screen

with the following bottom-screen message: ‘OFFICE/UNIT/WORKER RECORD HAS BEEN SUCCESSFULLY DELETED’.

This record is no longer available for inquiry or modification. 3) OFFICE/UNIT/WORKER DATA ENTRY This function allows users to Add up to 17 worker-level contact data records at one time. Users

may only enter Action Code ‘U’. If screen WCN060 is transmitted with an ‘I’ in the Action code, the following error message is displayed at the bottom of the screen:

‘Invalid Action code - Must be "U" (Update) for this Selection’. When ‘U’ is properly entered, CNS screen WCN064 is displayed.



‐WCN064 WMS/Client Notice Subsystem Date / / Office/Unit/Worker Data Entry Screen Time : : DISTRICT OFC UNIT WORKER NAME PHONE NUMBER EXT. ___ _____ _____ ____________________________ ___ ___ ____ ____ ___ _____ _____ ____________________________ ___ ___ ____ ____ ___ _____ _____ ____________________________ ___ ___ ____ ____ ___ _____ _____ ____________________________ ___ ___ ____ ____ ___ _____ _____ ____________________________ ___ ___ ____ ____ ___ _____ _____ ____________________________ ___ ___ ____ ____ ___ _____ _____ ____________________________ ___ ___ ____ ____ ___ _____ _____ ____________________________ ___ ___ ____ ____ ___ _____ _____ ____________________________ ___ ___ ____ ____ ___ _____ _____ ____________________________ ___ ___ ____ ____ ___ _____ _____ ____________________________ ___ ___ ____ ____ ___ _____ _____ ____________________________ ___ ___ ____ ____ ___ _____ _____ ____________________________ ___ ___ ____ ____ ___ _____ _____ ____________________________ ___ ___ ____ ____ ___ _____ _____ ____________________________ ___ ___ ____ ____ ___ _____ _____ ____________________________ ___ ___ ____ ____ ___ _____ _____ ____________________________ ___ ___ ____ ____ CONTINUE (Y/N) N Xmit _

Users then enter Office-Unit-Worker combinations and their corresponding Name and Phone

Number information. After transmitting, users are returned to the WCN060 screen with the following bottom-screen message displayed:

‘ENTRY OF OFFICE/UNIT/WORKER RECORD(S) COMPLETED’ If users change the Continue Indicator to ‘Y’ before transmitting, another blank WCN064 screen

is presented for further entry. DEFAULT RECORDS: As stated in this section’s introduction, in order to prevent errors during notice processing,

districts should establish default contact records. A DISTRICT DEFAULT record is created by indicating Selection Number 1 and Action = ‘U’.

The Program, Office and Unit ID fields are left BLANK. When the WCN062 screen appears, users should enter District Name, Address and Phone Number information for the most generic level of the agency. Default records may also be established for each of the Program Areas as well as each Office in the agency.

An OFFICE-UNIT-WORKER DEFAULT record is created by indicating Selection Number 2

and Action = ‘U’. Users then enter a value into any of the Program, Office or Unit fields or the Office and Unit ID fields with the remaining fields left BLANK. When the WCN063 screen appears, users enter the appropriate name and phone number information for the default level selected.



Contact Table Notice Hierarchies: CNS notice processing has a built-in hierarchy for determining what district address and phone

numbers will appear. A hierarchy is used as well to determine what unit/worker name and phone number is printed on a notice. The hierarchies are as follows:

DISTRICT – CNS first searches for (and will use on the notice) a record corresponding to the DISTRICT-

OFFICE-UNIT values associated with the case/notice. If this record is not found; then... CNS searches for (and will use on the notice) a record corresponding to the DISTRICT-

OFFICE values associated with the case/notice. If this record is not found; then... CNS searches for (and will use on the notice) a record corresponding to the PROGRAM

AREA value associated with the case. If this record is not found; then... CNS searches for (and will use on the notice) a record corresponding to the DISTRICT value

associated with the case. If this record is not found then the notice will NOT be produced and the case will be listed on a nightly CNS error report.

OFFICE-UNIT-WORKER – CNS first searches for (and will use on the notice) a record corresponding to the OFFICE-

UNIT-WORKER values associated with the case. If this record is not found; then... CNS searches for (and will use on the notice) a record corresponding to the OFFICE-UNIT

values associated with the case. If this record is not found; then... CNS searches for (and will use on the notice) a record corresponding to the OFFICE value

associated with the case. If this record is not found; then... CNS searches for (and will use on the notice) a record corresponding to the PROGRAM

AREA value associated with the case. If this record is not found; then... CNS searches for (and will use on the notice) a record corresponding to the DISTRICT value

associated with the case. If this record is not found then the notice will NOT be produced and the case will be listed on a nightly CNS error report.



5) ADVOCATE MAINTENANCE This function allows users to Inquire, Add, Change or Delete advocate contact data records.

Users are required to enter an Advocate Number. CNS screen WCN061 (Advocate Maintenance) is displayed. Screen results, according to the ACTION field value entered, follow below:

‐WCN061 WMS/Client Notice Subsystem Date / / Advocate Maintenance Screen Time : : ADVOCATE NUMBER ACTION (A,C,D) _ Page 1 of 1 NAME _____________________________________________________________ ADDRESS 1 ____________________________________ ADDRESS 2 ____________________________________ CITY ________________ STATE NY ZIP PHONE NUMBER ‐ ‐ DISTRICTS Advocate Serves _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ MORE DISTRICTS (Y/N) N * Served only by this Advocate Xmit _

WCN060 ACTION field = I: If the record exists, screen WCN061 is displayed with the advocate name, address and phone

number information that corresponds to the entry made on WCN060. The districts that the advocate serves are also listed. When the Menu key (SF-16) is depressed, screen WCN060 is returned with the bottom-screen message:

‘ADVOCATE RECORD HAS BEEN SUCCESSFULLY INQUIRED’ If the record does not exist, the message “Advocate record NOT found” is displayed on the

bottom of screen WCN060. WCN060 ACTION field = U: If the record does NOT already exist, a blank screen WCN061 is displayed with the

corresponding Advocate Number entry made on screen WCN060. Required data fields Name, Address, City, Zip and Phone Number are blank. The WCN061 ACTION field will be system-filled with an ‘A’ (ADD).

Users must enter the Advocate NAME, ADDRESS, CITY, ZIP and PHONE NUMBER. At the

bottom of the screen, users must also enter at least one District mnemonic (1st four characters) that the advocate serves.

If any of these entries are left blank, the field will blink and users will receive a ‘Required field

missing’ message at the bottom of screen WCN061. After an error-free transmission, screen WCN060 (Contact Data Maintenance Menu) is returned. The message:

‘ADVOCATE RECORD HAS BEEN SUCCESSFULLY ENTERED’ appears at the bottom

of screen WCN060.



If the record does already exist, screen WCN061 is displayed with the Name, Address, City, Zip, Phone Numbers and Districts Served previously entered. The ACTION field is initially blank-filled and requires an entry of ‘C’ (Change) or ‘D’ (Delete); the menu key (SF-16) may also be depressed.


following bottom-screen message: ‘UPDATE OF ADVOCATE RECORD HAS BEEN ABORTED’

If a ‘C’ (Change) is entered into the Action field, any modifications the user makes to the

advocate record will be effective immediately after transmitting. In order to remove a District Served, users must enter a ‘D’ next to the district mnemonic that the

advocate no longer serves. Upon transmitting, users are returned to the WCN060 menu screen with the following bottom-screen message:

’ADVOCATE RECORD HAS BEEN SUCCESSFULLY CHANGED’ If a ‘D’ (Delete) is entered into the Action field, users are returned to the WCN060 menu screen

with the following bottom-screen message: ‘ADVOCATE RECORD HAS BEEN SUCCESSFULLY DELETED’

This record is no longer available for inquiry or modification.

CLIENT NOTICES SYSTEM MANUAL CNS Section: O – NYC/Upstate Inquiry

Last Revised 3-25-08 Page O - 1

CNS Menu Selection 15 Users have the capability to search CNS notice history for notices sent by Upstate districts and New York City. Users may utilize one of five (5) different search criteria to view information about a specific notice or a complete list of notices that have been sent to a case or involved a particular individual. Transmitting from the WCN000 CNS Menu screen with Selection number 15 produces the WCN161 screen printed below:

‐WCN161 WMS/Client Notice Subsystem DATE 11/27/06 MATCHING REQUEST CRITERIA ENTRY SCREEN TIME 14:00:57 SEARCH BY: NOTICE NUMBER __________ CLIENT NUMBER ________ DISTRICT ____ CASE NUMBER __________ DISTRICT ____ SUFFIX __ (FOR NYC ONLY) (0 WILL LIST ALL THE NOTICES) SOC SEC NUMB ___ __ ____ DISTRICT ____ NAME LAST _________________ FIRST __________ MI _ SEX _ DISTRICT ____ OPTIONAL NAME SEARCH CRITERIA: BIRTH DATE __ __ ____ N RANGE CHECK (Y/N) MM DD YYYY 1 YEAR TRANSACTION HISTORY (Y/N) Y XMIT _

Users may select only one of the five WCN161 screen criteria for a search. A search can be initiated using one of following:

1. CNS Notice Number 2. Client ID Number (CIN) and District 3. Case Number and District 4. Client's Social Security Number and District 5. Client Name, Sex and District

Each of the WCN161 screen search options are explained on the following pages.



1) NOTICE NUMBER: Enter the Notice Number and transmit. The Client Notice Detail screen (WCN164) is returned. This

screen is a facsimile of CNS inquiry screen WCN052 (explained in Section M).

‐WCN161 WMS/Client Notice Subsystem DATE 11/28/06 MATCHING REQUEST CRITERIA ENTRY SCREEN TIME 11:24:26 SEARCH BY: NOTICE NUMBER U5300S4467 CLIENT NUMBER ________ DISTRICT ____ CASE NUMBER __________ DISTRICT ____ SUFFIX __ (FOR NYC ONLY) (0 WILL LIST ALL THE NOTICES) SOC SEC NUMB ___ __ ____ DISTRICT ____ NAME LAST _________________ FIRST __________ MI _ SEX _ DISTRICT ____ OPTIONAL NAME SEARCH CRITERIA: BIRTH DATE __ __ ____ N RANGE CHECK (Y/N) MM DD YYYY 1 YEAR TRANSACTION HISTORY (Y/N) Y XMIT _

The screen above is transmitted...

‐WCN164 WMS/Client Notice Subsystem Date 11/28/06 Client notice detail screen Time 11:28:07 Notice # U5300S4467 Page 1 of 1 CASE # C0117A30 DIST WASH TRANS 02 STATUS OPENING NAME C0117A30 O/U/W MAIL 10/06/06 ADDR AUTH NO 00137018 HEARING # CITY ST ZIP ‐ ASSC 1 ASSC 3 ASSC 2 ASSC 4 ENG/SPN S NOT IND ONLINE N PUBLIC ASSISTANCE FOOD STAMPS MEDICAL ASSISTANCE CASE ACTION OP REASON CODES A30 APPRVL: SAME EFFECTIVE DATE BUDGET VERSION IND CIN AX99388B IND CIN IND CIN IND CIN EFF DATE 00/00/00 EFF DATE EFF DATE EFF DATE PA ___ ___ ___ PA PA PA FS ___ ___ ___ FS FS FS MA ___ ___ ___ MA MA MA Notice Reprint _ Xmit _



2) CLIENT NUMBER & DISTRICT: Users enter the CIN and District mnemonic (1st 4 letters) and transmit. The CNS POSSIBLE

MATCHED WITHIN DISTRICT screen (WNC163) is returned.

‐WCN161 WMS/Client Notice Subsystem DATE 11/28/06 MATCHING REQUEST CRITERIA ENTRY SCREEN TIME 14:19:28 SEARCH BY: NOTICE NUMBER __________ CLIENT NUMBER AX99176C DISTRICT WASH CASE NUMBER __________ DISTRICT ____ SUFFIX __ (FOR NYC ONLY) (0 WILL LIST ALL THE NOTICES) SOC SEC NUMB ___ __ ____ DISTRICT ____ NAME LAST _________________ FIRST __________ MI _ SEX _ DISTRICT ____ OPTIONAL NAME SEARCH CRITERIA: BIRTH DATE __ __ ____ N RANGE CHECK (Y/N) MM DD YYYY 1 YEAR TRANSACTION HISTORY (Y/N) Y XMIT _

The screen above is transmitted to provide a list of case numbers in which the client was noticed for the district entered on screen WCN161 (WASH). *Please notice in this example, there are two different case numbers.

‐WCN163 WMS/Client Notice Subsystem DATE 11/28/06 POSSIBLE MATCHED WITHIN DISTRICT OF WASH TIME 14:23:19 N SEARCH NAME ‐ PAGE 01 OF 01 T OTH CASE NAME CASE NUM CIN SSN SEX DOB C NAM FIRST MI LAST _ ADDLN50928 Z005F LN5Z005F 53 AX99176C ‐ ‐ M 06/22/75 _ ADDLN50928 Z005F Z005F 53 AX99176C ‐ ‐ M 06/22/75 XMIT _



A list of notices in which the client was involved is produced by placing an ‘X’ on the line corresponding to the case number desired...

‐WCN163 WMS/Client Notice Subsystem DATE 11/28/06 POSSIBLE MATCHED WITHIN DISTRICT OF WASH TIME 14:23:19 N SEARCH NAME ‐ BLOCK PAGE 01 OF 01 T OTH CASE NAME CASE NUM CIN SSN SEX DOB C NAM FIRST MI LAST _ ADDLN50928 Z005F LN5Z005F 53 AX99176C ‐ ‐ M 06/22/75 X ADDLN50928 Z005F Z005F 53 AX99176C ‐ ‐ M 06/22/75 XMIT _

List screen WCN162 is produced when the screen above is transmitted...

‐WCN162 WMS/Client Notice Subsystem DATE 11/28/06 CLIENT NOTICE LIST SCREEN TIME 14:47:23 CASE # Z005F DIST WASH PAGE 01 OF 06 NAME Z005F TYPE NPA‐FS STATUS ACTIVE OFFICE UNIT WORKER Z R D NOTICE # FAIR HEAR # MAIL DT TRANS TYPE AUTH # AFFECTED IND P T PA ACTION EFF DT FS ACTION EFF DT MA ACTION EFF DT _ _ U5300S5800 11/28/06 05 CHANGE 00137191 AX75280S * B20‐NEW BGT AUT 01/01/07 _ _ U5300S4859 10/13/06 06 RECERT 00137098 AX75280S * B33‐RECRT: CAT 10/01/06 _ _ U5300S4772 10/12/06 06 RECERT 00137063 AX75280S * B91‐RECERT: GHS 10/01/06 _ _ U5300S4378 09/28/06 05 CHANGE 00136991 AX75280S * B20‐NEW BGT AUT 10/01/06 _ _ U5300S4024 09/22/06 05 CHANGE 00136919 AX75280S * B20‐NEW BGT AUT 10/01/06 XMIT _

Details of a particular notice may be reviewed by placing an ‘X’ next to the notice desired and transmitting...



‐WCN162 WMS/Client Notice Subsystem DATE 11/28/06 CLIENT NOTICE LIST SCREEN TIME 14:47:23 CASE # Z005F DIST WASH PAGE 01 OF 06 NAME Z005F TYPE NPA‐FS STATUS ACTIVE OFFICE UNIT WORKER Z R D NOTICE # FAIR HEAR # MAIL DT TRANS TYPE AUTH # AFFECTED IND P T PA ACTION EFF DT FS ACTION EFF DT MA ACTION EFF DT _ _ U5300S5800 11/28/06 05 CHANGE 00137191 AX75280S * B20‐NEW BGT AUT 01/01/07 _ X U5300S4859 10/13/06 06 RECERT 00137098 AX75280S * B33‐RECRT: CAT 10/01/06 _ _ U5300S4772 10/12/06 06 RECERT 00137063 AX75280S * B91‐RECERT: GHS 10/01/06 _ _ U5300S4378 09/28/06 05 CHANGE 00136991 AX75280S * B20‐NEW BGT AUT 10/01/06 _ _ U5300S4024 09/22/06 05 CHANGE 00136919 AX75280S * B20‐NEW BGT AUT 10/01/06 XMIT _

When the screen above is transmitted, the following screen is displayed...

‐WCN164 WMS/Client Notice Subsystem Date 11/29/06 Client notice detail screen Time 11:31:59 Notice # U5300S4859 Page 1 of 2 CASE # Z005F DIST WASH TRANS 06 STATUS RECERT NAME Z005F O/U/W MAIL 10/13/06 ADDR AUTH NO 00137098 HEARING # CITY ST ZIP ‐ ASSC 1 ASSC 3 ASSC 2 ASSC 4 ENG/SPN S NOT IND ONLINE N PUBLIC ASSISTANCE FOOD STAMPS MEDICAL ASSISTANCE CASE ACTION RT REASON CODES B33 RECRT: CAT 0 EFFECTIVE DATE 10/01/06 BUDGET VERSION IND CIN AX75280S IND CIN AX98779M IND CIN AX98780B IND CIN AX99175E EFF DATE 00/00/00 EFF DATE 00/00/00 EFF DATE 00/00/00 EFF DATE 00/00/00 PA ___ ___ ___ PA ___ ___ ___ PA ___ ___ ___ PA ___ ___ ___ FS ___ ___ ___ FS ___ ___ ___ FS ___ ___ ___ FS ___ ___ ___ MA ___ ___ ___ MA ___ ___ ___ MA ___ ___ ___ MA ___ ___ ___ Notice Reprint _ Xmit _



3) CASE NUMBER & DISTRICT: Users enter the Case Number and District mnemonic (1st 4 letters) and transmit. The CLIENT

NOTICE LIST SCREEN (WCN162, described above) is returned. This is a facsimile of CNS Inquiry screen WCN051.

Users may enter SUFFIX for NYC only (entry of a 0 in this field will list all notices). One of the following may be entered in the DISTRICT FIELD: NYC, UPS (upstate) or a valid 4

character district mnemonic. 4) SOC SEC NUMB (Social Security Number) and DISTRICT Users enter the Social Security Number and District mnemonic (1st 4 letters) and transmit. The CNS

POSSIBLE MATCHED WITHIN DISTRICT screen (WNC163) is returned. The progression of screens is identical to CIN entry described above.

5) CLIENT NAME, SEX and DISTRICT Users enter Name, Sex and District mnemonic (1st 4 letters) and transmit. The POSSIBLE

MATCHED WITHIN DISTRICT SCREEN - WCN163 is returned. The progression of screens is identical to CIN entry described above.

The following may also be entered as part of a NAME search: Birth Date Range Check The default entry “N” requests a search for exact matches only. An entry of “Y” requests a birth

year range of plus (+) or minus (-) 1 year. Individuals with Birth dates one year prior to through one year later than the date entered are displayed.

Transaction History Range Check The default entry of “Y” selects individuals who have had system activity in the last year. An

entry of “N” requests all individuals. SPECIAL INSTRUCTIONS & FUNCTION KEYS for CNS Screens WCN161 - 4 On Line 3 (middle-right) of the CNS POSSIBLE MATCHED WITHIN DISTRICT screen (WNC163) is a field labeled BLOCK. This is only displayed when there are more than 153 possible matches. When this condition is true, match data is displayed in blocks. Each block contains six screens. On the first screen returned, this field will display a 1 and the Page number will be 1 of 6. Special Function key SF-4 allows users to toggle between blocks. Workers may use Special Function key SF-4 to return to the Client Notice List Screen (WCN162) from the Client Notice Detail Screen (WCN164). Workers may also use SF-4 to return to the Possible Matched within District Screen (WCN163) from the Client Notice List Screen (WCN162). Workers may use Special Function key SF-15 from the Possible Match, Notice List, or Notice Detail screens to return to the Matching Request Criteria Entry Screen (WCN161) with the original search criteria displayed.

CLIENT NOTICES SYSTEM MANUAL CNS Section: P – Specialized Input Screens

Last Revised 3-25-08 Page P - 1

Many of the reason codes associated with actions taken on a case/application collect data so varied that the use of the generic CNS notice input screen (WCN012) is not practical. For these reason codes, specialized data collection screens have been created. The index on the following pages divides these screens by program category and reason code. Screen examples and instructions are provided.

CLIENT NOTICES SYSTEM MANUAL CNS Section: P – Specialized Input Screens - Index


Specialized Input Screen INDEX TEMPORARY ASSISTANCE

CASE REASON CODE

SCREEN

TITLE

PAGE

R15 WCN119 Restriction Starts/Ends/Denied P 4-5

R16 WCN107 Shelter Supplement Denied/Ends P 6-7

R20/R30/R40 WCN118 Recoupment Starts/Pended/Closed/Closing Cases P 8-10

R50 WCN023 TA Work Requirements Determination P 11-14

R70 WCN026 Client Share of Temporary Housing Cost P 15

R71 WCN024 WCN025

Ineligible for Temporary Housing Assistance P 16-17

U40-4, U16 WCN018 PA/FS Resource Calculation P 18-19

V20-5 WCN170

WCN171

PA Fail to Verify Selection Entry

PA Fail to Verify Variable Entry

P 20

P 21-22

INDIV REASON CODE

SCREEN

TITLE

PAGE

V30 WCN050 PA Failure to Comply with IV-D Data Entry P 23

W40 WCN172 Failure/Refusal to Become Employable – Detail P 24-25

WE1-3 WCN150 WCN151

PA/FS Employment Reason Entry PA/FS Employment Worker Entry

P 26 P 27-28

WP1-8 WCN116 PA Intentional Program Violation Data Entry P 29-30 WS1-8

CLIENT NOTICES SYSTEM MANUAL CNS Section: P – Specialized Input Screens - Index


Specialized Input Screen INDEX FOOD STAMPS

CASE REASON CODE

SCREEN

TITLE

PAGE

R21-9 WCN013 WCN031

FS Claim Data Collection FS Overpayment Calculation

P 31-34 P 35-36

R39 WCN112 FS Claim Compromise – Repayment Agreement Acknowledgment

P 37-38

UI6, U40-1, U44-5, U97

WCN018 PA/FS Resource Calculation P 39

V19, V21 WCN120 WCN121

FS Fail to Verify Selection Entry FS Fail to Verify Variable Entry

P 40 P 41-42

INDIV REASON CODE

SCREEN

TITLE

PAGE

WE1-3 WCN150 WCN151

PA/FS Employment Reason Entry PA/FS Employment Work Entry

P 43

WF1-3 WCN110 FS IPV Disqualification Reason Entry P 44-45 HEAP

CASE REASON CODE

SCREEN

TITLE

PAGE

M03 WCN041 HEAP HH Resides in Ineligible Living Situation P 46

M04 WCN042 HEAP Emergency Denial P 47 MEDICAL ASSISTANCE

PLEASE SEE CNS MANUAL APPENDIX

CLIENT NOTICES SYSTEM MANUAL CNS Section: P – Specialized Input Screens – WCN119


WCN119 The R15 reason code/WCN119 screen is used to explain why a particular TA budget item is, is not, or is no longer, being restricted. Users must indicate both the action and the reason for the action for each budget item that is being restricted. One action and one reason are entered per item, although it is possible to indicate one action for a given item and another action for a different item on the same screen.

‐WCN119 WMS/Client Notice Subsystem Date 12/06/06 PA Restrictions Data Collection Time 13:28:21 CASE NAME Z001P CASE REASON R15 : RESTRICTION CASE NO Z001P ACTION VOLUN AGENCY CASH ALLOW/ NO $$ NOT (B,E,D) ITEM ‐TARY DECISION MISM'T AMOUNT BILLED EXPENSE IN BGT _ SHELTER _ _ _ _ _ _ HEATING _ _ _ _ _ _ _ UTILITIES _ _ _ _ _ _ _ WATER _ _ _ _ _ OTHER _ _ _ ______ _ _ CD __ SERVICE _________________ VENDOR ____________________ _ OTHER _ _ _ ______ _ _ CD __ SERVICE _________________ VENDOR ____________________ Xmit _

The WCN119 screen is explained below: DATE MM/DD/YY Today's date is computer generated. TIME HH:MM:SS The current time is computer generated. CASE NAME Appears as entered on WMS. REG/CASE NO Appears as entered on the CNS menu (WCN000). CASE REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. ACTION (Begin “B”, Deny “D” or End “E”)



(Restriction Reasons) Users must indicate with an ‘X’ whether the reason for the restriction is: Voluntary, Agency

Decision, Cash Mismanagement, client No longer has the Expense, or there is Not enough money In the Budget to cover the expense. Only one selection for any given budget item is allowed.

For the “Other’ allowances users must also:

• Provide either the Other Allowance code (CD) that had been entered on the stored ABEL budget or a description of the SERVICE for which part of the grant is being restricted.

• Provide the AMOUNT of the grant that is being restricted.

• Provide the VENDOR name.

If the worker needs to only explain the denial of a request that one or more items be restricted, the R15 reason code may be used with a “00” transaction type on CNS. In this situation, an abbreviated version of the PA Restrictions Denial Entry screen (WCN119) is presented. Only the “$$ NOT IN BGT” field is presented, since this is the only valid reason for denial of a restriction request. No action code is necessary. Please see the following example:

‐WCN119 WMS/Client Notice Subsystem Date 12/07/06 PA Restrictions Denial Entry Time 09:38:36 CASE NAME Z001P CASE REASON R15 : RESTRICTION CASE NO Z001P $$ NOT ITEM IN BGT SHELTER _ HEATING _ UTILITIES _ WATER _ OTHER _ SERVICE _________________ OTHER _ SERVICE _________________ Xmit _



WCN107 If the district participates in the Shelter Supplement program, the following screen is displayed:

‐WCN107 WMS/Client Notice Subsystem Date 12/07/06 Shelter Supplement Decision and Reason Entry Screen Time 10:50:50 CASE NAME Z028P CASE NO Z028P CASE REASON R16 : SHELT SUPLMT Decision: _ Shelter Supplement is denied. _ Shelter Supplement is ending effective ______. Reason: _ District does not participate in shelter supplement program. _ No dependent child in case or in care of case member. _ Sanctioned individual in household. _ Living arrangement does not qualify for shelter supplement. (Subsidized or public housing) _ Client would not agree to restrict supplement. _ Household does not meet district's plan criteria, as follows: * Homelessness * Danger of eviction Xmit _

The WCN107 screen is explained below: DATE MM/DD/YY Today's date is computer generated. TIME HH:MM:SS The current time is computer generated. CASE NAME Appears as entered on WMS. REG/CASE NO Appears as entered on the CNS menu (WCN000). CASE REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. DECISION Users must select one (and only one) of the decision options by placing an ‘X’ to the left of their

choice. If the “ending” option is selected, users are required to provide the date. REASON Users must select at least one reason for the decision, but may select as many that apply to the

situation. Following the last option, each districts’ plan criteria are listed preceded by asterisks (*).



If the district does not participate in the Shelter Supplement program, the following abbreviated WCN107 screen below is displayed. The same Decision/Reason requirements described above are applied.

‐WCN107 WMS/Client Notice Subsystem Date 12/07/06 Shelter Supplement Decision and Reason Entry Screen Time 09:48:10 CASE NAME MZ‐01 CASE NO MZ‐01 CASE REASON R16 : SHELT SUPLMT Decision: _ Shelter Supplement is denied. _ Shelter Supplement is ending effective ______. Reason: _ District does not participate in shelter supplement program. Xmit _



WCN118

‐WCN118 WMS/Client Notice Subsystem Date 12/07/06 PA Recoupment Data Collection Time 13:48:12 CASE NAME Z001P CASE REASON R20 : START RECOUP CASE NO Z001P Recoupment Type: _ Overpayment: Period: From MMYY ____ To MMYY ____ Amount: ________ Transfer Balance: Period: From MMYY ____ To MMYY ____ Amount: ________ Underpayment (Offset): Period: From MMYY ____ To MMYY ____ Amount: ________ If transfer, LN of resp indv: __. Bal Correction: _ Already Paid: ________ If recoupment for former county of residence, enter LN __ and District Code __ Overpayment Reasons: Income not counted: _ No timely report: _ Decreased needs (Amounts less than budgeted): Shelter _ Fuel _ Water _ Additional allowance type(s) incorrectly received: __ __ __ Indv(s) incorrectly included in case: ___________________________________ Resources more than limit: _ Real prop sold: _ Fair Hearing lost (A/C): _ Reason for action: _______________________________________________________ _______________________________________________________ Reconciliation(s): Fuel _ Non‐heat _ Combined _ Restricted Amount: ________ ________ ________ Amt paid by dist: ________ ________ ________ Xmit _

The WCN118 screen is explained below: DATE MM/DD/YY Today's date is computer generated. TIME HH:MM:SS The current time is computer generated. CASE NAME Appears as entered on WMS. REG/CASE NO Appears as entered on the CNS menu (WCN000). CASE REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. Recoupment Type: A required entry. This corresponds to the 1-6 recoupment type value entered on the stored ABEL

TA budget. Overpayment Period: A required entry. This corresponds to the FROM and TO date associated with the overpayment.

These entries are made in a Month/Year (MMYY) format. Overpayment Amount:



A required entry. This is the overpayment amount. Transfer Balance Period: An optional entry. This corresponds to the FROM and TO date associated with a previous

overpayment that is being transferred to this case. These entries are made in a Month/Year (MMYY) format.

Transfer Balance Amount: An optional entry. This is the amount associated with the transferred overpayment. Underpayment (Offset) Period: An optional entry. This is the FROM and TO date associated with a case underpayment that is

being used to offset part of the overpayment. These entries are made in a Month/Year (MMYY) format.

Underpayment (Offset) Amount: An optional entry. This is the amount of the underpayment. If transfer, LN of resp indv: A required entry if the Transfer Balance Amount is greater than zero. This is the Line Number of

the individual in the case to which this overpayment transfer is attributed. Bal Correction: An ‘X’ is placed here if this notice describes an overpayment balance correction to a notice

previously issued. Already Paid: This is the amount a client may have already returned to the agency prior to notification or the

start of the recoupment. If recoupment for former county of residence... Enter LN Users should enter the Line Number of the individual in this case. District Code Users should enter the numeric District Code of the former county of residence. Overpayment Reasons: Users may optionally provide an overpayment reason. The following selections require the entry

of an ‘X’: Income not counted No timely report Decreased needs (Amounts less than budgeted): Shelter _ Fuel _ Water _ Resources more than limit Real prop sold Fair Hearing lost (A/C) The selection, Additional allowance type(s) incorrectly received requires the entry of the

ABEL Allowance Type code.



The selection, Indv(s) incorrectly included in case is a “free-form” field where users key in the Names of the individuals incorrectly included in the case.

Reason for action: Users may optionally enter an explanation for the recoupment action. Reconciliation(s): Used for Recoupment Type 3 (Advance Payment) only, users have three categories to choose

from: • Fuel • Non-Heat • Combined

Users indicate their choice by placing an ‘X’ to the right of the appropriate field (only one choice

is allowed).

If any category is selected, users must provide: Restricted Amount Amt paid by dist XMIT This is the transmit position.



WCN023 This screen was developed to produce notices of Temporary Assistance Work Requirements Determination, both exempt and nonexempt. Manual versions of these notices exist under the form designations LDSS-4005 and LDSS-4005(a), and are available on the Intelligent Auto-Fill Forms System (IAF).

‐WCN023 WMS/Client Notice Subsystem Date 12/08/06 TA Work Requirements Determination Data Entry Screen Time 10:44:40 CASE NAME Z001P CASE NO Z001P CASE REASON R50 : TAWORKREQDET Work requirements determination has been made for: ____________________________ Effective date of determination: ______ EXEMPT: NONEXEMPT: MEDICAL _ MEDICAL _ OTHER THAN MEDICAL * _ MEDICAL ‐ WORK LIMITED * _ OTHER THAN MEDICAL * _ * (Complete next screen) Xmit _

The WCN023 screen is explained below: DATE MM/DD/YY Today's date is computer generated. TIME HH:MM:SS The current time is computer generated. CASE NAME Appears as entered on WMS. CASE NO Appears as entered on the CNS menu (WCN000). CASE REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. Work requirements determination has been made for: Users are required to enter the Name of the “determination” individual in the space provided. Effective date of determination: Users are required to enter the effective Date of the determination in the space provided.



EXEMPT If an exempt determination has been made, users must select one the following reasons with an

‘X’: • Exempt due to medical reasons • Exempt due to a reason other than medical

NON-EXEMPT If a non-exempt determination has been made, users must select one of the following reasons with

an ‘X’: • Nonexempt due to medical reasons • Nonexempt but work limited due to medical reasons • Nonexempt due to a reason other than medical

XMIT This is the transmit position. If the reason for the determination is Medical Reasons (exempt or non-exempt), no further data entry is required, however, after transmitting, a “More individuals to enter? Y/N” field will appear to the left of the transmit position. This field is pre-filled with an ‘N’. If there are no additional individuals in the case to be noticed concerning work requirements determinations, transmission of the screen with an “N” will return the user to the CNS menu (WCN000) with a notice number creation message. If additional individuals in the case require this notification, transmission of the screen with a “Y” in this field will present another blank WCN023 screen for completion. If the reason indicated is EXEMPT - “Other Than Medical”, screen WCN023 will be re-presented to the user for an additional exemption reason indication (see example below).

‐WCN023 WMS/Client Notice Subsystem Date 12/08/06 TA Work Requirements Determination Data Entry Screen Time 10:53:42 CASE NAME Z001P CASE NO Z001P CASE REASON R50 : TAWORKREQDET Work requirements determination has been made for: MR A Z001P Effective date of determination: 120106 EXEMPT: NONEXEMPT: MEDICAL MEDICAL OTHER THAN MEDICAL X MEDICAL ‐ WORK LIMITED OTHER THAN MEDICAL EXEMPT OTHER THAN MEDICAL. Indicate (X) reason individual is exempt _ Pregnant and within 30 days of expected date of delivery _ Parent or caretaker of child under 3 months of age, personally providing care for the child and not already exempt for this reason for 12 months _ 60 years of age or older _ Under the age of 19 and attending secondary, vocational or technical school full‐time _ Needed in home to care for medically verified ill, incapacitated or disabled household member and no other household member is available More Individuals to enter? Y/N N Xmit _ ONE and Only ONE Reason must be selected



Additional screen explanations: EXEMPT OTHER THAN MEDICAL Users are required to select the non-medical reason why the individual has been determined to be

exempt from TA work requirements. Users must place an ‘X’ to the left of the appropriate choice (only one is allowed). The “More individuals to enter? Y/N” field (previously explained) also appears.

XMIT This is the transmit position. If the reason for the determination is NON-EXEMPT - “Work Limited”, screen WCN023 will be re-presented to the user to collect an additional explanation (see the following example).

‐WCN023 WMS/Client Notice Subsystem Date 12/08/06 TA Work Requirements Determination Data Entry Screen Time 11:41:28 CASE NAME Z001P CASE NO Z001P CASE REASON R50 : TAWORKREQDET Work requirements determination has been made for: MR A Z001P Effective date of determination: 120106 EXEMPT: NONEXEMPT: MEDICAL MEDICAL OTHER THAN MEDICAL MEDICAL ‐ WORK LIMITED X OTHER THAN MEDICAL NONEXEMPT MEDICAL ‐ WORK LIMITED. Individual must participate in work activities within medical limitations. Complete the sentence: This determination that you are not exempt but work‐limited is based on a determination by a doctor or other medical professional that... _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ More Individuals to enter? Y/N N Xmit _

Additional screen explanations: NONEXEMPT MEDICAL – WORK LIMITED Users must complete the lower portion of the screen to explain the nature of the medical

limitations that led to the determination. The “More individuals to enter? Y/N” field (previously explained) also appears.

XMIT This is the transmit position.



If the reason for the determination is NON-EXEMPT - “Other Than Medical”, screen WCN023 will be re-presented to the user to collect an additional explanation (see the following example).

‐WCN023 WMS/Client Notice Subsystem Date 12/08/06 TA Work Requirements Determination Data Entry Screen Time 11:42:50 CASE NAME Z001P CASE NO Z001P CASE REASON R50 : TAWORKREQDET Work requirements determination has been made for: MR A Z001P Effective date of determination: 120106 EXEMPT: NONEXEMPT: MEDICAL MEDICAL OTHER THAN MEDICAL MEDICAL ‐ WORK LIMITED OTHER THAN MEDICAL X NONEXEMPT OTHER THAN MEDICAL . Individual must participate in work activities. Complete the sentence: (Name) has been determined to be NON‐EXEMPT from participating in temporary assistance work activities and must participate in work activities because... _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ More Individuals to enter? Y/N N Xmit _

Additional screen explanations: NONEXEMPT – OTHER THAN MEDICAL Users must complete the lower portion of the screen to explain the determination and why the

individual must participate in work activities. The “More individuals to enter? Y/N” field (previously explained) also appears.




WCN026 TA CNS case reason code R70 (Client’s Share of Temporary Housing Costs), was created to provide an explanation to clients who live in a temporary housing situation (shelter types 06, 19, 21, 33 & 36) when the restricted shelter amount on the ABEL budget is less than the actual shelter amount. The corresponding CNS notice will explain that the client must pay his/her share of the cost of the temporary housing to the provider.

‐WCN026 WMS/Client Notice Subsystem Date 12/08/06 Client's Share of Temporary Housing Cost Input Screen Time 14:46:24 CASE NAME Z001P CASE NO Z001P CASE REASON R70 : SHARETHCOSTS Complete the statement below for Temporary Assistance case openings and undercare actions when the shelter type is equal to 06, 19, 21, 33 or 36 and the restricted shelter amount is less than actual shelter cost. "You must pay $______ monthly to the temporary housing provider. The payment must be made to ___________________________________ at the rate of $______ every _________." Xmit _

The WCN026 screen is explained below: DATE MM/DD/YY Today's date is computer generated. TIME HH:MM:SS The current time is computer generated. CASE NAME Appears as entered on WMS. CASE NO Appears as entered on the CNS menu (WCN000). CASE REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. *Users are required to fill in the blanks appearing at the bottom of the screen. In order, the blanks

correspond to: Monthly Amount, Provider Name, Payment Amount and Payment Frequency. XMIT This is the transmit position.

CLIENT NOTICES SYSTEM MANUAL CNS Section: P – Specialized Input Screens – WCN024 & WCN025


WCN024 & WCN025 TA case reason code R71 (Ineligible for Temporary Housing Assistance) was created to allow workers to send an explanation to clients who are ineligible for Temporary Housing Assistance (THA). When the WCN024 screen is transmitted, the WCN025 screen is presented to capture Independent Living Plan (ILP) information.

‐WCN024 WMS/Client Notice Subsystem Date 12/08/06 Temporary Housing Assistance Data Collection Screen Time 15:11:01 CASE NAME Z001P CASE NO Z001P CASE REASON R71 : INELIG THA Client ineligible for THA effective ______ Name(s) of individual(s) who failed to comply: _______________________________ Assessment Requirement: _ Client failed to keep assessment appointment on ______ _ Client failed to complete assessment process by providing necessary information/documentation. State information/documentation not provided: ____________________________________________________________________________ _ Other: ____________________________________________________________________ _ Client failed to pay share of cost of temporary housing _ Client engaged in violent or disruptive behavior ____________________________________________________________________________ _ Client failed to accept referral to (specify housing resource refused): ____________________________________________________________________________ _ Client failed to seek other housing by making __ contacts per _wk _mo (ILP ‐ Next Screen) Xmit _

‐WCN025 WMS/Client Notice Subsystem Date 12/08/06 Temporary Housing Assistance Data Collection Screen Time 15:23:40 CASE NAME Z001P CASE NO Z001P CASE REASON R71 : INELIG THA Independent Living Plan (ILP): _ Client failed to develop ILP _ Client failed to cooperate with requirements of ILP _ First Instance _ Second or greater instance Directly quote the requirement(s) from the ILP that the client failed to meet: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Xmit _



Screens WCN024 and WCN025 are explained below: DATE MM/DD/YY Today's date is computer generated. TIME HH:MM:SS The current time is computer generated. CASE NAME Appears as entered on WMS. CASE NO Appears as entered on the CNS menu (WCN000). CASE REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. THA ineligible effective (Date) This is a required entry in the format MMDDYY. Name(s) If the household contains multiple individuals, the name(s) of the individual(s) who have failed to

comply with THA requirements must be entered. *Note: this field is not presented for 1-person cases.

Client action(s) that caused ineligibility for THA:

• At least one selection must be made on either screen. Some combinations of multiple selections are allowed, while inappropriate combinations will produce error messages.

• Generally, most selections require additional data entry, such as dates or worker explanations. • If the client has failed to comply with his/her Independent Living Plan (ILP), only the

effective date, and possibly the name is required on screen WCN024. Details concerning failure to comply with the ILP must be provided on screen WCN025.

XMIT This is the transmit position. Independent Living Plan (ILP): Users may select either the Client failed to develop or the Client failed to cooperate option. If the Client failed to cooperate option is indicated, users must indicate whether it is the first or

greater instance of this failure and provide details from the ILP that the client failed to meet in the space provided.




WCN018 The Resource Calculation screen is used by both the TA and FS categories. The screen title changes between “PA” and “FS” depending on which category of reason code has been entered. Field explanations follow the screen example below.

‐WCN018 WMS/Client Notice Subsystem Date 04/16/07 FS Resource Calculation Screen Time 09:11:15 CASE NAME MR10W CASE NO MRB‐10W CASE REASON U41 : EX RSRC TSFR RESOURCE LIMIT _ $2000 _ $3000 NUMBER OF MONTHS INELIGIBLE __ ENTER LIST OF CLIENT RESOURCES : LN RSRC TFR WHAT WE NO CODE IND DESCRIPTION VALUE COUNT __ __ _ ____________________________________ ________ ________ __ __ _ ____________________________________ ________ ________ __ __ _ ____________________________________ ________ ________ __ __ _ ____________________________________ ________ ________ __ __ _ ____________________________________ ________ ________ __ __ _ ____________________________________ ________ ________ __ __ _ ____________________________________ ________ ________ __ __ _ ____________________________________ ________ ________ __ __ _ ____________________________________ ________ ________ __ __ _ ____________________________________ ________ ________ Xmit _

DATE Today's date is computer-generated. TIME The current time is computer-generated. CASE NAME Appears as entered on WMS. REG NO or CASE NO Appears as entered on the CNS menu (WCN000). CASE REASON or INDIV REASON Appears as entered on the WCN011 reason code entry screen, with its corresponding mnemonic. RESOURCE LIMIT Users must enter an "X" to the left of the appropriate resource limit for the household. NUMBER OF MONTHS INELIGIBILE For FS case reason code U41 (Transfer of Resources), enter the number of months the household will

be ineligible. ENTER LIST OF CLIENT RESOURCES



Users are required to enter the following resource information: 1) LN NO Users must enter the line number of the individual(s) owning the resource. If the resources are owned

by an alien sponsor enter "88" in this field. 2) RSRC CODE Users enter the appropriate resource code(s):

Code Resource 01 Cash on hand 02 Bank accounts 03 Stocks, bonds, securities *04 Promissory Notes *05 Mortgages 06 Trust Fund *09 Burial Reserve 11 Individual Development Account 22 Vehicle *86 Income Tax Refunds 87 Non-exempt Real Property *88 Cash Value of Life Insurance 99 Other Resources

* PA Case Types Only 3) TFR IND Appears only if reason code equals U41 (Transfer of Resources). Users must enter an "X" for each

resource transferred. *For PA cases, users should enter the date of the transfer in the "Description" field described below.

4) DESCRIPTION Users enter a brief description of the resource. For example, "Savings account #123456 at All

American Bank". 5) VALUE Users enter the value of the resource, including cents...for example if the value of the resource is four

thousand dollars, users should enter 400000. 6) WHAT WE COUNT Users enter that portion of the resource value that is counted for PA and/or FS. XMIT This is the transmit position. NOTE: For PA/FS cases closed or denied because of excess resources or transfer of resources, dual

data entry of the same information on the PA/FS Resource Calculation Screen (WCN018) is not required. Information entered on the screen for PA will be carried over when the screen reappears for FS. Only the "What We Count" information that applies to FS needs to be entered.



WCN170

‐WCN170 WMS/Client Notice Subsystem Date 12/04/06 PA Fail To Verify Selection Entry Screen Time 15:45:43 Case Name Z001P CASE No Z001P CASE Reason V20 : FL PROV VER Client Verification Provide by date: ______ Select ONE or MORE of the following: _ Identity _ Marital Status _ Residence _ Household Comp/Size _ Age _ Relationship _ SSN ‐ Non‐Applying LRR _ Citizenship _ Alien Status _ Wages _ Self‐Employment Income _ Rental Income _ Roomer Income _ Boarder Income _ Day Care Provider Income _ Child Support (NOT IV‐D) _ Unemployment Insurance Benefits (UIB) _ Social Security Benefits _ Veterans Benefits _ Interest/Dividends _ Workers Compensation _ Other Earned/Unearned Income _ Bank/Credit Union Accounts _ Stocks, Bonds, CDs _ Motor Vehicle: Ownership _ Motor Vehicle: Value _ Health Insurance Coverage _ Health Status/Disability _ Other Xmit _

The WCN170 screen is explained below: DATE MM/DD/YY TIME HH:MM:SS Today's date and the current time are computer generated. CASE NAME Appears as entered on WMS. REG/CASE NO Appears as entered on the CNS menu (WCN000). CASE REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. CLIENT VERIFICATION PROVIDE BY DATE Entry is required in this field. Enter the date (MMDDYY) by which the client was to provide the

verification. SELECT ONE OR MORE OF THE FOLLOWING At least one item must be selected. Users enter an "X" next to the item(s) that the client needs to

verify. If the items to be verified require the input of additional variable information, the "PA Fail to Verify Variable" Entry screen (WCN171) will appear when this screen is transmitted.




WCN171 When the items to be verified (as indicated on the WCN170 screen) require the input of variable information, the WCN171 screen will appear for each such item. The following illustration shows the required fields for the “WAGES” selection. The fields and prompts displayed will vary according to the selection made.

‐WCN171 WMS/Client Notice Subsystem Date 12/04/06 PA Fail To Verify Variable Entry Screen Time 15:46:41 CASE NAME Z001P CASE NO Z001P CASE REASON V20 : FL PROV VER CATEGORY SELECTED: WAGES LN NAME/VEHICLE TYPE 4WK DATE(S)/ACCOUNT TYPE __ ____________________________ _ _________________________________ __ ____________________________ _ _________________________________ __ ____________________________ _ _________________________________ __ ____________________________ _ _________________________________ __ ____________________________ _ _________________________________ __ ____________________________ _ _________________________________ __ ____________________________ _ _________________________________ ENTER LINE NUMBER OR NAME; 4WK OR DATES FOR EACH INDIVIDUAL Xmit _

The WCN171 screen explanation appears below: DATE MM/DD/YY TIME HH:MM:SS Today's date and the current time are computer generated. CASE NAME Appears as entered on WMS. REG NO or CASE NO Appears as entered on the CNS menu (WCN000). CASE REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. LINE NO Appears as entered on the Reason Code Entry Screen (WCN011). CATEGORY SELECTED The item that needs to be verified as indicated on the PA Fail to Verify Selection Entry screen

(WCN170).



The following are data items for this example, plus others that may appear depending on category: LN Enter the line number of the individual for whom the verification is needed. This is valid only for

individuals already in the case. If the verification is needed for a non-applying individual, enter the name in the "Name/Vehicle Type" field.

NAME/VEHICLE TYPE Enter the name of the individual for whom the verification is needed. If a motor vehicle needs to be

verified, enter the type of vehicle. 4WK Appears if category selected is income related. Enter an "X" if verification of four week income is

required. DATE(S)/ACCOUNT TYPE Appears if category selected is income or resource related. Enter the dates for which income

verification is needed. If verification of an account is needed, enter the account type. NOTE: An entry can only be made in either the "4WK" field OR the "Date(s)/Account Type" field.

Entries cannot be made in both fields. EI Appears if the category selected is "Other Earned/Unearned Income". Enter the appropriate ABEL

Earned Income Source code(s). UI Appears if the category selected is "Other Earned/Unearned Income". Enter the appropriate ABEL

Other/Unearned Income Source code(s). OTHER Appears if category selected is "Other". Enter other information that is required. PROMPT LINE Users will receive prompts to assist in entering the appropriate information. XMIT This is the transmit position. NOTE: Special Function key SF-15 may be used to return to the FTV selection entry screen (WCN170)

from the variable entry screen (WCN171). The WCN170 screen returned will show the previous selections. Users may add or delete selections and re-transmit. All appropriate detail screens are presented in order. Detail data previously provided for the current selections appears as previously entered.



WCN050

‐WCN050 WMS/Client Notice Subsystem Date 12/05/06 PA FAILURE TO COMPLY WITH IV‐D DATA ENTRY SCREEN Time 11:44:44 CASE NAME Z001P CASE NO Z001P INDV REASON V30 : FAIL IVD REQ LINE NO 01 DATE NON‐COMPLIANCE WAS DETERMINED BY CHILD SUPPORT ENFORCEMENT UNIT: ______ SELECT (X) ALL THAT APPLY. CLIENT FAILED TO: _ APPEAR FOR A CHILD SUPPORT INTERVIEW ON ______ _ PROVIDE REQUIRED INFORMATION OR ATTEST TO LACK OF INFORMATION AS FOLLOWS: _________________________________________________________________________ _________________________________________________________________________ _ APPEAR TO PARTICIPATE IN A COURT OR OTHER HEARING ON ______ _ SUBMIT SELF AND/OR CHILD TO GENETIC TESTING ON ______ _ PAY TO THE SUPPORT COLLECTION UNIT ASSIGNED SUPPORT PAYMENTS RECEIVED DIRECTLY _ OTHER ________________________________________________________________________ ________________________________________________________________________ IF CLAIMED, DESCRIBE WHY GOOD CAUSE IS BEING DENIED. COMPLETE THE SENTENCE: "WE DO NOT AGREE THAT THE REASON GIVEN FOR NON‐COMPLIANCE IS A GOOD REASON BECAUSE..."____________________________________________________________________ ____________________________________________________________________ Xmit _

The WCN050 screen explanation appears below: DATE MM/DD/YY TIME HH:MM:SS Today's date and the current time are computer generated. CASE NAME Appears as entered on WMS. REG / CASE NO Appears as entered on the CNS menu (WCN000) INDV REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. LINE NO Appears as entered on the Reason Code Entry Screen (WCN011). DATE NON-COMPLIANCE WAS DETERMINED BY CHILD SUPPORT ENFORCEMENT

UNIT: This is a required entry. Users must enter the non-compliance date in the format MMDDYY. SELECT (X) ALL THAT APPLY. CLIENT FAILED TO: Users may select all conditions that apply. All date entries are in the format MMDDYY and are

required if an ‘X’ is placed in the corresponding indicator. Explanations are also required if an ‘X’ is placed in the corresponding indicator.




WCN172

‐WCN172 WMS/Client Notice Subsystem Date 12/06/06 Failure/Refusal to Become Employable ‐Detail Entry Time 09:10:50 CASE NAME MZ‐01 CASE NO MZ‐01 INDV REASON W40 : FL BE EMPLOY LINE NO 01 (NAME) has not done what is needed to try to become employable. With the proper medical care, training or rehabilitation program, (NAME) might be able to work. (NAME) would not accept referral to, or take active part in... PLEASE SELECT (X) ONE ACTIVITY: _ MEDICAL CARE _ VOCATIONAL REHABILITATION OR TRAINING AT (SPECIFY PROGRAM NAME) _______________________________________________________________________ We told (NAME) what to do. (NAME) failed or refused to do so, and has not given us a good reason why. Xmit _

The WCN172 screen explanation appears below: DATE MM/DD/YY TIME HH:MM:SS Today's date and the current time are computer generated. CASE NAME Appears as entered on WMS. REG NO or CASE NO Appears as entered on the CNS menu (WCN000). INDV REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. LINE NO Appears as entered on the CNS Reason Code Entry screen (WCN011). (NAME) This is the WMS Name associated with the Line No entered on CNS WCN011. *Users must select either the Medical Care or Vocational Rehabilitation activity in which the individual did not take part. Only one activity may be chosen.



MEDICAL CARE Users enter an ‘X’ if appropriate. For example, a doctor has stated that the client could work if

he/she received some sort of medical treatment. VOCATIONAL REHABILITATION OR TRAINING AT (SPECIFY PROGRAM NAME) Users enter an ‘X’ if appropriate. The name of the program in which the individual refused to

participate is required with this option. XMIT This is the transmit position.



WCN150

‐WCN150 WMS/Client Notice Subsystem Date 12/06/06 PA and FS Employment Reason Entry Screen Time 09:37:47 CASE NAME MZ‐01 CASE NO MZ‐01 INDV REASON WE1 : FL CMP EMP‐1 LINE NO 01 EMPLOYMENT ACTIVITIES: _ FAILED TO KEEP/COMPLETE ASSESSMENT APPOINTMENT _ FAILED TO KEEP/COMPLETE AN EMPLOYMENT/WORK ACTIVITY APPOINTMENT _ FAILED TO GO TO AN EMPLOYMENT/WORK ACTIVITY ASSIGNMENT _ FAILED CONTINUATION OF EMPLOYMENT/WORK ACTIVITY ASSIGNMENT _ FAILED TO KEEP/COMPLETE JOB SEARCH APPOINTMENT _ FAILED TO COMPLETE JOB SEARCH _ FAILED TO GO TO JOB OPENING INTERVIEW _ FAILED TO TAKE A JOB _ FAILED TO PROVIDE A MEDICAL REPORT _ FAILED TO PROVIDE A MEDICAL REPORT (LIMITATIONS) _ FAILED TO KEEP/COMPLETE A MEDICAL EXAM APPOINTMENT _ FAILED TO KEEP/COMPLETE A MEDICAL EXAM APPOINTMENT (LIMITATIONS) FAILED TO WORK REGISTER FAILED TO PROVIDE EMPLOYMENT STATUS FAILED TO ACTIVELY SEEK EMPLOYMENT AND PROVIDE PROOF _ OTHER Xmit _

The WCN150 screen explanation appears below: DATE MM/DD/YY Today's date is computer-generated. TIME HH/MM/SS The current time is computer-generated. CASE NAME Appears as entered on WMS. REG/CASE NO Appears as entered on the CNS menu (WCN000). INDV REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. LINE NO Appears as entered on the CNS Reason Code Entry screen (WCN011). EMPLOYMENT ACTIVITIES Users enter an ‘X’ to the left of the activity or activities the recipient/applicant failed to perform.

Multiple activities which will result in a single sanction are allowed. XMIT This is the transmit position.



WCN151 After the WCN150 screen (PA and FS Employment Reason Entry) is transmitted, the WCN151 screen (PA and FS Employment Worker Entry) appears for each activity selected that requires worker fill. For TA case types, after the last activity data has been collected, WCN151 is presented one final time for completion of the TA employment conciliation section. The following example shows the data collection fields and prompts required for the ‘FAILED TO KEEP/COMPLETE AN EMPLOYMENT/TRAINING APPOINTMENT’ activity. This screen changes dynamically, presenting data collection fields and prompts dependent on the activity selected.

‐WCN151 WMS/Client Notice Subsystem Date 12/06/06 PA and FS Employment Worker Entry Screen Time 09:50:12 CASE NAME MZ‐01 CASE NO MZ‐01 INDV REASON WE1 : FL CMP EMP‐1 LINE NO 01 SELECTION: FAILED TO KEEP/COMPLETE AN EMPLOYMENT/TRAINING APPOINTMENT DATE ______ INFO _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ ENTER DATE: APPOINTMENT DATE ENTER INFO: APPOINTMENT LOCATION Xmit _

The two different WCN151 screen explanations appear below:

DATE Today's date is computer-generated. TIME The current time is computer-generated. CASE NAME Appears as entered on WMS. REG NO or CASE NO Appears as entered on the CNS menu (WCN000). INDV REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. LINE NO Appears as entered on the CNS Reason Code Entry screen (WCN011).



SELECTION The title of the activity selected from the WCN150 screen is presented. (Data Collection fields) The data collection fields are presented depending on the activity selected. (Prompts) Users will receive prompts to assist in entering the appropriate information. XMIT This is the transmit position. For TA case types, after the last activity data has been collected, WCN151 is presented one final time for completion of the TA employment conciliation section. Users are required to indicate one of the three (3) options presented by placing an ‘X’ to the left of the appropriate selection. If the second option is indicated, users are required to also provide a date in the MMDDYY format.

‐WCN151 WMS/Client Notice Subsystem Date 12/06/06 PA and FS Employment Worker Entry Screen Time 09:54:47 CASE NAME MZ‐01 CASE NO MZ‐01 INDV REASON WE1 : FL CMP EMP‐1 LINE NO 01 CHOOSE ONE OF THE FOLLOWING CONCILIATION MESSAGES: _ DID NOT RESPOND TO THE CONCILIATION LETTER SENT _ DID NOT APPEAR FOR SCHEDULED CONCILIATION ON : DATE ______ _ NOT SATISFIED THROUGH CONCILIATION CHOOSE A CONCILIATION MESSAGE Xmit _



WCN116 Entry of TA individual reason codes WP1-8 and WS1-8 will present screen WCN116 (PA Intentional Program Violation Data Entry) to collect details concerning the IPV. Workers must select one of the four disqualification reasons and supply necessary date information. If reason codes WP8 or WS8 are used to either pend or start a court ordered disqualification, workers must enter the number of months the client is disqualified and the IPV violation number. Lastly, if an IPV that had been previously pended is now starting, the worker should so indicate, and must provide the month and year when the original notice was sent.

‐WCN116 WMS/Client Notice Subsystem Date 12/12/06 PA Intentional Program Violation Data Entry Screen Time 11:32:42 CASE NAME MZ‐01 CASE NO MZ‐01 INDV REASON WS1 : ST IPV‐1 6MO LINE NO 01 Indicate (X) reason for disqualification: _ IPV determined by administrative disqualification hearing held on ______ Decision date ______ _ Client waived rights to administrative disqualification hearing on ______ _ Client found guilty of crime/offense by court of law on ______ for IPV _ Client signed disqualification consent agreement on ______ Agreement: _ Did not need to be confirmed by court; or, _ Confirmed by court on ______ Court ordered disqualification period: __ months This IPV is violation number _ _ This IPV was previously pended. Prior notice sent (MMYY) ____. Xmit _

The WCN116 screen explanation appears below: DATE MM/DD/YY Today's date is computer-generated. TIME HH/MM/SS The current time is computer-generated. CASE NAME Appears as entered on WMS. REG/CASE NO Appears as entered on the CNS menu (WCN000). INDV REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic.



LINE NO Appears as entered on the CNS Reason Code Entry screen (WCN011). Indicate (X) reason for disqualification: Users must select one of the four (4) disqualification reasons and supply the necessary date

information. If the fourth selection (signed disqualification consent agreement) is indicated, users must indicate whether the agreement was confirmed by the court or did not need to be. If the confirmed choice is indicated, the confirmation date must be provided.

Court ordered disqualification period: __ months This IPV is violation number __ These two fields are presented only if reason codes WP8 or WS8 are entered on WCN011. Users

are required to enter the number of months the client is disqualified (1 to 99) and the IPV violation number (1 to 9).

IPV was previously pended Users indicate with an ‘X’ if the IPV being started had been previously pended. If indicated,

users must provide the month and year (MMYY) when the original notice was sent. *Note: this field does not appear for reason codes WP1 - WP8. XMIT This is the transmit position.



WCN013 This screen’s appearance is dependent on the claim type reason code that is entered on the WCN011 Reason Code Entry screen. The two variations of this screen are shown below: *Note: ALL amount fields are entered with Cents, but NO decimal point; for example, two-hundred-

eleven dollars is entered as 21100. AGENCY ERROR / INADVERTENT HOUSEHOLD ERROR

‐WCN013 WMS/Client Notice Subsystem Date 12/12/06 FS Claim Data Collection Time 14:38:58 CASE NAME Z004F CASE NO Z004F CASE REASON R21 : AE CLM RECP DATE OF DISCOVERY MMDDYY: ______ ACTION EXPL: Complete the following "We are taking this action because..." _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ O/I FROM MMYY: ____ O/I TO MMYY: ____ OVER‐ISSUANCE AMOUNT: _______ TR O/I FROM MMYY: ____ TR O/I TO MMYY: ____ TRANSFER BALANCE AMT: _______ IF CLAIM TRANSFER, LINE NO OF RESPONSIBLE INDIVIDUAL: __ OFFSET AMOUNTS: ALREADY PAID: _______ UNDERPAYMENT: _______ UNDERPAYMENT MONTHS: ________________________________________________ CLAIM BAL CORRECTION _ 1st MO PAY AMT: ________ XMIT _

The WCN013 Agency Error / Inadvertent Household Error screen explanation appears below: DATE MM/DD/YY Today's date is computer-generated. TIME HH/MM/SS The current time is computer-generated. CASE NAME Appears as entered on WMS. CASE NO Appears as entered on the CNS menu (WCN000). CASE REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. DATE OF DISCOVERY MMDDYY A required entry. Users must provide the date of discovery in MMDDYY format.



ACTION EXPL A required entry. Users must complete the action statement in the space provided. *Over-Issuance vs. Transfer: Users are required to make entries in either the Over-Issuance or Transfer Over-Issuance fields: O/I FROM MMYY / O/I TO MMYY This is the Over-Issuance time period. Both the FROM and TO dates are entered in a

MONTH/YEAR (MMYY) format. OVER-ISSUANCE AMOUNT This is the total over-issuance amount associated with this category of claim. TR O/I FROM MMYY / TR O/I TO MMYY This is the original Over-Issuance time period associated with a claim that is being transferred to

this case. Both the FROM and TO dates are entered in a MONTH/YEAR (MMYY) format. TRANSFER BALANCE AMT This is the original, total over-issuance amount associated with the category of claim being

transferred to this case. LINE NO OF RESPONSIBLE INDIVIDUAL If transferred claim dates and amount are entered, users must provide the WMS Line Number of

the individual to whom the claim is attributed. OFFSET AMOUNTS: These are optional entries to reflect an offset of the balance owed. Both options may be used

together. • ALREADY PAID

This is the amount the client has already repaid the agency prior to the start of the recoupment.

• UNDERPAYMENT This is a prior underpayment amount owed to the client by the district (not already paid) that is now being used to reduce the overpayment amount.

• UNDERPAYMENT MONTHS If the underpayment amount field has been entered, users are required to provide the underpayment time period in the space provided.

CLAIM BAL CORRECTION If the details of a previous AE or IHE claim notice were incorrect, users can mark this field with

an ‘X’ and complete the screen with the correct overpayment details. 1st MO PAY AMT If FS claim reason code R27 or R28 had been entered, this field is presented to collect the first

month payment amount owed by the client. This amount will appear on the notice’s accompanying Compromise/Repayment Request form.




INTENTIONAL PROGRAM VIOLATION

‐WCN013 WMS/Client Notice Subsystem Date 12/13/06 FS Claim Data Collection Time 14:27:11 CASE NAME Z004F CASE NO Z004F CASE REASON R23 : IPV CLM RECP DATE OF DISCOVERY MMDDYY: ______ ACTION EXPL: Complete the following "We are taking this action because..." _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ O/I FROM MMYY: ____ O/I TO MMYY: ____ OVER‐ISSUANCE AMOUNT: _______ TR O/I FROM MMYY: ____ TR O/I TO MMYY: ____ TRANSFER BALANCE AMT: _______ IF CLAIM TRANSFER, LINE NO OF RESPONSIBLE INDIVIDUAL: __ PREV IHE: _ OFFSET AMOUNTS: ALREADY PAID: _______ UNDERPAYMENT: _______ UNDERPAYMENT MONTHS: ________________________________________________ IPV REPAYMENT AGREEMENT SIGNED: _ IPV COURT ORDER: _ IF REPAYMENT AGREEMENT SIGNED OR COURT ORDER, LIST REPAYMENT CONDITIONS: _________________________________________________________________________ _________________________________________________________________________ IPV DISPLACES AE/IHE CLAIM _ CLAIM BAL CORRECTION _ 1st MO PAY AMT: ________ XMIT _

The explanation for the IPV WCN013 screen is the same as provided for AE and IHE, plus the additional fields highlighted above. These fields are explained below: PREV IHE If this claim was a prior Inadvertent Household Error that, through investigation, was determined

to be an IPV, this field is indicated with an ‘X’. IPV REPAYMENT AGREEMENT SIGNED This is an optional entry field. If a court order has been signed directing repayment, users should

indicate this by placing an ‘X’ in this field. This field may not be ‘X-ed’ if an IPV Court Order has been indicated.

IPV COURT ORDER This is an optional entry field. If the client has signed a Disqualification Consent Repayment

Agreement, users should indicate this by placing an ‘X’ in this field. This field may not be ‘X-ed’ if the Repayment Agreement Signed has been indicated.

LIST REPAYMENT CONDITIONS If either the Repayment Agreement Signed or IPV Court Order has been indicated, users must

complete this field with the details of the repayment conditions. IPV DISPLACES AE/IHE CLAIM If the IPV claim is displacing an Agency Error or Inadvertent Household Error claim that is

currently in place, users should mark this field with an ‘X’.



CLAIM BAL CORRECTION If the details of a previous IPV claim notice were incorrect, users can mark this field with an ‘X’

and complete the screen with the correct overpayment details. 1st MO PAY AMT If claim reason code R29 had been entered, this field is presented to collect the first month

payment amount owed by the client. This amount will appear on the notice’s accompanying Compromise/Repayment Request form.

XMIT This is the transmit position. *When either of the WCN013 screens is transmitted, the FS Overpayment Calculation screen (WCN031) on the next page is presented.



WCN031 This screen is presented for all FS claim reason codes. Users must provide a monthly accounting of any overpayments made to the client. *Note: Both amount fields are entered with Cents, but NO decimal point; for example, two-hundred-

eleven dollars is entered as 21100.

‐WCN031 WMS/Client Notice Subsystem Date 12/13/06 FS Overpayment Calculation Time 14:45:35 CASE NAME Z004F CASE NO Z004F CASE REASON R23 : IPV CLM RECP FS Benefit Corrected FS Issuance MMYY Amount Issued Entitlement ____ ________ ________ ____ ________ ________ ____ ________ ________ ____ ________ ________ ____ ________ ________ ____ ________ ________ ____ ________ ________ ____ ________ ________ ____ ________ ________ ____ ________ ________ ____ ________ ________ ____ ________ ________ MORE TO ENTER (Y/N) N XMIT _

The WCN031 screen explanation appears below: DATE MM/DD/YY Today's date is computer-generated. TIME HH/MM/SS The current time is computer-generated. CASE NAME Appears as entered on WMS. CASE NO Appears as entered on the CNS menu (WCN000). CASE REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. FS Benefit Issuance MMYY This is a required entry. Users enter each month in the overpayment period in the format

Month/Year (MMYY). This screen allows up to twelve (12) months of entry. Sequential order is not required, although it is strongly encouraged.



Amount Issued This is a required entry. Users enter the benefit amount received by the client in the

corresponding MMYY. During notice production, CNS will sum all entries made and provide the total on the resulting notice.

Corrected FS Entitlement Users enter the benefit amount that the client should have received in the corresponding MMYY.

During notice production, CNS will sum all entries made and provide the total and the overpayment amount on the resulting notice.

MORE TO ENTER (Y/N) N Entry of a ‘Y’ will present another blank WCN031 screen. Workers can request up to four (4)

additional screens, allowing up to sixty (60) months of overpayments. XMIT This is the transmit position.



WCN112 The R39 reason code and the WCN112 screen were developed to allow a CNS district response to a client’s FS claim compromise request. The FS Repayment Agreement has been renamed the Food Stamp Compromise/Repayment Agreement Request. The text of the repayment agreement was modified to include “claim compromise” language for reason codes R27 (Agency Error) and R28 (Inadvertent Household Error). Claim compromise is NOT allowed for R29 (IPV) claims.

‐WCN112 WMS/Client Notice Subsystem Date 12/14/06 FS Claim Compromise ‐ Repayment Agreement Acknowledgment Time 10:35:18 CASE NAME 22CNS CASE NO 22CNS CASE REASON R39 : FS CLM ACKN COMPROMISE REQUEST: _ ACCEPTED _ DENIED _ MODIFIED as follows: Compromise Comments: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ REPAYMENT AGREEMENT REQUEST: _ ACCEPTED _ DENIED _ MODIFIED as follows: Repayment Agreement Comments: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Repayment Amount $ ________ Xmit _

The WCN112 screen explanation appears below: DATE MM/DD/YY Today's date is computer-generated. TIME HH/MM/SS The current time is computer-generated. CASE NAME Appears as entered on WMS. CASE NO Appears as entered on the CNS menu (WCN000). CASE REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. *Note: An ‘X’ entry is required in the Compromise or Repayment Agreement ACCEPTED, DENIED

or MODIFIED field. Entries in BOTH Compromise Request and Repayment Agreement



categories are allowed, however, only one (1) of each category’s three selection types may = ‘X’.

COMPROMISE COMMENTS / REPAYMENT AGREEMENT COMMENTS If either MODIFIED selection is chosen, an entry in the corresponding COMMENTS section is

required. REPAYMENT AMOUNT This is a required entry. This represents the monthly amount the district has determined is

due from the client. XMIT This is the transmit position.



WCN018 Because both TA and FS Excess Resource reason codes direct the user to the same screens, please go to pages P 18-19 to read the screen explanations.



WCN120

‐WCN120 WMS/Client Notice Subsystem Date 12/14/06 VERIFICATION SELECTION ENTRY SCREEN Time 13:56:12 CASE NAME Z004F CASE NO Z004F CASE REASON V21 : FAIL PRO VER CLIENT VERIFICATION PROVIDE BY DATE: ______ SELECT ONE OR MORE OF THE FOLLOWING: _ IDENTITY OF PERSON INTERVIEWED _ RESIDENCE _ HOUSEHOLD SIZE _ WAGES _ CHILD SUPPORT (NOT IV‐D) _ UNEMPLOYMENT INSURANCE BENEFITS (UIB) _ SOCIAL SECURITY BENEFITS _ VETERANS BENEFITS _ INTEREST/DIVIDENDS _ WORKERS COMPENSATION _ SELF‐EMPLOYMENT INCOME _ RENTAL INCOME _ ROOMER INCOME _ BOARDER INCOME _ DAY CARE PROVIDER INCOME _ ALIEN SPONSOR INCOME _ OTHER EARNED/UNEARNED INCOME _ BANK/CREDIT UNION ACCOUNTS _ STOCKS, BONDS, CDS _ PROPERTY _ MOTOR VEHICLE: OWNERSHIP _ MOTOR VEHICLE: VALUE _ TRAINING ALLOWANCE _ OTHER Xmit _

The WCN120 screen is explained below: DATE MM/DD/YY TIME HH:MM:SS Today's date and the current time are computer generated. CASE NAME Appears as entered on WMS. REG/CASE NO Appears as entered on the CNS menu (WCN000). CASE REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. CLIENT VERIFICATION PROVIDE BY DATE Entry is required in this field. Enter the date (MMDDYY) by which the client was to provide the

verification. SELECT ONE OR MORE OF THE FOLLOWING Enter an "X" next to the item(s) that the client needs to verify. If the items to be verified require

the input of additional variable information, the "FS Fail to Verify Variable" Entry screen (WCN121) will appear when this screen is transmitted.




WCN121 When the items to be verified (as indicated on the WCN120 screen) require the input of variable information, the WCN111 screen will appear for each such item. The following illustration shows the required fields for the “IDENTITY” selection. The fields and prompts displayed will vary according to the selection made.

‐WCN121 WMS/CLIENT NOTICE SUBSYSTEM DATE 12/14/06 FS FAIL TO VERIFY VARIABLE ENTRY SCREEN TIME 14:25:29 CASE NAME Z004F CASE NO Z004F CASE REASON V21 : FAIL PRO VER CATEGORY SELECTED: IDENTITY OF PERSON INTERVIEWED LN NAME/VEHICLE TYPE __ ____________________________ __ ____________________________ ENTER LINE NUMBER OR NAME FOR APPLICANT, AUTHORIZED REP., OR HOH. XMIT _

The WCN121 screen explanation appears below: DATE MM/DD/YY TIME HH:MM:SS Today's date and the current time are computer generated. CASE NAME Appears as entered on WMS. REG NO or CASE NO Appears as entered on the CNS menu (WCN000). CASE REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. LINE NO Appears as entered on the Reason Code Entry Screen (WCN011). CATEGORY SELECTED The item that needs to be verified as indicated on the FS Fail to Verify Selection Entry screen

(WCN120).



The following are data items for this example, plus others that may appear depending on category: LN Enter the line number of the individual for whom the verification is needed. This is valid only for

individuals already in the case. If the verification is needed for a non-applying individual, enter the name in the "Name/Vehicle Type" field.

NAME/VEHICLE TYPE Enter the name of the individual for whom the verification is needed. If a motor vehicle needs to

be verified, enter the type of vehicle. 4WK Appears if category selected is income related. Enter an "X" if verification of four week income

is required. DATE(S)/ACCOUNT TYPE Appears if category selected is income or resource related. Enter the dates for which income

verification is needed. If verification of an account is needed, enter the account type. NOTE: An entry can only be made in either the "4WK" field OR the "Date(s)/Account Type" field.

Entries cannot be made in both fields. EI Appears if the category selected is "Other Earned/Unearned Income". Enter the appropriate

ABEL Earned Income Source code(s). UI Appears if the category selected is "Other Earned/Unearned Income". Enter the appropriate

ABEL Other/Unearned Income Source code(s). OTHER Appears if category selected is "Other". Enter other information that is required. PROMPT LINE Users will receive prompts to assist in entering the appropriate information. XMIT This is the transmit position. NOTE: Special Function key SF-15 may be used to return to the FTV selection entry screen (WCN170)

from the variable entry screen (WCN171). The WCN170 screen returned will show the previous selections. Users may add or delete selections and re-transmit. All appropriate detail screens are presented in order. Detail data previously provided for the current selections appears as previously entered.



WCN150 / WCN151 Because both TA and FS reason codes WE1-3 direct the user to the same screens, please go to pages P 26-28 to read the screen explanations.



WCN110 The WCN110 screen below appears when Individual reason code WF1-3 is entered during undercare transaction types 05, 06, 07 and 08. A modified version (seen on the next page) appears during full data entry transaction types 02, 10 and 03.

‐WCN110 WMS/Client Notice Subsystem Date 12/19/06 FS IPV Disqualification Reason Entry Screen Time 13:55:40 CASE NAME Z004F CASE NO Z004F INDV REASON WF1 : FS IPV‐1 LINE NO 01 NEW IPV SELECT ONE: _ ADMINISTRATIVE HEARING HEARING DATE: ______ _ WAIVER OF HEARING DATE SIGNED: ______ _ COURT DECISION DECISION DATE: ______ _ DQ CONSENT AGREEMENT DATE SIGNED: ______ EXISTING IPV DISQUALIFICATION END DATE: ______ SELECT ONE DISQUALIFICATION STATUS: _ CONTINUE DISQUALIFICATION Xmit _

The WCN110 screen explanation appears below: DATE MM/DD/YY TIME HH:MM:SS Today's date and the current time are computer generated. CASE NAME Appears as entered on WMS. REG NO or CASE NO Appears as entered on the CNS menu (WCN000). INDV REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. LINE NO Appears as entered on the Reason Code Entry Screen (WCN011). NEW IPV This area is used for new instances of FS IPV. Users must place an ‘X’ next to the process by

which the individual was found guilty of an intentional program violation (only one selection is allowed). Users must also enter the corresponding date for the selection indicated.



EXISTING IPV This area is used when a previously disqualified individual either moves into a multi-person food

stamp household or applies for food stamps on their own. Users must enter the future Disqualification End Date and place an ‘X’ in the Continue Disqualification indicator.

XMIT This is the transmit position. For full data entry transaction types 02 (Opening), 10 (Re-opening) and 03 (Denial), the NEW IPV selection choices are not presented on the WCN110 screen...

‐WCN110 WMS/Client Notice Subsystem Date 12/19/06 FS IPV Disqualification Reason Entry Screen Time 14:02:44 CASE NAME MZIPV1 REG NO 288959 INDV REASON WF1 : FS IPV‐1 LINE NO 01 EXISTING IPV DISQUALIFICATION END DATE: ______ SELECT ONE DISQUALIFICATION STATUS: _ CONTINUE DISQUALIFICATION Xmit _



WCN041 Screen WCN041 is presented for the HEAP reason code M03. Users are required to indicate the one selection that best describes the ineligible living situation.

‐WCN041 WMS/Client Notice Subsystem Date 12/21/06 HEAP HH Resides in Ineligible Living Situation Time 15:10:06 CASE NAME HM03 CASE NO HM03 CASE REASON M03 : HEAP:INEL LV Complete the following sentence: 'This is because you reside in an ineligible living situation. You...' (INDICATE ONE WITH AN 'X') _ live in government‐subsidized housing and your heat is included in your rent. _ are a roomer/boarder in private housing. _ are living temporarily in a motel/hotel or recreational vehicle. _ are living in a motor vehicle or van. _ are a resident of a congregate care facility, dormitory, group home or institution. _ are living in government provided housing on a military base with no heat or utility bills in your name. _ are a migrant/seasonal farm worker with no heating or heat related expenses. _ have no responsibility for heating costs and you do not make undesignated payments for heat in the form of rent. Xmit _

The WCN041 screen explanation appears below: DATE MM/DD/YY TIME HH:MM:SS Today's date and the current time are computer generated. CASE NAME Appears as entered on WMS. CASE NO Appears as entered on the CNS menu (WCN000). CASE REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. Ineligible Living Situations Users are required to indicate the one selection that best describes the ineligible living situation. XMIT This is the transmit position.



WCN042 Screen WCN042 is presented for the HEAP reason code M04. Users are required to indicate at least one selection (but as many as necessary) that best describes the HEAP emergency denial.

‐WCN042 WMS/Client Notice Subsystem Date 12/21/06 HEAP Emergency Denial Time 15:12:32 CASE NAME HM04 CASE NO HM04 CASE REASON M04 : HEAP:EMRG DN Complete the sentence: 'This is because...' (SELECT ANY NECESSARY WITH AN 'X') _ your utility service for heating (natural gas or electric) is NOT terminated or scheduled for termination. _ your utility service necessary to operate the primary heating equipment, including service to start or run the furnace or boiler, or electricity necessary to distribute the heat or electric to operate the thermostat in order to ensure heat delivery to the applicant's dwelling, is NOT terminated or scheduled for termination. _ your household is NOT without heating fuel or does NOT have less than a seven‐day's supply of fuel and cannot obtain a delivery. _ your applicant owned primary heating equipment is NOT inoperable or unsafe and is NOT in need of repair or replacement. _ your household is NOT in an emergency home heating situation which is deemed by the SSD to be detrimental to the health and/or safety of household members if temporary shelter or relocation is not provided. _ you do not meet the home ownership criteria as defined by HEAP. Xmit _

The WCN042 screen explanation appears below: DATE MM/DD/YY TIME HH:MM:SS Today's date and the current time are computer generated. CASE NAME Appears as entered on WMS. CASE NO Appears as entered on the CNS menu (WCN000). CASE REASON Appears as entered on the WCN011 Reason Code Entry screen with its corresponding mnemonic. Emergency Denial Reasons Users are required to indicate at least one selection (but as many as necessary) that best describes

the HEAP emergency denial. XMIT This is the transmit position.

CLIENT NOTICES SYSTEM MANUAL CNS Section: R – Supervisory Review Report

Last Revised 3-25-08 Page R - 1

Whenever pending notices are created and the user has been returned to the WCN000 CNS menu screen with the notice number created message, a Supervisory Review Report is automatically generated. The purpose of this report is to allow district supervisory staff to examine ALL the case and individual reason codes entered, as well as any worker-entered variable data, used to create the pending notice corresponding to the action being taken. The report format appears on the next page:



MM/DDYY CLIENT NOTICE SUBSYSTEM PAGE x SUPERVISORY REVIEW REPORT CURRENT CASE DATA: CASE NAME xxxxxxxxxxxxxxxxxx CASE NUMBER xxxxxxxxxx CASE STATUS xx xxxxxxxx CASE TYPE xx xxxxx OFFICE xxx UNIT xxxxx WORKER xxxxx FS IND xx NOTICE NUMBER xxxxxxxxxx TRANS TYPE xx xxxx OFFICE xxx UNIT xxxxx WORKER xxxxx FS IND xx CASE REASON CODES: PA REASONS xxx xxxxxxxxxxxxx USER VARIABLES xxxxxxxxxxxxxxxxxxxxxxx xxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxxxxx xxx xxxxxxxxxxxxx USER VARIABLES xxxxxxxxxxxxxxxxxxxxxxx xxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxxxxx FS REASONS xxx xxxxxxxxxxxxx USER VARIABLES xxxxxxxxxxxxxxxxxxxxxxx xxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxxxxx xxx xxxxxxxxxxxxx USER VARIABLES xxxxxxxxxxxxxxxxxxxxxxx xxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxxxxx INDIVIDUAL REASON CODES: LINE # xx NAME xxxxxxxxxxxxxxxxxxxxxx, xxxxxxxxxxxxxxxx x CIN xxxxxxxx PA REASONS xxx xxxxxxxxxxxxx USER VARIABLES xxxxxxxxxxxxxxxxxxxxxxx xxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxxxxx xxx xxxxxxxxxxxxx USER VARIABLES xxxxxxxxxxxxxxxxxxxxxxx xxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxxxxx



The report explanation follows: MM/DD/YY The current date is printed. CASE NAME This appears as entered on WMS. REG/CASE NO This appears as entered on the CNS menu (WCN000). CASE STATUS The current WMS status appears with its corresponding mnemonic. CASE TYPE This appears as entered on WMS with its corresponding mnemonic. OFFICE, UNIT, WORKER These appear as entered on WMS. FS IND The PA/FS Indicator value from WMS appears here with its corresponding mnemonic. NOTICE NUMBER This is the identifying number generated by the system. TRANS TYPE This appears as entered on the CNS menu (WCN000) with its corresponding mnemonic. OFFICE, UNIT, WORKER These appear as entered on the CNS WCN011 Reason Code Entry screen. If no O-U-W entries

were made on this screen, then these are the values as entered on WMS. FS IND The PA/FS Indicator value entered on WCN011 appears here with its corresponding mnemonic. CASE REASON CODES Each reason code entry made on the WCN011 Reason Code Entry screen is displayed with its

corresponding mnemonic. Category headings are dropped if no corresponding reason code entries were made; e.g. only the FS REASON heading will appear for food stamp case types because no PA or MA reason code entries are made.

USER VARIABLES Case reason code user-entered data, preceded by its corresponding prompt, appear as entered on

the CNS data collection screens.



INDIVIDUAL REASON CODES The LINE #, NAME and CIN of the individual(s) for whom reason codes were entered are

printed followed by all reason code entries made on the WCN011 Reason Code Entry screen. The corresponding mnemonic for each reason code is also printed. Like the case reasons above, category headings are dropped if no corresponding reason code entries were made; e.g. only the FS REASON heading will appear for food stamp case types because no PA or MA reason code entries are made.

USER VARIABLES Individual reason code user-entered data, preceded by its corresponding prompt, appear as

entered on the CNS data collection screens.

CLIENT NOTICES SYSTEM MANUAL CNS Section: S – PA-FS Indicator

Last Revised 3-25-08 Page S - 1

For Upstate users only, an entry is generally required in the PA/FS Indicator field for transactions/notices involving Temporary Assistance cases. The following tables show the acceptable PA/FS Indicator values and the valid FS reason codes that may be entered for each of the TA case transaction types. Transaction Type = 02 (OPEN) or 10 (RE-OPEN) PA/FS Ind. Value Valid FS Case R/C Valid FS Indv. R/C 01 – Autorized FS A30-4, A36, A38, A40, L92, L94, Q21-2

B10, L10-4, R21-6, V19 B23, B84, G34

ALL Denial r/c All Close r/c None Allowed

02 – Declined FS A02 Only None Allowed 03 – Denied FS ALL Denial r/c ALL Denial r/c 04 – Non TA in HH A04 Only None Allowed 05 – Pending Determination J05 Only None Allowed 06 – FS Issued in Co-op Case L02 Only None Allowed Transaction Type = 03 (DENIAL) or 07 with Emergency Indicator = X (“Calculated” DENIAL) PA/FS Ind. Value Valid FS Case R/C Valid FS Indv. R/C 02 – Declined FS A02 Only None Allowed 03 – Denied FS ALL Denial r/c ALL Denial r/c 05 – Pending Determination J05 Only None Allowed 70 – Deny TA/Continue FS R11-2, R21-6, L92, L94, V19,

J05, Z10, Z12-3, Z15, Z17-8, Z90-3 ALL Recert-Cl r/c None Allowed

71 – Deny TA/Continue FS with Expedited FS

R11-2, F21-6, L92, L94, V19, J05, Z10, Z12-3, Z15, Z17-8, Z90-3

ALL Recert Cl r/c None Allowed

80 – Deny TA/Recert-Cl FS ALL Recert-Close r/c + J05, R27-9 ALL Recert-Cl r/c 81 – Deny TA/Recert Cl FS with Expedited FS

ALL Recert-Close r/c + J05, R27-9 ALL Recert-Cl r/c

90 – Deny TA/Close FS ALL Close r/c + J05, R27-9 ALL Close r/c 91 – Deny TA/Close FS with Expedited FS

ALL Close r/c + J05, R27-9 ALL Close r/c



Transaction Type = 05 (CHANGE) PA/FS Ind. Value Valid FS Case R/C Valid FS Indv. R/C 01 – Authorized FS former value = 01 former value = any value former value NOT = 01 former value = 02 03 05 09 former value = 04 06 09

B20-2 B24-5 B81-5 L92 L94 R21-6 G34 V19 X01-5 Y22-3 Y20 (only if TA r/c = B50 X01-4, L65) 903 960 965 966 991-994 J05 V19 A30-4 A36 A38 A40 L92 L94 Q21-2 B20-2 B24-5 B81-5 L92 L94 R21-6 V19

ALL r/c * None Allowed None Allowed 903 only None Allowed None Allowed ALL Denial r/c ALL r/c *

02 – Declined FS A02 Only None Allowed 03 – Denied FS ALL Denial r/c + Z97 ALL Denial r/c 04 – Non TA in HH A04 Only None Allowed 05 – Pending Determination J05 V19 (only if former P/F Ind = 05) None Allowed 06 – FS Issued in Co-op Case L02 (only if former P/F Ind NOT= 06) None Allowed 09 – Close FS ALL Close r/c + B10, L10-4, R27-9

A05, J05, G35 L05 (only if former P/F Ind = 06)

ALL r/c * None Allowed None Allowed

(*other than recert-cl only r/c’s) Transaction Type = 06 (RECERTIFICATION) PA/FS Ind. Value Valid FS Case R/C Valid FS Indv. R/C 01 – Authorized FS former value = 01 former value NOT = 01 former value = 02 03 05 09 former value = 04 06 09

B30-2 B34-5 B91-3 L92 L94 R21-6 V19 X01-5 J05 V19 A30-4 A36 A38 A40 L92 L94 Q21-2 B30-2 B34-5 B91-3 L92 L94 R21-6 V19

ALL r/c * None Allowed None Allowed ALL Denial r/c ALL r/c *

02 – Declined FS A02 Only None Allowed 03 – Denied FS ALL Denial r/c + Z97 ALL Denial r/c 04 – Non TA in HH A04 Only None Allowed 06 – FS Issued in Co-op Case L02 (only if former P/F Ind NOT= 06) None Allowed 09 – Close FS ALL Recert-Close r/c, R27-9

A05, J05, L05 (only if former P/F Ind = 06)

ALL r/c * None Allowed None Allowed (*other than close only r/c’s)



Transaction Type = 07 (CLOSE with Emergency Indicator = blank) PA/FS Ind. Value Valid FS Case R/C Valid FS Indv. R/C 03 – Denied FS ALL Denial r/c ALL Denial r/c 05 – Pending Determination J05 Only None Allowed 07 – Close TA/ Continue FS B10, L10-4, L92, L94, R21-6, V19

J05, Z10, Z12-3, Z15, Z17-8, Z90-3 ALL Close r/c None Allowed

08 – Close Both TA & FS ALL Close r/c, Z27-9 J05 J06 L05 (only if former P/F Ind = 06)

ALL Close r/c F90-2 (ct 11, 12 only) None Allowed None Allowed

09 – Close FS ALL Close r/c, Z27-9 J05 J06 L05 (only if former P/F Ind = 06)


Transaction Type = 08 (RECERT-CLOSE) PA/FS Ind. Value Valid FS Case R/C Valid FS Indv. R/C 02 – Declined FS A02 Only None Allowed

05 – Pending Determination J05 Only None Allowed 07 – Close TA/ Continue FS B10, L10-4, L92, L94, R21-6, V19

J05, Z10, Z12-3, Z15, Z17-8, Z90-3 ALL Close r/c None Allowed

08 – Close Both TA & FS ALL Close r/c, Z27-9 J05 J06 L05 (only if former P/F Ind = 06)


09 – Close FS ALL Close r/c, Z27-9 J05 J06 L05 (only if former P/F Ind = 06)


10 – Recert-Cl TA/ Deny FS ALL Denial r/c Z97

ALL Denial r/c None Allowed



Transaction Type = 14 (CLOSED CASE MAINTENANCE) PA/FS Ind. Value Valid FS Case R/C Valid FS Indv. R/C 03 – Denied FS E10 & N10 Only None Allowed 09 – Close FS M20 Only None Allowed Transaction Type = 00 (Non-Transaction, CNS-Only) (** PA/FS Indicator entry is NOT ALLOWED) (** PA/FS Reason Code entry is REQUIRED if PA/FS Indicator value = 01) PA/FS Ind. Value Valid FS Case R/C Valid FS Indv. R/C 01 – Authorized FS * PA r/c = R15, R16 * PA r/c = R30 * PA r/c = X02, X04 * PA r/c = Y20

Y20 R24-6, Y20 X02, X04, Y20 R24-6, V19, X02, X04, Z98

None Allowed None Allowed None Allowed None Allowed

Other Than 01 (NOT Authorized FS) * PA r/c = R30 * PA r/c = R40 * PA r/c = X02, X04, R15 * PA r/c = Y20 * PA r/c = L99 * PA r/c = Y20 (closed case)

R27-9, Y20 R27-9, Y20 no-entry - FS r/c 943 will be generated L99, R27-9, V19, Z97 L99, R27-9, V19, Z97 R39

None Allowed None Allowed None Allowed None Allowed None Allowed None Allowed

CLIENT NOTICES SYSTEM MANUAL CNS Section: T – Reports

Last Revised 3-25-08 Page T - 1

CNS prepares reports that are available on a daily basis through the BICS queue for each local district. Each local district will receive only those reports appropriate to the results of the prior night's processing. All reports are produced in Office/Unit/Worker sequence and should be distributed to appropriate district staff. NOTE: Reports are sent to NYC electronically on the Print Distribution System (PDS). Each NYC site has access

to the PDS and is able to print available reports. CNS00000 - COVER PAGE This is a list of all possible reports. An 'X' is placed next to each report generated for that local district. A blank next to the report means that the local district did not have any cases in that category and no report is available. This cover page is produced every day, even if no reports were created. Report Date MM/DD/YY NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES PAGE DISTRICT REPORT COVER SHEET

**************************** * THIS REPORT CONTAINS * * CONFIDENTIAL INFORMATION *

PERIOD COVERED BY REPORT: AS OF MM/DD/YY WMS REPORT CNS00000 * FOR INTERNAL USE ONLY * ****************************

DISTRICT DISTRIBUTION: DISTRICT MANAGEMENT REFERENCE NO EACH REPORT NAME YOU WILL RECEIVE IS FOLLOWED BY AN X ‐ IF BLANK, NO REPORT WILL BE SENT CNS00001 CNS0011 CNS0021 CNS00002 CNS0012 CNS00003 CNS0013 CNS00004 CNS0014 CNS00005 CNS0015 CNS00006 CNS0016 CNS00007 CNS0017 CNS00008 CNS0018 CNS00009 CNS0019 CNS00010 CNS0020



CNS00001 – Timely/Adequate Indicator = N This report lists cases from the prior day that had a WMS transaction with a Timely/Adequate Indicator value equal to 'N'. CNS notices were NOT produced for these cases. Report Date 01/08/07 NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES Page 1 CLIENT NOTICES NOT GENERATED WMS TRANSACTIONS WITH TIMELY/ADEQUATE IND = N **************************** FOR DISTRICT, BY OFFICE/UNIT/WORKER * THIS REPORT CONTAINS * * CONFIDENTIAL INFORMATION * PERIOD COVERED BY REPORT: AS OF – 01/07/07 WMS REPORT CNS00001 * FOR INTERNAL USE ONLY * **************************** DISTRICT: XXXX DISTRIBUTION: DISTRICT MANAGEMENT REFERENCE NO LOCAL OFFICE: UNIT: UN3 WORKER: WK3 CASE # TYPE NAME NOTICE NO. AUTH NO. TX TYPE DATE PA R/C FS R/C MA R/C T/A F102343 31 PONTIAC, MARY 00105718 07 01/07/07 E30 F211488 31 FORD, JOHN 00105687 07 01/07/07 F19

CNS00002 - Bottom Line Budget Case This report lists those cases whose notices required budget data and the only ABEL budget present is a Bottom-Line budget. A manual notice must be issued. Report Date 01/08/07 NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES Page 1 MANUAL CLIENT NOTICE REQUIRED CASE HAS BOTTOM‐LINE BUDGET **************************** FOR DISTRICT, BY OFFICE/UNIT/WORKER * THIS REPORT CONTAINS * * CONFIDENTIAL INFORMATION * PERIOD COVERED BY REPORT: AS OF – 01/07/07 WMS REPORT CNS00002 * FOR INTERNAL USE ONLY * **************************** DISTRICT: XXXX DISTRIBUTION: DISTRICT MANAGEMENT REFERENCE NO LOCAL OFFICE: OF1 UNIT: UN1 WORKER: WK1 CASE # TYPE NAME NOTICE NO. AUTH NO. TX TYPE DATE PA R/C FS R/C MA R/C T/A F102343 31 PONTIAC, MARY 00105718 07 01/07/07 E30 F211488 31 FORD, JOHN 00105687 07 01/07/07 E40



CNS00003 - Invalid Data on Batch Notice This report lists those cases entered on the Batch Notice screen which will not have notices generated due to failure to meet a batch notice criteria (e.g., case status not active). Manual notices must be issued. Report Date 01/08/07 NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES Page 1 CLIENT NOTICES NOT GENERATED BATCH NOTICE RECORDS IN ERROR **************************** FOR DISTRICT, BY OFFICE/UNIT/WORKER * THIS REPORT CONTAINS * * CONFIDENTIAL INFORMATION * PERIOD COVERED BY REPORT: AS OF – 01/07/07 WMS REPORT CNS00003 * FOR INTERNAL USE ONLY * **************************** DISTRICT: XXXX DISTRIBUTION: DISTRICT MANAGEMENT REFERENCE NO LOCAL OFFICE: OF1 UNIT: UN1 WORKER: WK1 CASE # BATCH # CATEGORY REASON DATA ERROR F102343 00064 02 Z10 CASE STATUS NOT ACTIVE F005782 00064 02 Z10 CASE STATUS NOT ACTIVE F104821 00065 02 Z10 CASE STATUS NOT ACTIVE F104933 00065 02 Z10 CASE STATUS NOT ACTIVE F107085 00065 02 Z10 CASE STATUS NOT ACTIVE

CNS00004 – Blank Timely-Adequate Indicator – Includes MA Extension Cases This report lists cases with a timely-adequate indicator of blank, when the lack of an indicator is not specifically allowed (for example, TA and FS undercare notices). A manual notice must be issued. Report Date 04/16/2008 NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES Page 2 CLIENT NOTICES NOT GENERATED BLANK TIMELY‐ADEQUATE INDICATOR – INCLUDES MA EXTENSION CASES **************************** FOR DISTRICT, BY OFFICE/UNIT/WORKER * THIS REPORT CONTAINS * * CONFIDENTIAL INFORMATION * PERIOD COVERED BY REPORT: AS OF – 04/16/2008 WMS REPORT CNS00004 * FOR INTERNAL USE ONLY * **************************** DISTRICT: XXXX DISTRIBUTION: DISTRICT MANAGEMENT REFERENCE NO LOCAL OFFICE: UNIT: WORKER: CASE # TYPE NAME NOTICE NO. AUTH NO. TX TYPE DATE PA R/C FS R/C MA R/C T/A MAEXT99 20 CLYDE BARROW 00140087 02 041608 752



CNS00005 - Reason Code "Other" Used This report lists cases which used the Other-Manual Notice Required reason code (Y92, Y77, Y98, Y99) for the WMS transaction. Manual notices must be issued. Report Date 01/08/07 NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES Page 1 MANUAL CLIENT NOTICE REQUIRED NOTICE INCLUDES REASON CODE OF OTHER **************************** FOR DISTRICT, BY OFFICE/UNIT/WORKER * THIS REPORT CONTAINS * * CONFIDENTIAL INFORMATION * PERIOD COVERED BY REPORT: AS OF – 01/17/07 WMS REPORT CNS00005 * FOR INTERNAL USE ONLY * **************************** DISTRICT: XXXX DISTRIBUTION: DISTRICT MANAGEMENT REFERENCE NO LOCAL OFFICE: OF1 UNIT: UN1 WORKER: WK1 CASE # TYPE NAME NOTICE NO. AUTH NO. TX TYPE DATE PA R/C FS R/C MA R/C T/A P107662 11 JOHNSON, MARY 00203488 07 01/16/07 Y99 P219188 31 DODGE, JOHN 00203687 07 01/16/07 Y92

CNS00006 – Informational This report lists those cases with a WMS transaction that did not require a client notice. Report Date 01/08/07 NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES Page 1 CLIENT NOTICES NOT GENERATED TRANSACTION DOES NOT REQUIRE A NOTICE **************************** FOR DISTRICT, BY OFFICE/UNIT/WORKER * THIS REPORT CONTAINS * * CONFIDENTIAL INFORMATION * PERIOD COVERED BY REPORT: AS OF – 01/07/07 WMS REPORT CNS00006 * FOR INTERNAL USE ONLY * **************************** DISTRICT: XXXX DISTRIBUTION: DISTRICT MANAGEMENT REFERENCE NO LOCAL OFFICE: OF1 UNIT: UN1 WORKER: WK1 CASE # TYPE NAME NOTICE NO. AUTH NO. TX TYPE DATE PA R/C FS R/C MA R/C T/A F104332 31 JOHNSON, ARLO 00590118 07 01/06/07 Y10



CNS00007 - Invalid Call-In (Upstate Only) This report lists those cases for which a recertification call-in notice was not generated because the interview date is greater than the authorization TO date. Report Date 01/06/07 NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES Page 1 CLIENT NOTICES NOT GENERATED INTERVIEW DATE GREATER THAN AUTHORIZATION TO DATE **************************** FOR DISTRICT, BY OFFICE/UNIT/WORKER * THIS REPORT CONTAINS * * CONFIDENTIAL INFORMATION * PERIOD COVERED BY REPORT: AS OF – 01/05/07 WMS REPORT CNS00007 * FOR INTERNAL USE ONLY * **************************** DISTRICT: XXXX DISTRIBUTION: DISTRICT MANAGEMENT REFERENCE NO LOCAL OFFICE: OF1 UNIT: UN1 WORKER: WK1 CASE # TYPE NAME NOTICE NO. R/C AUTH TO DATE INTERVIEW DT P102343000 16 FISCHER U5300C9824 Z20 061231 070115 P203066120 11 GRAVITY U5300C9836 Z20 061231 070115 F007510019 31 APPLE U5300C9906 Z10 061231 070120 F109332467 31 STUTZ U5300C9978 Z10 061231 070119

CNS00008 - MA Financial Reason Used - No Budget Available This report lists MA case closings that require budget data, but no stored MABEL budget is present. Manual notices must be issued. Report Date 01/06/07 NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES Page 1 MANUAL CLIENT NOTICE REQUIRED MA FINANCIAL REASON USED; NO BUDGET AVAILABLE **************************** FOR DISTRICT, BY OFFICE/UNIT/WORKER * THIS REPORT CONTAINS * * CONFIDENTIAL INFORMATION * PERIOD COVERED BY REPORT: AS OF – 01/05/07 WMS REPORT CNS00008 * FOR INTERNAL USE ONLY * **************************** DISTRICT: XXXX DISTRIBUTION: DISTRICT MANAGEMENT REFERENCE NO LOCAL OFFICE: OF1 UNIT: UN1 WORKER: WK1 CASE # TYPE NAME NOTICE NO. AUTH NO. TX TYPE DATE MA R/C M018743 20 SAMUELS, JOHN 02304526 02 070105 X41



CNS00009 - Error Identified In CNS Processing (Data Exceptions) This report lists those cases which had CNS data errors identified during nightly notice processing which prevented generation of an accurate notice. Manual notices must be issued. Report Date 01/06/07 NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES Page 1 MANUAL CLIENT NOTICE REQUIRED ERROR IDENTIFIED IN CNS PROCESSING **************************** FOR DISTRICT, BY OFFICE/UNIT/WORKER * THIS REPORT CONTAINS * * CONFIDENTIAL INFORMATION * PERIOD COVERED BY REPORT: AS OF – 01/05/07 WMS REPORT CNS00009 * FOR INTERNAL USE ONLY * **************************** DISTRICT: XXXX DISTRIBUTION: DISTRICT MANAGEMENT REFERENCE NO LOCAL OFFICE: OF1 UNIT: UN1 WORKER: WK1 CASE # TYPE TX TYPE AUTH NO. NOTICE NO. ERROR MESSAGE P017723 16 07 02920834 CNS OUTPUT ERROR

CNS00010 – Authorization Date Too Far in Future (Upstate Only) This report lists those Food Stamp cases for which a recertification call-in notice was not generated because the case Authorization TO Date is too far in the future. For Food Stamps, a recertification call-in letter must be sent so that the household receives it no earlier than the first day of the second to the last month of the certification period. For example, if a household's certification period ends on March 31st, the call-in notice cannot be prepared prior to February 1st. Report Date 01/06/07 NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES Page 1 CLIENT NOTICES NOT GENERATED AUTHORIZATION DATE TOO FAR IN FUTURE **************************** FOR DISTRICT, BY OFFICE/UNIT/WORKER * THIS REPORT CONTAINS * * CONFIDENTIAL INFORMATION * PERIOD COVERED BY REPORT: AS OF – 01/05/07 WMS REPORT CNS00010 * FOR INTERNAL USE ONLY * **************************** DISTRICT: XXXX DISTRIBUTION: DISTRICT MANAGEMENT REFERENCE NO LOCAL OFFICE: OF1 UNIT: UN1 WORKER: WK1 CASE # TYPE NAME NOTICE NO. AUTH NO. TX TYPE DATE PA R/C FS R/C MA R/C F014781 31 SAMUELS, JOHN U5300N2388 02304526 043007 Z10



CNS00011 - AUTHORIZATION DATE TOO CLOSE FOR RECERT (Upstate Only) This report lists those Food Stamp cases for which a recertification call-in notice was not generated because the case Authorization TO Date is too close to the present date for a timely recertification. For Food Stamps, the call-in letter cannot be sent later than one day before the last month of the certification period. For example, if a household's certification period ends on March 31st, the notice must be prepared no later than February 28th. For Medical Assistance, the call-in letter cannot be mailed later than seven (7) days prior to the last day of the last month of the certification period. For example, if a household's MA certification period ends March 31st, the notice must be mailed by March 25th. Report Date 01/06/07 NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES Page 1 CLIENT NOTICES NOT GENERATED AUTHORIZATION DATE TOO CLOSE FOR RECERT **************************** FOR DISTRICT, BY OFFICE/UNIT/WORKER * THIS REPORT CONTAINS * * CONFIDENTIAL INFORMATION * PERIOD COVERED BY REPORT: AS OF – 01/05/07 WMS REPORT CNS00011 * FOR INTERNAL USE ONLY * **************************** DISTRICT: XXXX DISTRIBUTION: DISTRICT MANAGEMENT REFERENCE NO LOCAL OFFICE: OF1 UNIT: UN1 WORKER: WK1 CASE # TYPE NAME NOTICE NO. AUTH NO. TX TYPE DATE PA R/C FS R/C MA R/C F017112 31 PETERS, JANE U5300L9348 02304728 013107 Z10

CNS00012 - MA FINANCIAL R/C USED; INVALID BUDGET DATA (Upstate Only) This report lists those MA cases for which a notice was not generated because, even though there is a stored budget, all the budget fields necessary to calculate eligibility have not been completed. Manual notices must be issued. Report Date 01/06/07 NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES Page 1 MANUAL CLIENT NOTICE REQUIRED MA FINANCIAL REASON USED; INVALID BUDGET DATA **************************** FOR DISTRICT, BY OFFICE/UNIT/WORKER * THIS REPORT CONTAINS * * CONFIDENTIAL INFORMATION * PERIOD COVERED BY REPORT: AS OF – 01/05/07 WMS REPORT CNS00012 * FOR INTERNAL USE ONLY * **************************** DISTRICT: XXXX DISTRIBUTION: DISTRICT MANAGEMENT REFERENCE NO LOCAL OFFICE: OF1 UNIT: UN1 WORKER: WK1 CASE # TYPE NAME NOTICE NO. AUTH NO. TX TYPE DATE MA R/C M013452 20 PETERS, JANE U5300L9348 02304728 07 013107 E57



CNS00013 – Multiple MA End Dates (Upstate Only) This report lists those Medical Assistance cases for which a notice was not generated because, during an MA closing transaction, ALL individual "coverage-to-dates" were not the same and ONLY a case level reason code was used. NOTE: This does not apply to NYC. In NYC when MA individuals do not have the same coverage-to-date, WMS

will error the closing. Report Date 01/06/07 NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES Page 1 MANUAL CLIENT NOTICE REQUIRED MULTIPLE MA COVERAGE CODE END DATES **************************** FOR DISTRICT, BY OFFICE/UNIT/WORKER * THIS REPORT CONTAINS * * CONFIDENTIAL INFORMATION * PERIOD COVERED BY REPORT: AS OF – 01/05/07 WMS REPORT CNS00013 * FOR INTERNAL USE ONLY * **************************** DISTRICT: XXXX DISTRIBUTION: DISTRICT MANAGEMENT REFERENCE NO LOCAL OFFICE: OF1 UNIT: UN1 WORKER: WK1 CASE # TYPE NAME NOTICE NO. AUTH NO. TX TYPE DATE M013452 20 PETERS, JANE 04302728 07 010407

CNS00014 - TEXT PROCESSING ERROR This report lists those cases where a notice was not produced due to an error in the paragraph request or

text processing program. Manual notices are required. CNS00015 - LDF/BICS ERROR (Upstate Only) This report lists those cases where an error occurred in LDF or BICS processing. CNS cannot release the

notice because the WMS transaction was rejected. Manual notices are required. CNS00016 - REASON FAILED WMS EDITS (Upstate Only) This report lists those cases where WMS edits performed in CNS failed (primarily MA reason code S19).

Manual notices are required. CNS00018 – PA BUDGET FROM DATE < AID TO CONTINUE DATE This report lists those Change and Recertification transaction cases where notices were not produced

because the PA budget FROM Date was LESS THAN the Aid to Continue Date (Current date + 10 Days). Manual notices are required.

CNS00019 – INFORMATIONAL NOTICES RELEASED VIA BATCH AUTHORIZATION This report lists those cases that were sent a notice produced by CNS Function 07 – Notice

Authorization/Release. CNS00020 – HEAP AUTO-PAY NOTICES WHERE BENEFIT TYPE NOT = ‘R’ This report lists those PA and FS cases (included in the HEAP AutoPay mass authorization) that did not

have a notice produced (when HEAP locks were turned ‘OFF”) because the stored or previous HEAP budget was NOT a Regular Benefit “R” budget. Manual notices are required.



CNS00021 – HEAP AUTO-PAY NOTICES PROCESSED BEFORE “LOCKS-OFF” This report lists those PA and FS cases (included in the HEAP AutoPay mass authorization) that did not have a notice produced (when HEAP locks were turned ‘OFF”) because the stored or previous HEAP budget was NOT a Regular Benefit “R” budget. Manual notices are required. CNS00100 - RECERTIFICATION SCHEDULE FOR RECEPTION AREA This report provides the local district reception area with a list of all recertification appointments scheduled during the previous night's notice processing. The report sort sequence is: Office - Benefit Category - Appointment Date - Appointment Time - Case Name. Report Date 01/16/07 NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES Page 1 **************************** Recertification Appointment List * THIS REPORT CONTAINS * For Reception Area Use * CONFIDENTIAL INFORMATION * By Benefit Category/Date * FOR INTERNAL USE ONLY * WMS REPORT CNS00100 **************************** Appointment Date: 02/15/07 Office: Benefit Category: FS District: Xxxxxxxxxxxx Distribution: Local Management Reference No. Appt. Time Case Name Case No. Case Type Office Unit Worker Worker Name 9:30 Apple F102390 31 OF1 FS1 WK1 Adams 9:30 Zink F206184 31 OF1 FS1 WK2 Madison 10:00 Lowe F008362 31 OF1 FS2 WK8 Monroe 2:30 Phillips F211398 31 OF1 FS2 WK4 Jefferson 3:00 Wilson F456009 31 OF1 FS1 WK1 Adams Appointment Date: 02/17/07 Office: Benefit Category: FS Appt. Time Case Name Case No. Case Type Office Unit Worker Worker Name 1:30 Frank F102390 31 OF1 FS1 WK1 Adams 1:30 Goner F109882 31 OF1 FS1 WK2 Madison 1:30 Jackson F222673 31 OF1 FS1 WK6 Nixon Appointment Date: 02/15/07 Office: Benefit Category: MA District: Xxxxxxxxxxxx Distribution: Local Management Reference No. Appt. Time Case Name Case No. Case Type Office Unit Worker Worker Name 8:30 Arthur M104672 20 OF1 MA1 WK1 Carter 8:30 Unger M166007 20 OF1 MA1 WK2 Lincoln 10:00 Best M002993 20 OF1 MA2 WK7 Bush

CNS00110 - RECERTIFICATION SCHEDULE FOR WORKER REFERENCE This report provides local district workers with list of all recertifications (all "Z" codes) scheduled during the previous night's processing. The report sort sequence is: Office-Unit-Worker - Reason Code - Appointment Date - Appointment Time - Case Name.



Report Date 01/16/07 NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES Page 1 **************************** Recertification Appointment List * THIS REPORT CONTAINS * For Worker Use * CONFIDENTIAL INFORMATION * By Benefit Category/Date * FOR INTERNAL USE ONLY * District: Xxxxxxxxxxxx WMS REPORT CNS00110 **************************** Distribution: Local Management Reference No. Office: OF1 Unit: FS1 Worker: WK1 Benefit Category: FS Appt. Date Appt. Time Case Name Case No. Case Type Reason Code 02/15/07 9:30 Apple F102390 31 Z10 02/15/07 3:00 Wilson F456009 31 Z10 02/17/07 3:00 Frank F102390 31 Z10 Office: OF1 Unit: FS1 Worker: WK2 Benefit Category: FS Appt. Date Appt. Time Case Name Case No. Case Type Reason Code 02/15/07 9:30 Zink F206184 31 Z10 02/15/07 1:30 Goner F109882 31 Z10 Office: OF1 Unit: FS1 Worker: WK4 Benefit Category: FS Appt. Date Appt. Time Case Name Case No. Case Type Reason Code 02/15/07 2:30 Phillips F211398 31 Z10 Office: OF1 Unit: FS1 Worker: WK6 Benefit Category: FS Appt. Date Appt. Time Case Name Case No. Case Type Reason Code 02/17/07 1:30 Jackson F222673 31 Z10 Office: OF1 Unit: FS1 Worker: WK8 Benefit Category: FS Appt. Date Appt. Time Case Name Case No. Case Type Reason Code 02/15/07 10:00 Lowe F008362 31 Z10 Office: OF1 Unit: MA1 Worker: WK1 Benefit Category: MA Appt. Date Appt. Time Case Name Case No. Case Type Reason Code 02/15/07 8:30 Arthur M104672 20 Z46 Office: OF1 Unit: MA1 Worker: WK2 Benefit Category: MA Appt. Date Appt. Time Case Name Case No. Case Type Reason Code 02/15/07 8:30 Unger M166007 20 Z46



CNS00120 - DISTRICT RECORDS This report lists all district Contact Data records, including address and all telephone numbers. The report sequence is: OFFICE – UNIT - PROGRAM AREA. CNS00130 - WORKER RECORDS This report lists all district Contact Data worker records, including telephone number. The report

sequence is: OFFICE – UNIT - PROGRAM AREA - WORKER NAME. CNS00135 - WORKER RECORDS This report lists all worker records, including telephone number. Reports sequence is: WORKER

NAME, UNIT and WORKER ID. CNS00145 - PROVIDER IDS NOT CONVERTED This report lists providers ID's entered that could not be converted to a Provider Name and Address from

the provider database. Notice copies are not printed for these providers. The client copy and any other associated notice copies are still produced. Attachments will be sent to the client only.

CNS00180 - VENDOR LETTERS NOT ISSUED This report lists Shelter and/or Fuel vendors for whom a vendor notice should have been produced, but

was NOT because a name and address could not be found in the BICS database for that vendor ID. The client copy and any other associated notice copies are still produced.



CNS00920 - Deleted Pending Client Notice Records This report provides local district workers with a list of pending notices that were automatically deleted because they were in a pending status after WMS Batch Update on a Friday before a scheduled CNS migration. The report is issued in Office/Unit/Worker sequence by notice number and case number. Report Date 01/06/07 NEW YORK STATE DEPARTMENT OF SOCIAL SERVICES Page 1 DELETED PENDING CLIENT NOTICE RECORDS **************************** FOR CENTER, BY OFFICE/UNIT/WORKER * * * THIS REPORT CONTAINS * WMS REPORT CNS00920 * CONFIDENTIAL INFORMATION * * FOR INTERNAL USE ONLY * PERIOD COVERED BY REPORT: AS OF – 01/05/07 **************************** DISTRIBUTION: DISTRICT MANAGEMENT REFERENCE NO CENTER : LOCAL OFFICE: OF1 UNIT: UN1 WORKER: WK1 CASE # NAME NTC/BTCH # DATE B/C R/C NTC KEY DELETED M013452 PETERS, JANE U0100T6548 12/29/06 03 E57 0308C0005700001 M084660 ROBERTS, JAMES U0100S7736 12/02/06 03 E57 0308C0005700001

CLIENT NOTICES SYSTEM MANUAL CNS Section: U – Fair Hearing Interface

Last Revised 3-25-08 Page U - 1

The Fair Hearings/Client Notices interface begins when the client receives a notice and does not agree with the action (to be) taken. The primary identification key for the Client Notices subsystem is the Client Notice Number, or CNN. When the request for a Fair Hearing is received by the Office of Administration Hearings (OAH), the Fair Hearings worker must ascertain the CNN for the notice action disputed. The CNN also appears on the tear off portion of the notice if the client mails in a written request for a fair hearing. After the correct notice number has been determined, the fair hearing request is entered in the Fair Hearing Information System (FHIS). Certain fair hearing requests require that aid continuing determinations be made. Pertinent information taken from the local district notice at the time of request is reviewed. Depending upon the type and timing of the request, aid continuing status is assigned. If the decision regarding A/C is disputed by the client or local district, the Department Fair Hearing office is contacted for review and resolution. When a Fair Hearing is requested, the notice is automatically retrieved from the notice archives and reloaded for online access. A complete copy of the notice is sent to the originating district through the BICS queue or retrieved using COLD. The local district BICS operator accesses the Client Notices file. Notices on which a fair hearing has been requested are printed. The BICS operator distributes the notices to the appropriate local district staff.

CLIENT NOTICES SYSTEM MANUAL CNS Section V - MA Openings

Revised December 2010 V-1

MEDICAL ASSISTANCE

To open an MA, FHP, FPBP case, the worker chooses one of the following codes.

Note: Since MA uses only Extensive Fill and not Limited Fill, the word “Fill” will be used in the section.

The term “TAD Based” is also used in this section. TAD Based is defined as the method of notice

production, which requires no information be entered on CNS.

FULL COVERAGE

*C50 (Y0001) All Covered Care and Services

(TAD Based) Applicant is accepted for Medicaid for all covered care and services.

COMMUNITY COVERAGE

*C24 (Y0055) Community Coverage with Community-Based Long Term Care

(TAD Based) Applicant accepted for Medicaid coverage with community-based LTC as

requested. No resource history was completed.

S82 (Y0056) Community Coverage without Long Term Care

(Fill) Applicant who has not requested long term care coverage is eligible for community Medicaid

coverage.

Worker must choose one of the following:

Community Coverage, No Long Term Care

Not Eligible/No Longer eligible for Long Term Care

S83 (Y0044) Ancillary Coverage Only, Institutionalized Individual, Due to failure to Provide

Documentation of Resources, Excess Income, Spenddown Not Met (Fill) (Budget Required) Applicant is accepted for ancillary coverage because they failed to

provide resource documentation. In order to make a determination for nursing home facility

services the applicant must provide proof of their countable resources for the past 36 months (60

months for trusts). MA coverage is available for other care and services not included in the

facility’s rate (example: eyeglasses, hearing aides, dentures and acute hospital care), but they must

meet the excess income spenddown requirement.

Worker must enter:

Net Income Amount

MA Income Limit

Monthly Excess Income Amount

Resources Failed to Verify

S84 (Y0034) Ancillary Coverage Only, Institutionalized Individual, Due to Failure to

Provide Documentation of Resources, No Excess

(Fill) Applicant is accepted for ancillary coverage because they failed to provide resource

documentation. In order to make a determination for nursing home facility services the applicant

must provide proof of their countable resources for the past 36 months (60 months for trusts). MA

coverage is available for other care and services not included in the facility’s rate (example:

eyeglasses, hearing aides, dentures and acute hospital care), there is no excess.

Worker must enter:

Documentation Failed to Verify



FAMILY HEALTH PLUS (CASE TYPE 24)

S37 (Y0028) Accept FHP, MA Ineligible Due to Excess Income, ESHI is Offered, ESHI is not

Cost Effective or ESHI is not Offered, FNP Parent

(Fill) (Budget Required) Applicant is an FNP Parent accepted for Family Health Plus coverage.

MA ineligible due to excess income.

Worker must choose one of the following messages:

Message # 1 Employee Sponsored Health Insurance Offered

Message # 2 Employee Sponsored Health Insurance Not Cost Effective

Message # 3 Employee Sponsored Health Insurance Not Offered

Worker must enter:

Net Income Amount

MA Income Limit

Health Plan Name


Cost Effective or ESHI is Not Offered, FP

(Fill) (Budget Required) Applicant is an FP individual accepted for Family Health Plus. MA

Ineligible due to excess income.





Worker must enter:

Net Income Amount

MA Income Limit


Health Plan Name


Cost Effective, ESHI is Not Offered, S/CC

(Fill) (Budget Required) Applicant is an S/CC individual(s) accepted for Family Health Plus. MA

ineligible due to excess income.


Message #1 If client is female

Message #2 IF client is male, no message





Worker must enter:

Net Income Amount

Medicaid Standard



FAMILY HEALTH PLUS PREMIUM ASSISTANCE PROGRAM (FHP-PAP)

S93 (Y0073) Accept FHP/FHP-PAP, FP

(Fill) (Budget Required) Applicant is a FP individual accepted for Family Health Plus, Family

FAMILY HEALTH PLUS PREMIUM ASSISTANCE PROGRAM (FHP-PAP) (Cont’d)

Health Plus-PAP.

Worker must enter:

Net Income Amount

MA Income Limit

Monthly Income Amount

S94 (Y0074) Accept FHP/PHP-PAP, FNP Parent

(Fill) (Budget Required) Applicant is a FNP Parent accepted for Family Health, Family Health

Plus-PAP.

Worker must enter:

Net Income Amount

MA Income Limit

S95 (Y0075) Accept FHP/PHP-PAP, S/CC

(Fill) (Budget Required) Applicant is a Single Childless couple accepted for Family Health,

Family Health Plus-PAP.


Message # 1 (If applicant is female)

Message # 2 (If applicant is male, no message )

Worker must choose one of the following messages and enter:

Message # 1 Gross Income Over 185% of the Medicaid Standard

Gross Income Amount

185% Medicaid Standard

Message # 2 Net Income Over the Medicaid Standard

Net Income Amount

Medicaid Standard

S96 (Y0065) Accept FHP/PAP Employer Buy-In

(Fill) (Budget Required) Recipient is able to enroll in a health insurance plan offered by

employer. Ineligible for Medicaid due to Excess Income.

Use For All:

Net Income Amount

Medicaid Income Limit


RETRO COVERAGE

S57 (Y0014) Approve Retro, Deny Ongoing, Medicaid Ineligible Due to Excess Income, FHP

Ineligible Due to Excess Income, Equivalent Health Insurance, Public Federal Employee

or Over 65, S/CC

(Fill) (Budget Required) Applicant is an S/CC individual(s) approved for Medicaid coverage in

the retro period, denied ongoing Medicaid due to excess income. FHP ineligible due to excess

income, equivalent health insurance public federal employee or is over 65.



RETRO COVERAGE (Cont’d)

Worker must enter:

Retro MA Coverage “From” Date

Retro MA Coverage “To” Date


Message # 1 Gross Income Over 185% Medicaid Standard

Gross Income Amount


Message # 2 Over Income

Net Income Amount

Medicaid Standard


Message # 1 FHP Over Income

Gross Income Amount

FHP Income Limit

Message #2 FHP Equivalent Health Insurance

Message #3 Public Federal Employee

Message #4 FHP Over 65

S58 (Y0015) Approve Ongoing, Deny Retro Medicaid Due to Excess Income S/CC

(Fill) (Budget Required) Applicant is an S/CC individual(s) approved for ongoing Medicaid

coverage, denied retro coverage due to excess income and/or resources.

Worker must enter:





Gross Income Amount



Net Income Amount

Medicaid Standard

S59 (Y0016) Approve Retro, Deny Ongoing Medicaid Due to Excess Income, FHP Ineligible Due

to Excess Income, Equivalent Health Insurance, Federal Employee or Over 65, FNP Parent

(Fill) (Budget Required) Applicant is an FNP Parent approved for Medicaid coverage in the retro

period, denied ongoing Medicaid due to excess income, FHP ineligible due to

excess income, equivalent health insurance federal employee or is over 65.

Worker must enter:





Net Income Amount




Gross Income Amount




FHP Income Limit


Message #3 Federal Employee


S60 (Y0017) Approve Ongoing, Deny Retro Medicaid Due to Excess Income, FNP Parent

(Fill) (Budget Required) Applicant is an FNP Parent approved for ongoing Medicaid coverage,

denied retro coverage due to excess income.

Worker must enter:





Net Income Amount

MA Income Limit

S80 (Y0059) Approve Retro, Deny Ongoing Medicaid Due to Excess Income and/or Resources,

FHP Ineligible Due to Excess Income, Equivalent Health Insurance Federal Employee or

Over 65, FP

(Fill) (Budget Required) FP Applicant is approved for Medicaid coverage in the retro period,

denied continuing Medicaid due to excess income and/or resources, FHP ineligible due to excess

income, equivalent health insurance, federal employee or is over 65.

Worker must enter:

Retro Coverage “From” Date

Retro Coverage “To” Date



Net Income Amount



Message # 2 Over Resources

Total Countable Resources

Medicaid Resource Limit

Excess Resource Amount

Message # 3 Income and Resources

Net Income Amount








Gross Income Amount

FHP Income Limit







S81 (Y0060) Approve Ongoing, Deny Retro MA Due to Excess Income, FP

(Fill) (Budget Required) Applicant is approved for ongoing MA, denied retro MA due to excess

income. Applicant did not have paid or unpaid medical expenses not covered by insurance that

were equal to or more than the excess income amount.

The worker must enter:



Net Income Amount

MA Income Limit


FAMILY PLANNING BENEFIT PROGRAM (FPBP)

*C43 (Y0026) Accept FPBP, Waived Right to MA/FHP

(TAD Based) (Budget Required) Applicant indicated they did not wish to apply for MA or FHP.

Eligibility was considered for the Family Planning Benefit Program only.

S61 (Y0040) Accept FPBP, MA Ineligible Due to Excess Income and/or Resources, FHP Ineligible

Due to Excess Income, Non- ESHI, Federal Employee, ESHI is Not Cost Effective, FP

(Fill) (Budget Required) Applicant is an FP individual(s) eligible for the Family Planning Benefit

Program with income at or below 200% of the FPL. Applicant is MA ineligible due to excess

income and/or resources, FHP ineligible due to excess income Non Employer Sponsored Health

Insurance, Employee Sponsored Health insurance is not cost effective or Federal Employee.



Net Income Amount







Message # 3 Income and Resources

Net Income Amount








Gross Income Amount

FHP Income Limit

Message #2 Non-Employee Sponsored Health Insurance


Message #4 Employee Sponsored Health Insurance-Not Cost Effective



FAMILY PLANNING BENEFIT PROGRAM (FPBP) (Cont’d)

S66 (Y0041) Accept FPBP, Medicaid Ineligible Due to Excess Income, FHP Ineligible Due to

Excess Income, Non-ESHI, Federal Employee or ESHI is Not Cost Effective, S/CC

(Fill) (Budget Required) Applicant is an S/CC individual(s) eligible for the Family Planning

Benefit Program with income at or below 200% of the FPL. Applicant is Medicaid ineligible due

to excess income, FHP ineligible due to excess income Non-Employer Sponsored Health Insurance

or Employee Sponsored health Insurance- Not Cost Effective or federal employee.



Gross Income Amount



Net Income Amount

Medicaid Standard



Gross Income Amount

FHP Income Limit



Message #4 Employee Sponsored Health Insurance- Not Cost Effective

S67 (Y0050) Accept FPBP, MA Ineligible Due to Excess Income, FHP Ineligible Due to Excess

Income, Non-ESHI, Federal Employee, ESHI- Not Cost Effective, FNP Parent#

(Fill) (Budget Required) Applicant is an FNP Parent eligible for the Family Planning Benefit

Program with income at or below 200% of the FPL. Applicant is Medicaid ineligible due to excess

income, FHP ineligible due to excess income, Non-Employer Sponsored Health Insurance, Federal

Employee or Employer Sponsored Health Insurance- Not Cost Effective.

Net Income Amount




Gross Income Amount

FHP Income Limit



Message #4 Employee Sponsored Health Insurance- Not Cost Effective

PRENATAL CARE

*C42 (Y0054) Accept Pregnancy, 100%

(TAD Based) (Budget Required) Applicant is eligible for prenatal care with a budget level at or

below 100% of the Federal Poverty Level.

S35 (Y0008) Prenatal Care, Between 100% and 200%

(Fill) (Budget Required) Applicant is eligible for limited MA services for prenatal care with a

budget level over 100% but at or below 200% of the Federal Poverty Level.

Worker must enter:

Net Income Amount



PRENATAL CARE (Cont’d)

MA Income Limit


NEWBORN/UNBORN

923 (N0007) Case Opened for Newborn (System Generated)

MA case will be opened for a newborn.

MBI-WPD (MEDICAID BUY-IN FOR WORKING PEOPLE WITH DISABILITIES)

S32 (Y0013) Accept MBI-WPD, No Premium Payment

(Fill) (Budget Required) Applicant is eligible for Medicaid coverage under the Medicaid Buy-In

for Working People with Disabilities program with no premiums.

Worker must enter:

Net Income Amount

MBI-WPD Income Limit




Message # 1 Community Coverage, No LTC

Message # 2 Community Coverage with Community-Based LTC

Message # 3 No Longer Eligible for LTC

Message # 4 None of the Above

MEDICARE BUY-IN

*C44 (Y0009) Accept SLIMB

(TAD Based) (Budget Required) Applicant is eligible for MA to pay Medicare Part B Premiums as

a Specified Low Income Medicare Beneficiary.

X54 (Y0003) Accept Medicare Buy-In Program, QMB

(Fill) Applicant is fully eligible for MA to pay Medicare Part B Premiums, deductibles, and

coinsurance.

QMB Effective Date

COBRA

*C21 (Y0005) Conditional Acceptance, COBRA Continuation

(TAD Based) Applicant is accepted for MA payment of group health insurance premiums under

the COBRA Continuation program pending documentation. If documentation is received and

eligibility is not established, applicant will be responsible to MA for repayment of premiums paid

on their behalf.

*C41 (Y0004) Accept COBRA Continuation

(TAD Based) (Budget Required) Applicant is eligible for Medicaid payment of COBRA

Continuation of group health insurance premiums.



COUNTY TO COUNTY MOVE

C37 (Y0064) Transition of MA/FHP/FH-PAP/MSP Eligibility “County B” letter, NYC to

Upstate/Upstate to Upstate Manual

(No Fill) (Budget Required) Applicant is moving from NYC to Upstate/ Upstate to Upstate.

Applicant will be opened in a MA/FHP/FHP PAP/MAS case in “County B”, County will be

system generated, with previous Client Identification Number.

HEALTH INSURANCE

X26 (Y0061) Accept MA Payment of Insurance Premiums

(Fill) MA has determined that it is cost effective to pay the applicant’s health insurance premiums.

Worker must enter:

Premium Effective Date

QI-1 (QUALIFIED INDIVIDUALS)

*C28 (Y0006) Accept Qualified Individual (QI-1)

(TAD Based) Applicant is accepted for MA payment of Medicare Part B Premiums.

EXCESS INCOME AND/OR RESOURCES

S20/AA (X0001) Excess Income, Spenddown Met, FHP Ineligible Due to Excess Income, Chose

Spenddown, Equivalent Health Insurance Federal Employee or Over 65,

(Fill) (Budget Required) Applicant is eligible for Medicaid with a spenddown of excess income

requirement which has currently been satisfied for at least one and up to five months. FHP

ineligible due to excess income, chose spenddown, has equivalent health insurance, Federal

Employee or is over 65.

Worker must choose on the variable entry screen:

I. Level not eligible for (A) MA and

II. Excess Income (A) Met

Worker must then enter:

Net Income Amount



Outpatient Coverage “From” Date

Outpatient Coverage “To” Date






Optional Provider/Recipient Letter will be presented



Gross Income Amount

FHP Income Limit

Message # 2 FHP Chose Spenddown of Income

Message # 3 FHP Equivalent Health Insurance

Message #4 FHP Federal Employee



EXCESS INCOME AND/OR RESOURCES (Cont’d)


S20/AB (X0006) Provisional Coverage, Excess Income, FHP Ineligible Due to Excess Income,

Chose Spenddown, Equivalent Health Insurance, or Over 65, Adults Only

(Fill) (Budget Required) Adult applicant is eligible for Medicaid with a spenddown requirement

which has currently not been satisfied. Applicant must submit paid or unpaid bills equal to or

more than the excess income amount. Also evaluated for FHP, ineligible due to excess income,

chose spenddown, has equivalent health insurance or is over 65.



II. Excess Income(B) To Be Met





Gross Income Amount

FHP Income Limit



Message # 4 FHP Over 65






S20/AC (X0002) Excess Income, 6 Month Spenddown Met, FHP Ineligible Due to Excess Income,

Chose Spenddown, Equivalent Health Insurance Federal Employee or Over 65


requirement which has been satisfied for a 6 month period. FHP ineligible due to excess

income, chose spenddown, has equivalent health insurance, is a federal employee or is over 65.



II. Excess Income (C) 6 Month Met


Net Income Amount



6 Month Coverage Start Date (MMYY)






Optional Provider/Recipient Letter will be presented.






Gross Income Amount

FHP Income Limit





S20/AD (X0003) Excess Resources, Spenddown Met

(Fill) (Budget Required) Applicant is eligible for Medicaid with a spenddown of excess

resources which have been spent down to the MA level with paid or unpaid expenses equal to or

more than the excess resource amount.



II. Excess Resources (D) Met



MA Resource Limit









Optional Provider/ Recipient Letter will be presented

S20/AE (X0004) Excess Income and Resources, Both Met, FHP Ineligible Due to Excess Income,

Chose Spenddown, Equivalent Health Insurance Federal Employee or Over 65


and resources. Spenddown of income has been satisfied for at least one and up to five months,

resources have been spent down to the Medicaid level. FHP ineligible due to excess income,

chose spenddown, has equivalent health insurance, Federal Employee or is over 65.



II. Excess Income and Resources (E) Met


Net Income Amount



















Gross Income Amount

FHP Income Limit

Message # 2 FHP Chose Spenddown of Income and Resources




S20/AF (X0007) Excess Income and Resources, Resource Spenddown Met, FHP Ineligible Due to

Excess Income, Chose Spenddown, Equivalent Health Insurance Federal Employee or

Over 65


and resources. Spenddown of income has not been satisfied, resources have been spent down to

the Medicaid level. FHP ineligible due to excess income, chose spenddown, has equivalent

health insurance, is a federal employee or is over 65.



II. Excess Income and Resources (F) Only Resources Met


Net Income Amount













Gross Income Amount

FHP Income Limit





S20/AG (X0005) Excess Income and Resources, Resource and 6 Month Spenddown Met, FHP

Ineligible Due to Excess Income, Chose Spenddown, Equivalent Health Insurance, Federal

Employee or Over 65





and resources, 6 month spenddown of income has been satisfied, resources have been spent

down to the Medicaid level. FHP ineligible due to excess income, chose spenddown, has

equivalent health insurance, is a federal employee or is over 65.



II. Excess Income and Resources (G) Resources and 6 Month Met


Net Income Amount















Gross Income Amount

FHP Income Limit





S20/BA (X0149) Child 1-5 at 133%, Excess Income, Spenddown Met

(Fill) (Budget Required) Applicant is a child age 1-5 ineligible for MA at 133% of the FPL.

Child is eligible for MA with a spenddown requirement of monthly income. Spenddown has

been satisfied for at least one and up to five months.


I. Level not eligible for (B) 133% and














S20/BC (X0157) Child 1-5 at 133%, Excess Income, 6 Month Spenddown Met


Child is eligible for Medicaid with a spenddown requirement of monthly income. Spenddown

has been satisfied for 6 months.












S20/BE (X0154) Accept MA-SSI Related Child 1-5 at 133%, Excess Income and Resources, Both

Met

(Fill) (Budget Required) Applicant is a child age 1-5 ineligible for Medicaid at 133% of the

FPL. Child is eligible for Medicaid with a spenddown requirement of monthly income and

resources. Spenddown of income has been satisfied for at least one month and up to five,

resources have been spent down to the Medicaid level.













S20/BG (X0151) Accept MA-SSI Related Child 1-5 at 133%, Excess Income and Resources,

Resource and 6 Month Spenddown Met

(Fill) (Budget Required) Applicant is a child 1-5 ineligible for Medicaid at 133% of the FPL.

Child is eligible for Medicaid with a spenddown requirement of monthly income and resources.

Spenddown of income has been satisfied for 6 months and resources have been spent down to

Medicaid level.

Worker must choose on the variable entry screen


II. Excess Income and Resources (G) Resources and 6 Month Met












S20/CA (X0228) Child 6-18, Over 100%, Excess Income, Spenddown Met


Child is eligible for Medicaid with a spenddown of income. Spenddown of income has been

satisfied for at least one and up to five months.


I. Level not eligible for (C) 100 % and









Message # 4 None of the Above 9


S20/CC (X0231) Child 6-18 Over 100%, Excess Income, 6 Month Spenddown Met



satisfied for 6 months.




On the variable entry screen worker must enter:








S20/CE (X0230) Accept MA-SSI Related Child 6-18 Over 100%, Excess Income and Resources,

Both Met



satisfied for at least one and up to five months, resources have been spent down to MA level.
















S20/CG (X0229) Accept MA-SSI Related Child 6-18 Over 100%, Excess Income and Resources,

Resource and 6 Month Spenddown Met



satisfied for 6 months, resources have been spent down to Medicaid level.



II. Excess Income and Resources (G) Resources and 6 Months Met









ALIENS

*C22 (Y0052) Non-Immigrant/Undocumented Immigrant, Emergency Coverage Only

(TAD Based) Applicant is eligible for emergency services only.

S77 (Y0051) Non-Immigrant/Undocumented Immigrant, Emergency, Excess Income Monthly or,

6 Month Spenddown Met (Fill) (Budget Required) Applicant is eligible for emergency services with a spenddown of income.

Spenddown of income has been satisfied for at least one and up to five months, or for six months.


Message # 1 Monthly Excess Income, Spenddown Met


Message # 2 Six Month Excess Income, Spenddown Met


6 Month Coverage From Date (MMDDYY)

S78 (Y0057) Non-Immigrant/Undocumented Immigrant, Emergency, Excess Resources,

Spenddown Met

(Fill) (Budget Required) Applicant is eligible for emergency services with a spenddown of

resources. Resources have been spent down to MA level.

Worker must enter:





ALIENS (Cont’d)


S79 (Y0058) Non-Immigrant/Undocumented Immigrant, Emergency, Excess Income and

Resources, Either Both Met or Resource and 6 Month Spenddown Met

(Fill) (Budget Required) Applicant is eligible for emergency services with a spenddown of income

and resources. Spenddown of income has been satisfied for 6 months. Resources have been spent

down to MA level.


Message # 1 Monthly Excess Income and Resource Spenddown Met

Net Income Amount

MA Income Limit


MA Resource Limit



Message # 2 Resource and 6 Month Spenddown Met

Net Income Amount

MA Income Limit


MA Resource Limit



6 Month Coverage From Date (MMDDYY)

S89 (X0093) Accept RMA Excess Income

(Fill) Budget Required) Recipient has been accepted for Medicaid under the Refugee Medical

Assistance Program. Ineligible for Medicaid due to excess income.

Worker Must Enter:

Net Income Amount


TRANSFERS

S68 (X0227) Accept Limited Coverage Due to Transfer, Individual in Community, Excess Income,

Spenddown Not Met, FHP Ineligible Due to Excess Income, Chose Spenddown, Equivalent

Health Insurance or Over 65

(Fill) (Budget Required) Applicant is ineligible for full MA due to a transfer. The applicant is also

ineligible for FHP due to excess income, chose spenddown, equivalent health insurance or

over 65 years of age. The applicant is eligible for reduced MA coverage with a spenddown of

excess income. The spenddown requirement has not been met.

Worker must enter:

Net Income Amount

MA Income Limit




Gross Income Amount



TRANSFERS (Cont’d)

FHP Income Limit



Message # 4 FHP Over 65

Worker must enter the following:

Date Eligible For Nursing Home Sevices after penalty period ends

Date of Transfer

Asset Transferred

Fair Market Value of the resource or income amount

Amount of Compensation Received

Monthly regional rate of the district in which the individual is institutionalized

Month, first day of the month and the year in which limited coverage (Ineligibility for

Nursing Home Services) begins (MMDDYY)

S69 (Y0029) Accept Limited Coverage Due to Transfer, Individual in Community, No Excess

(Fill) (Budget Required) Applicant is ineligible for full MA due to a prohibitive transfer. The

applicant is eligible for reduced MA coverage. There is no excess of income or resources. Worker

must enter:

Date eligible for Nursing Home Services after penalty period ends

Date of Transfer

Asset Transferred


Amount of Compensation Recieved




S70 (Y0010) Accept Institutionalized Individual Limited Coverage Due to Prohibited Transfer,

No Excess

(Fill)(Budget Required) Applicant is ineligible for full MA due to a prohibited transfer. The

applicant is eligible for reduced MA coverage. There is no excess.

Worker must enter:

Date Eligible for Nursing Home Services after penalty period ends

Date of Transfer

Asset Transferred

Fair Market value of the resource or income amount

Amount of Compensation Recieved




S71 (Y0035) Accept Institutionalized Individual Limited Coverage Due to Prohibition

Transfer, Excess Income, Spenddown Met (Fill)(Budget Required) Applicant is ineligible for full MA due to a prohibited transfer. The

applicant is eligible for reduced MA coverage with a spenddown of excess income. The

spenddown requirement has been satisfied for a least one month and up to five months.

Worker must enter:

Spendown Met “From” Date




Spenddown Met “To” Date

Net Income Amount

MA Income Limit



Date Of Transfer

Asset Transferred






S72 (Y0031) Accept Institutionalized Individual Limited Coverage Due to Prohibited Transfer

6 Month Excess Income and Resource Spenddown Met

(Fill)(Budget Required) Applicant is ineligible for full MA due to prohibited transfer. The

applicant is eligible for reduced MA coverage with a 6 month spenddown of excess income and

resources. Spenddown of income and resources met for 6 months.

Worker must enter:

Net Income Amount

MA Income Limit


MA Resource Limit



Spenddown Met “From” Date

Date Eligible For Nursing Home Services after penalty period ends

Date of Transfer

Asset Transferred




Month, first day of the month and the year in which limited coverage (ineligibility for



Spenddown Met

(Fill) (Budget Required) Applicant is ineligible for full MA due to a prohibited transfer. The

applicant is eligible for reduced MA coverage with a spenddown of excess income. The

spenddown requirement has been satisfied for at least one and up to five months.

Worker must enter:



Net Income Amount

MA Income Limit



Date of Transfer




Asset Transferred







6 Month Spenddown Met

(Fill) (Budget Required) Applicant is ineligible for full MA due to a transfer. The applicant is

eligible for reduced MA coverage with a spenddown of excess income. The spenddown

requirement has been satisfied for six months.

Worker must enter:


Net Income Amount

MA Income Limit



Date of Transfer

Asset Transferred






S75 (Y0030) Accept Institutionalized Individual Limited Coverage Due to Prohibited Transfer,

Excess Resources, Spenddown Met

(Fill) (Budget Required) Applicant is ineligible for chronic care MA due to a prohibited transfer.

The applicant is eligible for reduced MA coverage with a spenddown of excess resources.

Resources have been spent down to MA level.

Worker must enter:



Net Income Amount

MA Income Limit



Date of Transfer

Asset Transferred






S76 (X0034) Accept Limited Coverage Due to Transfer, Individual in Community, Excess

Resources, Spenddown Met



TRANSFERS (con’t)

(Fill) (Budget Required) Applicant is ineligible for full MA due to a prohibited transfer. The

applicant is eligible for reduced MA coverage with a spenddown of excess resources. Resources

have been spent down to MA level.

Worker must enter:

Spenddown Met “ From” Date



MA Resource Limit



Date of Transfer

Asset Transferred






HOME EQUITY INTEREST

*C30 (Y0007) Community Coverage without LTC, Home Equity Interest Exceeds Limit, No Undue

Hardship, No Spenddown

(TAD Based) Applicant is eligible for Community Coverage without LTC. It has been determined

that the applicant(s) home equity interest exceeds the limit and that undue hardship does not exist.

There is no spenddown requirement.

S91 (Y0037) Community Coverage without LTC, Home Equity Interest Exceeds Limit, No Undue

Hardship, Excess Income, Spenddown Met

(Fill) (Budget Required) Applicant is eligible for Community Coverage without LTC with a

spenddown requirement and limited coverage. It has been determined that the applicant(s) home

equity interest exceeds the limit and that undue hardship does not exist. The applicant has met the

spenddown requirement for at least one month and up to five months. Worker must enter:



Net Income Amount

MA Income Limit


X91 (Y0033) Community Coverage without LTC, Home Equity Interest Exceeds Limit, No Undue

Hardship, Excess Income and/or Resources, Either Income and/or Resources Spenddown

Met or Resource and 6 month Spenddown met

(Fill) (Budget Required) Applicant is eligible for Community Coverage without LTC with a

spenddown requirement. It has been determined that the applicant(s) home equity interest exceeds

the limit and that undue hardship does not exist. The applicant has met the spenddown of income

for 6 months and/or resources have been spent down to MA level.


Message # 1 Over income

Net Income Amount



HOME EQUITY INTEREST (Cont’d)

MA Income Limit


6 Month Coverage “From” Date



MA Resource Limit


MA Coverage “To” Date

MA Coverage “From” Date

Message # 3 Over Income and Resources

Net Income Amount

MA Income Limit


MA Resource Limit



6 Month Coverage “From” Date

INCARCERATION

*C56 (U0176) Reopening: Case Closed as Incarcerated in Error (Upstate)

(TAD Based) Recipient’s original case was closed in error. Recipient

was not incarcerated.

*C57 (Y0070) (Open) Suspended MA Coverage for Inmate of NYS/Local Correctional Facility

(Upstate)

(TAD Based) Recipient’s coverage has been suspended due to incarceration in a NYS/Local

Correctional Facility.

*C66 (U0175) FHP to MA, Incarcerated Individual Released

(TAD Based) Recipient is no longer incarcerated. MA will be reinstated.

COUNTY TO COUNTY MOVE

C37 (Y0064)Transition of MA/FHP/FHP-PAP/MSP Eligibility, County “B” letter (NYC to

Upstate, Upstate to Upstate)

(NO Fill) Recipients case will be opened in County “B”.

OTHER

I94 Used as Case Reason Code When All Case Members Have an Individual Reason Code

Y99 Manual Notice Required

CLIENT NOTICES SYSTEM MANUAL CNS Section W - MA Denials

Revised December 2010 W-1

MEDICAL ASSISTANCE

To deny an MA Case, the worker chooses one of the following codes:

NOTE: Since MA uses only Extensive Fill and not Limited Fill, the word "Fill" will be used in this

section. The term "TAD Based" is also used in this section. TAD Based is the method of notice

production which requires no information to be entered on CNS.

FAILURE TO PROVIDE VERIFICATION

*E80 (D0043) Failure to Provide Required Information about Non-Applying Legally

Responsible Relative, Income and/or Resources

(TAD Based) Applicant failed to provide information about the income/resources of a non-

applying legally responsible relative. (LRR)

U20 (D0039) (D0040) Verification of Factors Which Affect Eligibility, Did Not State Unable

to Get Information (Fill) Applicant failed to provide documentation necessary to determine eligibility and did

not state unable to get information.

Worker must enter:

Documentation required on the Fail to Verify Selection Entry Screen (WCN140) and

the Fail to Verify Variable Entry Screen (WCN141) (See CNS Manual Section F).

U21 (D0041) (D0042) Verification of Factors Which Affect Eligibility, Unable to Get

Information, But Not a Good Reason (Fill) Applicant failed to provide documentation necessary to determine eligibility and did

not have a good reason for not obtaining this information.

Worker must enter:

Documentation required on the Fail to Verify Selection Entry Screen (WCN140) and

the Fail to Verify Variable Entry Screen (WCN141) (See CNS Manual Section F).

V17 (D0137) Incorrect/Fraudulent Social Security Number

(Fill) Applicant provided incorrect/fraudulent Social Security Number.

Worker must enter:

Name or Line # of person(s) with incorrect/fraudulent SSN

X23 (D0160) Deny MA/FHP, Attester Failed to Provide Amount of Resource(s) at

Application

(Fill) Applicant is ineligible for MA due to failure to document resources.

Worker must enter:

Resources not documented

FAILURE TO CHOOSE A HEALTH PLAN FOR FHP

X45 (D0123) Deny MA Due to Excess Income and/or Resources, Failed to Choose a Health

Plan for FHP, FP (Fill) (Budget Required) FP –Applicant failed to choose a health plan for Family Health Plus,



FAILURE TO CHOOSE A HEALTH PLAN FOR FHP (Cont’d)

which is a requirement for that program. MA ineligible due to excess income and/or

resources.


Message #1: Over Income

Net Income Amount

MA Income Limit


Message #2: Over Resources


MA Resource Limit


Message #3: Over Income and Resources

Net Income Amount

MA Income Limit


MA Resource Limit



X46 (D0124) Deny Medicaid Due to Excess Income, Failed to Choose

Health Plan for FHP, S/CC

(Fill) (Budget Required) S/CC –Applicant failed to choose a health plan for Family Health

Plus, which is a requirement for that program. Medicaid ineligible due to excess income

Worker must enter:

Net Income Amount

Medicaid Standard

X47 (D0125) Deny MA Due to Excess Income, Failed to Choose a Health Plan for FHP, FNP

Parent (Fill) (Budget Required) FNP Parent-Applicant failed to choose a health plan for Family

Health Plus, which is a requirement for that program. MA ineligible due to excess income

Use For All:

Net Income Amount

MA Income Limit

EXCESS INCOME/RESOURCES (S/CC, FNP PARENT)

U35 (D0115) Deny Medicaid Due to Excess Income, FHP Ineligible Due to Excess Income,

Non-ESHI, Federal Employee or ESHI Not Cost Effective. FPBP Ineligible Due to

Excess Income or Eligible but Declines, S/CC # (Fill) (Budget Required) Applicant is an S/CC who is being denied Medicaid due to

excess income, FHP ineligible due to excess income, non-ESHI, federal employee or

ESHI-Not Cost Effective, FPBP ineligible due to excess income or is eligible but declines.




EXCESS INCOME/RESOURCES (S/CC, FNP PARENT) (Cont’d)

Message #1: Gross Income Over 185% Medicaid Standard

Gross Income Amount


Message #2: Net Income Over Medicaid Standard

Net Income Amount

Medicaid Standard


Message #1: FHP Over Income

Gross Income Amount

FHP Income Limit

Message #2 Non-Employer Sponsored Health Insurance


Message # 5 Employer Sponsored Health Insurance-Not Cost Effective


Message #1: FPBP Over Income (No Need to Notify, No Message)

Message #2: FPBP Eligible but Declines

U49 (D0134) Deny Medicaid Due to Excess Income, FHP Ineligible Due to Excess Income,

Non-ESHI, Federal Employee, ESHI Not Cost Effective, FNP Parent

(Fill) (Budget Required) Applicant is an FNP parent who is being denied Medicaid due to

excess income, FHP ineligible due to excess income, Non ESHI, Federal Employee or ESHI-

Not Cost Effective. FPBP ineligible due to excess income or is eligible but declines.

Net Income Amount




Gross Income Amount

FHP Income Limit

Message #2 Non-Employer Sponsored Health Insurance


Message #4 Employer Sponsored Health Insurance-Not Cost Effective


Message #1: FPBP Over Income, No Need to Notify, No Message

Message #2: FPBP Eligible but Declines

EXCESS INCOME/RESOURCES/TRANSFERS(LIF, ADC-REL, SSI-REL, S/CC)

*E55 (X0077) Child 1-5, Excess Income

(TAD Based) (Budget Required) Child(ren) one through five, with net family income over

133% of the Federal Poverty Level. Income is over the Medicaid level. Also, we have not

received documentation that the applicant(s) has paid or unpaid medical expenses not

covered by insurance that are equal to or more than the excess income amount.



EXCESS INCOME/RESOURCES/TRANSFERS(LIF, ADC-REL, SSI-REL, S/CC) (Cont’d)

*E56 (X0078) Child 1-5, Excess Income and Resources

(TAD Based) (Budget Required) Child(ren) one through five, with net family income over

133% of the Federal Poverty Level. Income and countable resources are over the Medicaid

levels. Also, we have not received documentation that the applicant(s) has paid or unpaid

medical expenses not covered by insurance that are equal to or more than the excess income

and resource amounts.

*E59 (X0041) Pregnant Woman, Excess Income Over 200% of the FPL, Bills Do Not Meet

Spenddown

(TAD Based) (Budget Required) Applicant has net income over 200% of the Federal Poverty

Level. Medical bills do not equal or exceed the excess income amount.

*E67 (X0076) Child Up to Age One, Excess Income (Mother did not receive Medicaid in any

month of her pregnancy), Spenddown Not Met

(TAD Based) (Budget Required) Child(ren) up to the age of one, mother did not have

Medicaid coverage for any month of her pregnancy. Net family income is over 200% of the

Federal Poverty Level. Also, we have not received documentation that the applicant(s) has

paid or unpaid medical expenses not covered by insurance that are equal to or more than the

excess income amount.

S88 (D0158) Child 6-18, Deny MA Due to Excess Income or Income and Resources, FPBP

Ineligible Due to Excess Income, Eligible But Declines or Age Ineligible

(Tad Based) (Budget Required) Child(ren) 6-18 being denied for MA due to excess income

or excess income and resources. Also, we have not received documentation that the

applicant(s) has paid or unpaid medical expenses not covered by insurance that are equal to

or more than the excess income or income and resource amounts. FPBP ineligible due to

excess income, eligible but declines or is age ineligible.

U32 (X0008) Excess Income (Fill) (Budget Required) Applicant is ineligible for MA due to excess income. Also, we have

not received documentation that the applicant(s) has paid or unpaid medical expenses not

covered by insurance that are equal to or more than the excess income amount

Worker must enter:

Net Income Amount

MA Income Limit


U34 (D0116) Deny MA Due to Excess Income and/or Resources, FHP Ineligible Due to Excess

Income, Non-ESHI, Federal Employee or ESHI Not Cost Effective, FPBP ineligible Due

to Excess Income or Eligible but Declines, FP

(Fill) (Budget Required) FP-Applicant is ineligible for MA due to excess income and/or

resources. Also, we have not received documentation that the applicant(s) has paid or unpaid


and/or resource amounts. FHP ineligible due to excess income Non-ESHI,

Federal Employee, ESHI-Not Cost Effective, FPBP ineligible due to excess income or

is eligible but declines.






Net Income Amount

MA Income Limit




MA Resource Limit



Net Income Amount

MA Income Limit


MA Resource Limit





Gross Income Amount

FHP Income Limit



Message #4 Employee Health Insurance not cost effective


Message #1: FPBP Over Income (No Need to Notify, No Message)

Message #2: FPBP Eligible But Declines

U40 (X0009) Excess Resources (Fill) (Budget Required) Applicant is ineligible for MA due to excess resources. Also, we have

not received documentation that the applicant(s) has paid or unpaid medical expenses not covered

by insurance that are equal to or more than the excess resource amount

Worker must enter:



U59 (X0010) Excess Income and Excess Resources

(Fill) (Budget Required) Applicant is ineligible for MA due to income and resources over the

Medical Assistance limits. Also, we have not received documentation that the applicant(s) has

paid or unpaid medical expenses not covered by insurance that are equal to or more than the

excess income and resource amounts

Worker must enter:

Net Income Amount

MA Income Limit


MA Resource Limit






V85 (D0138) FPBP Ineligible Due to Excess Income, No Application for MA/FHP (Fill) (Budget Required) Applicant is ineligible for FPBP due to excess income. No application

was submitted for MA or Family Health Plus.

Worker must enter:

Net Income Amount

FPBP Income Limit

X10 (X0086) Inpatient Hospital Bill Does Not Meet 6-Month Excess Income Amount

(Fill) (Budget Required) Applicant’s inpatient hospital bills do not meet the six (6) month excess

income amount.

Worker must enter:

Six Month Excess Income Amount

Amount of Inpatient Hospital Bills

LIVING ARRANGEMENT

*E60 (D0006) Unable to Locate

(TAD Based) Applicant's whereabouts are unknown.

*E61 (D0005) Not a Resident of District

(TAD Based) Applicant is not a resident of the county.

*E62 (D0002) Between 21-65, In a Psychiatric Institution

(TAD Based) Applicant is in receipt of inpatient psychiatric services and is between 21-65 years

old.

*E63 (D0004) Not a State Resident

(TAD Based) Applicant living in another state.

*E79 (D0001) MA Not Provided in Current Living Arrangement

(TAD Based) Applicant is now residing in a public institution which provides medical care.

Example of an Institutions not covered by MA/FHP/FPBP is Veteran's (VA) Hospitals.

U79 (D0070) Concurrent benefits, Inter-state, Intra-state (Fill) Applicant has been determined to be receiving benefits from another location within or

outside NYS.

Worker must enter:

Location of Concurrent Benefit

U84 (D0102) Concurrent Benefits, AFIS-Match Intra-State

(fill) Applicant has been determined to be receiving benefits from another location

Worker must enter:

Location of Concurrent Benefit



OTHER FAILURES

*E09 (D0064) Photo ID Refusal (TAD Based) Applicant refused to comply with Photo ID Requirements.

*F12 (D0011) Failure to Apply for Social Security Benefits (TAD Based) Applicant failed to apply for Social Security benefits.

*F40 (D0008) Failure to enroll in a Group Health Plan Through Employer (TAD Based) Applicant refused to enroll in a health insurance plan offered through employer.

V13 (D0014) Failure to Apply for or Utilize Benefits and/or Resources (Fill) Applicant failed to apply for or use benefits and/or resources.

Worker must enter:

Benefit(s) or resource(s) which the recipient failed to apply for or use

V14 (D0026) Deny MA/FHP Failed to Complete Declaration of Citizenship/Immigration

Status (Fill) Applicant failed to complete the Declaration of Citizenship/Immigration status section of

the application for one or more household members.

Worker must enter:

Line number(s) of the individual(s) for whom the Declaration of

Citizenship/Immigration was not completed

V30 (D0007) Failure to Comply with IV-D Requirements (Fill) Applicant failed to comply with the Child Support Enforcement Unit to obtain medical

support or paternity for applying children whose parent(s) does not live with them.

Worker must choose one or more of the following messages and enter:

Message #1: Failure/Refusal to Assign Rights from Health Insurance

Did Not Assign Rights for Health Insurance From

Appropriate child(ren) Line Number(s)

Message #2: Failure to Assign Rights to Court Ordered Support

Did Not Assign Rights to Support for Medical Care From


Message #3: Failure/Refusal to cooperate with Child Support Enforcement Unit

regarding paternity - Failed to provide information

Line number of child for whom paternity was to be established


regarding paternity - Failed to appear as a witness

Line number of child for whom paternity was to be established


regarding support - Failed to provide information

Did Not Cooperate in Obtaining Support From


Message #6: Failure/Refusal to cooperate with the Child Support Enforcement Unit

regarding support - Failed to appear as a witness

Did Not Cooperate in Obtaining Support From



OTHER FAILURES (Cont’d)


V31 (D0013) Failure to Provide a Social Security Number (Fill) Applicant failed to provide a Social Security number(s) or proof of application for Social

Security number(s) for one or more household members.

Worker must enter:

Line number of individual(s) for whom no social security number

is provided

SPOUSAL IMPOVERISHMENT

*H10 (D0034) Spousal Impoverishment, Failure to Provide Resource Information, No Undue

Hardship (TAD Based) Institutionalized applicant failed to provide information about the amount/value of

the community spouse's resources. Undue hardship does not exist.

*H11 (D0038) Spousal Impoverishment, Failure to Provide Resource Information, Undue

Hardship (TAD Based) The amount/value of the community spouse's resources are unknown. Even though

undue hardship exits, the institutionalized spouse would not sign forms allowing Social Services

to seek the amount of the countable resources over the maximum community spouse allowance.

X13 (D0036) Spousal Impoverishment, Excess Resources for Institutionalized Spouse (Fill) The institutionalized spouse and the community spouse have countable resources that are

more than the MA resource levels. Medical bills do not equal or exceed the excess

resource amount.

Worker must enter:

Total countable resources for household

Community spouse resource allowance

MA resource level for one (1) institutionalized spouse

HEALTH INSURANCE

*E81 (D0074) QI-1 Annual Fund Exhausted (TAD Based) Medical Assistance cannot pay for Medicare Part B premium because funding has

been exhausted for the year.

U80 (D0072) Qualified Individual (QI-1), Over Income or Other (Fill) (Budget Required) Applicant is not QI-1 eligible. MA will not pay for Medicare Part B

premiums.



Net Income Amount

135% of the Federal Poverty Level

Message #2: Other

Reason for Denial



HEALTH INSURANCE (Cont’d)

X25 (D0159) Deny MA Payment of Health Insurance Premiums (Fill) MA will not pay for health insurance premiums for one of the following reasons.


Message #1: Not Cost Effective

Message #2: No Longer Insured

Message #3: Other

Reason for Denial

X50 (D0016) Deny Payment of Cobra Continuation of Group Health Insurance Premiums (Fill) (Budget Required) MA will not pay for COBRA Continuation of Group Health Insurance

premiums for one or more of the following reasons.


Message #1: Not Entitled to COBRA Continuation Coverage

Reason not entitled to COBRA


Net Income Amount

Income Limit



Resource Limit

Message #4: Not Cost Effective

Message #5: Only Available for 75 or More Employees

Message #6: Other

Reason for Denial

X52 (D0023) Medicare Buy-In Program, QMB Ineligible (Fill) (Budget Required) MA will not pay for Medicare premiums, deductibles and

coinsurance for Qualified Medicare Beneficiaries (QMB). This is because the recipient has excess

income is not enrolled in or eligible for Medicare Part A or other reason(s)



Net Income Amount

Income Limit (100% of the Federal Poverty Level)

Message # 2: Applicant is not Enrolled in or Eligible for Medicare Part A from

SSA (choose one)

Not Enrolled In

Not Eligible For

Message # 3: Other

Reason for Denial

X53 (D0045) Medicare Buy-In Program, SLIMB Ineligible (Fill) (Budget Required) MA will not pay for Medicare premiums for Specified Low Income

Medicare Beneficiaries (SLIMB) for one or more of the following reasons.





HEALTH INSURANCE (cont’d)

Net Income Amount

Income Limit (120% of the Federal Poverty Level)

Message #2: Not Enrolled in or Eligible for Part A From SSA (choose one)

Not Enrolled In

Not Eligible For

Message #3: Other

Reason for Denial

MBI-WPD (Medicaid Buy-In for Working People with Disabilities)

*B44 (D0149) MBI-WPD Ineligible, Failed to Provide a Medical Statement (TAD Based) Applicant failed to provide a medical statement.

*B45 (D0150) MBI-WPD Ineligible, Death Before Determination, Insufficient Information to

Make Determination

(TAD Based) Applicant has become deceased before a determination was made. Not enough

information to make a determination.

*B46 (D0151) MBI-WPD Ineligible, Death Before Determination, No Medical Bills in Retro Period

(TAD Based) Applicant has become deceased before a determination was made. There are no

medical bills in the retro period.

U19 (D0152) MBI-WPD Ineligible Due to Excess Income and/or Resources, MA Ineligible Due to

Excess Income and/or Resources,

(Fill) (Budget Required) Applicant is ineligible for MBI-WPD due to excess income and/or

resources. MA ineligible due to excess Income and/or resources. Also, we have not received

documentation that the applicant(s) has paid or unpaid medical expenses not covered by insurance

that are equal to or more than the excess income and/or resource amounts. FHP ineligible


Message # 1 Over Income MBI-MA

Net Income Amount


Net Income Amount

MA Income Limit




MA Resource Limit


Message # 3 Over Income and Resources for MBI and MA

Net Income Amount



MA Resource Limit

Net Income Amount



MBI-WPD (Medicaid Buy-In for Working People with Disabilities) (Cont’d)

MA Income Limit



Message # 4 Over Resources MBI and Over Income and Resources MA


MA Resource Limit

Net Income Amount

MA Income Limit



U60 (D0154) MBI-WPD Ineligible, Not Currently Working, MA Ineligible Due to Excess Income

and/or Resources, FHP Ineligible Due to Excess Income, Equivalent

Health Insurance or Federal Employee.

(Fill) (Budget Required) Applicant is ineligible for Medicaid coverage under the Medicare Buy-In

program for Working People with Disabilities because they are not currently working. Applicant

is ineligible for Medicaid due to excess income and/or resources. Also, we have not received


that are equal to or more than the excess income and/or resource amounts. We also evaluated

eligibility for FHP, the applicant is ineligible for FHP due to excess income, equivalent health

insurance or federal employee.



Net Income Amount








Net Income Amount








Gross Income Amount

FHP Income Limit


Message #2: Equivalent Health Insurance

Message #3: FHP Federal Employee



U62 (D0156) MBI-WPD Ineligible, Not Certified Disabled, MA Ineligible Due to Excess Income,

FHP Ineligible Due to Excess Income, Equivalent Health Insurance or Federal Employee,

FP


program for Working People with Disabilities because it was determined that the applicant is not

disabled. Applicant is ineligible for Medicaid due to excess income. Also, we have not received


that are equal to or more than the excess income and/or resource amounts. We also evaluated


insurance or Federal Employee.

Use For All:

Net Income Amount





Gross Income Amount

FHP Income Limit


Message #3: Federal Employee

U64 (D0157) MBI-WPD Ineligible, Not Certified Disabled, Medicaid Ineligible Due to Excess

Income, FHP Ineligible Due to Excess Income, Equivalent Health Insurance or Federal

Employee, S/CC (Fill) (Budget Required) Applicant is ineligible for Medicaid coverage under the Medicare Buy-In


disabled. Applicant is ineligible for Medicaid due to excess income. We also evaluated


insurance or federal employee.


Message #1: Gross Income Over 185% Medicaid Standard

Gross Income Amount


Message #2: Net Income Over Medicaid Standard

Net Income Amount

Medicaid Standard



Gross Income Amount

FHP Income Limit



U70 (D0155) MBI-WPD Ineligible, Failed to Submit Proof of Work, MA Ineligible Due to Excess

Income and/or Resources, FHP Ineligible Due to Excess Income and/or Resources or

Equivalent Health Insurance.




(Fill) (Budget Required) Applicant is ineligible for MA coverage under the Medicare Buy-In

program for Working People with Disabilities because it was determined that the applicant failed

to submit proof of employment. Applicant is ineligible for MA due to excess income and/or

resources. Also, we have not received documentation that the applicant(s) has paid or unpaid


and/or resource amounts. We also evaluated eligibility for FHP, the applicant is ineligible for

FHP due to excess income and/or resources or equivalent health insurance.



Net Income Amount

MA Income Limit




MA Resource Limit



Net Income Amount

MA Income Limit


MA Resource Limit





Gross Income Amount

FHP Income Limit

Message #2: FHP Over Resources


FHP Resource Limit

Message #3: FHP Over Income and Resources

Gross Income Amount

FHP Income Limit


FHP Resource Limit


U74 (D0162) MBI-WPD Ineligible, Not Certified Disabled, MA Ineligible Due to Excess Income,

FHP Ineligible Due to Excess Income, Equivalent Health Insurance or Federal Employee,

FNP Parent



disabled. Applicant is ineligible for Medicaid due to excess income. We also evaluated eligibility

for FHP, the applicant is ineligible for FHP due to excess income, equivalent health insurance or

public federal employee.




Net Income Amount




Gross Income Amount

FHP Income Limit


Message #3: Federal employee

ALIENS

*E06 (D0060) MA Ineligible, Non-Immigrant/Undocumented Immigrant, No Medical Emergency (TAD Based) Applicant is a non-immigrant/undocumented immigrant who does not have a

medical emergency.

U63 (X0127) Non-Immigrant/Undocumented Immigrant, Emergency Medical Condition, Excess

Income and/or Resources, FP (Fill) (Budget Required) Applicant is an FP non-immigrant/undocumented immigrant who is

ineligible for emergency medical assistance due to excess income and/or resources.

Worker must enter:

Medical Emergency “From” Date

Medical Emergency “To” Date



Net Income Amount

MA Income Limit




MA Resource Limit



Net Income Amount

MA Income Limit


MA Resource Limit



U73 (D0065) Non-Immigrant/Undocumented Immigrant, Emergency Medical Condition, Excess

Income, S/CC (Fill) (Budget Required) Applicant is an S/CC non-immigrant/undocumented immigrant who is

ineligible for emergency medical assistance due to excess income.

Worker must enter:

Medical Emergency “From” Date

Medical Emergency “To” Date



ALIENS (Cont’d)


Message #1: Gross Income Over 185% of the Medicaid Standard

Gross Income Amount



Net Income Amount

Medicaid Standard

OTHER

*E18 (D0047) Death before Determination, No Medical Bills in Retro Period

(TAD Based) Applicant died before the eligibility determination was completed. There were

no medical bills for MA covered services in the month of application or in the three (3) months

prior to the month of application.

*E19 (D0048) Death Before Determination, Insufficient Information to Make a Determination

(TAD Based) Applicant died before the eligibility determination was completed. There was

insufficient information to make a determination.

*F29 (D0018) Deny MA, Entered State to Obtain Medical Care

(TAD Based) Medical Assistance is not available to persons temporarily in the State. Applicant

has entered the state for the sole purpose of obtaining medical care.

*H15 (D0050) Deny MA/FHP Voluntary Withdrawal of Application (TAD Based) Applicant has made a verbal request or a written request that the Medical

Assistance application be withdrawn.

U66 (D0003) Deny MA/FHP/FPBP Currently in Receipt of Assistance Within the Same District (Fill) Applicant is already receiving MA/FHP/FPBP under another case number.

Worker must enter:

Case number under which recipient is currently receiving benefits

Y99 Other - Manual Notice Required Denial for cases which there is no appropriate CNS reason code. No notice is generated by the

system. Workers must manually complete the notice. For Upstate, worker must enter an "N" in

the Notice Indicator field on the TAD.

NO ELIGIBLE INDIVIDUAL

I94 Used as the case reason code when all case members have an individual reason code.

CLIENT NOTICES SYSTEM MANUAL CNS Section X - MA Case/Individual Discontinuance Codes

Revised December 2010 X-1

MEDICAL ASSISTANCE

To close an MA/FHP/FPBP case, the worker chooses one of the following codes:

NOTE: Since MA uses only Extensive Fill and not Limited Fill, the word "Fill" will be used in this

section. The term "TAD Based" is also used in this section. TAD Based is defined as the

method of notice production which requires no information to be entered on CNS.

FAILURE TO RECERTIFY

*F10 (C0195) Discontinue MA/RMA/FHP/FHP-PAP, Failed to Return Renewal Form

(TAD Based) Recipient or their representative has failed to return the renewal form.

U14 (C0261) Failed to Return FPBP Renewal Form

(TAD Based) Recipient or their representative has failed to return the renewal form.


*E80 (C0067) Discontinue MA/FHP, Failure to Provide Required Information About Non-

Applying Legally Responsible Relative, Income and/or Resources

(TAD Based) Recipient failed or refused to verify the income and/or resources of the non-

applying legally responsible relative(s).

*C88 (C0300) Discontinue MA/FHP/FHH-PAP/FPBP, Failure to Provide Proof of U.S. Citizenship

and Identity

(TAD Based) Recipient failed to provide documentation proving U.S. Citizenship and identity.

S63 (C0248) Discontinue MA/FHP/FPBP, Failure to Provide Information to Clear Up Income

and/or Resource Information Discrepancy

(Fill) Recipient failed to submit information explaining discrepancies regarding income and/or

resources reported by the recipient and the investigation by the LDSS office.

Worker must enter:

Due Date

Owner of Resource

Resource(s) Failed to Verify

U20 (C0063/C0064) Discontinue MA/RMA/FHP/FHP-PAP/FPBP Due to Verification of

Factors Which Affect Eligibility, Did Not State Unable to Get Information

(Fill) Recipient failed to provide documentation to verify continuing eligibility and did not state

unable to get the information.

Worker must select one or more of failed to provide reasons:

The information required on the Fail to Verify Selection Entry Screen(WCN140) and the

Fail to Verify Variable Entry Screen(WCN141) (See CNS Manual Section F)

U21 (C0065/C0066) Discontinue MA/RMAFHP/FHP-PAP/FPBP Due to Verification of

Factors Which Affect Eligibility, Unable to Get Information, But Not a Good Reason

(Fill) Recipient failed to provide documentation necessary to determine continuing eligibility

and did not have a good reason for not obtaining this information.

Worker must select one or more of failed to provide reasons:



FAILURE TO PROVIDE VERIFICATION (Cont’d)

The Information required on the Failure to Verify Selection Entry Screen (WCN140) and

the Fail to Verify Entry Screen (WCN141) (See CNS manual Section F)

V17 (C0050) Incorrect or Fraudulent Social Security Number

(Fill) Recipient submitted an incorrect/fraudulent Social Security number.

Worker must enter:

Individual name or line of person(s) with incorrect Social Security Number

X23 (C0265) Failed to Provide Amount of Income and/or Resource(s) at Renewal

(Fill) Recipient failed to document income and/or resources at renewal.

Worker must enter:

Income and/or Resources not Verified

OTHER FAILURES

*E09 (C0126) Photo ID Refusal

(TAD Based) Recipient refused to have Photo ID taken.

*E22 (X0088) Failed to Meet or Pay-In Excess Income for 3 Consecutive Months

(TAD Based) Recipient has failed to meet the excess income liability for three or more

consecutive months. Also, no paid or unpaid medical bills have been submitted that are equal

to or more than the excess income amount.

*F12 (C0012) Failure to Apply for Social Security Benefits

(TAD Based) Recipient failed to apply for Social Security benefits.

*F40 (C0009) Failure to Enroll in a Group Health Plan (TAD Based) Recipient has refused to enroll in a free health insurance plan offered through

their employer.

V13 (C0015) Failure to Apply for or Utilize Benefits

(Fill) Recipient failed to apply for or use benefits or resources that can reduce or end the need

for MA/FHP.

Worker must enter:

Benefit or resource not applied for

V30 (C0008) Failure to Comply with IV-D Requirements (Fill) Recipient did not comply with the Child Support Enforcement Unit to obtain medical

support or proof of paternity from the absent parent. Failure to comply without good cause is

grounds for discontinuance of MA/FHP benefits.


Message # 1- Assign Rights From Health Insurance

Absent Parent’s name

Appropriate child(ren)’s line number(s) for CT 20 or name(s) for CT 24

Message # 2 – Assign Rights From Court Ordered Support

Did not assign rights for medical care from Name of Absent parent


Message # 3- Cooperate with CSEU Regarding Paternity Fail to Provide Information



OTHER FAILURES

Did not cooperate in establishing paternity Line number(s) for CT 20 or name(s) for

CT 24 of child (ren) for whom paternity was to be established

Message # 4-Cooperate with CSEU Regarding Paternity Fail to Appear As a Witness

Did not appear as a witness in establishing paternity for line number(s) for CT 20 or

name(s) CT 24 of child (ren)

Message #5-Cooperate with CSEU Regarding Child Support Fail to Provide Information

Did not cooperate in obtaining support from Name of absent parent

Appropriate child (ren)’s line number(s) for CT 20 or name for CT 24

Message #6-Cooperate with CSEU Regarding Child Support Fail to Appear As a

Witness


Appropriate child (ren)’s line number(s) for CT 20 or name for CT 24

V31 (C0014) Failure to Provide Social Security Number

(Fill) Recipient failed to provide or apply for a Social Security number of all household

members applying.

Worker must enter:

Line number of individual whose Social Security number was not provided

V38 (C0072) Failure to Contact Agency as Requested (Fill) Recipient failed to contact agency with information required to make a determination for

MA.

Worker must enter:

Contact date


U57 (C0183) Discontinue Medicaid Due to Excess Income, FHP Ineligible Due to Excess

Income Equivalent Insurance or Employee, FPBP Ineligible Due to Excess Income or

Eligible But Declines, S/CC

(Fill) (Budget Required) Recipient is an S/CC individual who is no longer eligible for

MA/FHP. Recipient is Medicaid ineligible due to excess income, FHP ineligible due to excess

income equivalent health insurance or Federal employee. FPBP ineligible due to excess income

or eligible but declines.



Gross Income Amount

FHP Income Limit



U72 (C0136) Excess Income Due to COLA, S/CC

(Fill) (Budget Required) Due to COLA the recipient’s income is over the allowable MA income

limit.


Net Income Amount

Net Income Limit



EXCESS INCOME/RESOURCES (S/CC, FNP PARENT) (cont’d)

V94 (C0099) Discontinue FHP/FHP-PAP Due to Excess Income, FPBP Ineligible Due to Excess

Income or Eligible But Declines

(Fill) (Budget Required) Recipient is FHP ineligible due to excess income, FPBP ineligible due

to excess income or eligible but declines.

Use For All:

Gross Income Amount

FHP Income Limit

X17 (P0005) Discontinue Mother, Medicaid Ineligible Due to Excess Income and/or Resources,

FHP Ineligible Due to Excess Income and/or Resources, FPBP Ineligible Due to Excess

Income, 60 Days Post-Partum, No Infant, S/CC

(Fill) (Budget Required) Recipient is an S/CC individual, 60 days post-partum, while pregnant

income was compared to 200% of the FPL. Income is now compared to the MA/FHP income

limits. Recipient is MA/FHP ineligible due to excess income and/or resources, FPBP ineligible

due to excess income. No Infant.


Message #1 FHP Over Income

Gross Income Amount

FHP Income Limit

Message # 2 FHP Over Resources


FHP Resource Limit

Message # 3 FHP Over Income and Resources

Gross Income Amount

FHP Income Limit


FHP Resource Limit

X48 (C0235) Discontinue Medicaid Due to Excess Income, FHP Ineligible Due to Excess

Income Equivalent Insurance or Employee, FPBP Ineligible Due to Excess Income or

Eligible But Declines, FNP Parent

(Fill) (Budget Required) Recipient is an FNP Parent. Medicaid ineligible due to excess income,

FHP ineligible due to excess income equivalent health Insurance or federal employee, FPBP

ineligible due to excess income or eligible but declines.



Gross Income Amount

FHP Income Limit



Choose one of the following messages:

REFUGEE MEDICAL ASSISTANCE (RMA)

X28 (C0274) Discontinue RMA, MA Ineligible Due to Excess Income, FHP Ineligible due to

Over Income, Equivalent Health Insurance or Federal Employee, FPBP Ineligible

Due to Over Income or Eligible but Declines



REFUGEE MEDICAL ASSISTANCE (RMA) (Cont’d)

(Fill) (Budget Required) Recipient will be discontinued for Medicaid coverage under the

Refugee Medical Assistance Program. Ineligible for MA due to excess income. Ineligible

for FHP due to excess income, equivalent insurance or federal employee. FPBP over

income or eligible but declines.

Worker must choose one of the following and enter:

Message#1 Over Income

Gross Income Amount

Family Health Plus Income Limit

Message #2 Equivalent Insurance

Message #3 federal Employee

EXCESS INCOME/RESOURCES /TRANSFER (LIF, ADC-REL, SSI-REL, S/CC)

*E44 (X0064) Child Turning 6, Excess Income, Spenddown Not Met

(TAD Based) (Budget Required) When a child becomes 6 years old, the Medicaid level

changes from 133% to 100% of the FPL. Now that the net income is over 100% of the FPL, it

is now compared to the Medicaid limit. If the recipient is blind or disabled to qualify for

spenddown, the recipient must tell us about their resources if they have not already done so.

Also, if the recipient incurs medical bills equal to or more than the excess income amount, they

may reapply.

*E45 (X0065) Child Turning 6, Excess Income and Resources, Spenddown Not Met

(TAD Based) (Budget Required) When a child becomes 6 years old, the Medicaid level

changes from 133% to 100% of the FPL. Now that the net income is over 100% of the FPL, it

is now compared to the Medicaid limit and there is now a resource test. We have not received

documentation that the recipient has spent down the excess resources by establishing or adding

to a burial trust/ fund. Also, if the recipient incurs medical bills in the amount of the excess

resources or has bills equal to or more than the excess income amount, or if the income or

resources go down, they may reapply.


(TAD Based) (Budget Required) When a child turns age 1, the Medicaid level changes from

200% to 133% of the FPL. Because the net income is over 133% of the FPL, it is now

compared to the Medicaid limit. If eligibility is based on being certified blind or disabled,

resources will be compared to the Medicaid resource limit. To qualify for spenddown, the

recipient must tell us about their resources if they are certified blind or disabled if they have not

already done so. Also, if the recipient incurs medical bills in the amount of the excess income

or the income goes down, they may reapply.

*E55 (X0060) Child 1-5, Excess Income, Spenddown Not Met

(TAD Based) (Budget Required) The net income is more than 133% of the FPL which is the

income level for a child age 1-5. Now that the net income is over 133% of the FPL, it is now


resources will be compared to the Medicaid Resource Limit. To qualify for spenddown, the


already done so. Also, if the recipient incurs medical bills in the amount of the excess income

or the income goes down, they may reapply.



EXCESS INCOME/RESOURCES /TRANSFER (LIF, ADC-REL, SSI-REL, S/CC) (Cont’d)

*E56 (X0061) Child 1-5, Excess Income and Resources, Spenddown Not Met

(TAD Based) (Budget Required) For a child between the ages of 1-5 net income is compared

to 133% of the FPL. Now that the income and countable resources are over 133% of the FPL,

income is now compared to the Medicaid limit and there is now a resource test. We have not

received documentation that the recipient has spent down the excess resources by establishing

or adding to a burial trust/ fund. Also, if the recipient incurs medical bills in the amount of

the excess resource or has bills equal to or more than the excess income amount, or if the

income or resources go down, they may reapply.

*E68 (X0067) Child Turning 1, Excess Income and Resources, Spenddown Not Met

(TAD Based) (Budget Required) When a child turns age 1, the Medicaid level changes from

200% to 133% of the FPL. Now that the net income and countable resources are over 133%

of the FPL, income is now compared to the Medicaid limit and there is now a resource test.

We have not received documentation that the recipient has spent down the excess resources

by establishing or adding to a burial trust/ fund. Also, if the recipient incurs medical bills in

the amount of the excess resource or has bills equal to or more than the excess income

amount, or if the income or resources go down, they may reapply.

U32 (X0022) Excess Income

(Fill) (Budget Required) Recipient has excess income over the allowable MA income level.

Also, the recipient did not have paid or unpaid medical expenses not covered by insurance that

are equal to or more than the excess income amount. To qualify for spenddown, the recipient

must tell us the amount of their resources if they have not already done so. If recipient incurs

medical bills in the amount of the excess income, they may reapply.

Worker must enter:

Net Income Amount

MA Income Limit


U33 (X0170) Turning 19, Medicaid Ineligible Due to Excess Income and/or Resources, FHP

Ineligible Due to Excess Income Equivalent Health Insurance or Federal Employee, FPBP

Ineligible Due to Excess Income or Eligible But Declines (Fill) (Budget Required) For a child under age 19 the net income is compared at 100% of the

FPL. When the child turns 19 the income and resources are compared to the MA/FHP income

limits and there is no longer a consideration of expanded budgeting. Recipient is now Medicaid

ineligible due to excess income and/or resources, FHP ineligible due to excess income equivalent

health insurance or federal employee, FPBP ineligible due to excess income or eligible but

declines.



Gross Income Amount

FHP Income Limit






U40 (X0023) Excess Resources

(Fill) (Budget Required) Recipient has excess resources over the allowable MA resource limit.

Also, we have not received documentation that the recipient has unpaid medical expenses not

covered by insurance equal to or more than the excess resource amount or that they have spent

down resources by establishing or adding to a burial trust/fund. If the recipient incurs bills in the amount of

the excess resource or the resources go down, they may reapply.

Worker must enter:



U58 (C0184) Discontinue Medicaid Due to Excess Income and/or Resources, FHP Ineligible

Due to Excess Income Equivalent Insurance or Federal Employee, FPBP Ineligible Due to

Excess Income or eligible but Declined, FP

(Fill) (Budget Required) Recipient is an FP individual ineligible for Medicaid due to excess

income and/or resources, FHP ineligible due to excess income equivalent health insurance or

Federal employee, FPBP ineligible due to excess income or eligible but declines.



Gross Income Amount

FHP Income Limit



U59 (X0024) Excess Income and Resources

(Fill) (Budget Required) Recipient has excess income and resources over the allowable MA

limit. Also, we have not received documentation that they have spent down resources by

establishing or adding to a burial trust/fund. If the recipient incurs bills in the amount of the

excess resources or expects to have medical bills that are equal to or more than the excess

income amount or if the income or resources go down, they may reapply.

Worker must enter:

Net Income Amount

MA Income Limit



Excess Resource Limit

U91 (C0226) Child 6-18, Discontinue Medicaid Due to Excess Income or Income and

Resources, FPBP Ineligible Due to Excess Income, Eligible but Declines or Age Ineligible

(Budget Required) Discontinuance-Recipient is a child(ren) between the ages of 6-18,

Medicaid ineligible due to excess income or Income and resources, FPBP ineligible due to



V84 (C0190) FPBP Ineligible Due to Excess Income, Over 19

(Tad Based)(Budget Required) Recipient is over 19 years of age, FPBP ineligible due to excess

income.




V94 (C0099) Discontinue FHP Due to Excess Income and/or Resources, FPBP Ineligible Due

to Excess Income or Eligible But Declines

(Tad Based) (Budget Required) Recipient is FHP ineligible due to excess income and/or

resources, FPBP ineligible due to excess income or is eligible but declines.


FHP Ineligible Due to Excess Income, FPBP Ineligible Due to Excess Income, 60 Days

Post-Partum, No Infant, FP

(Tad Based) (Budget Required) Recipient is an FP individual no longer pregnant and at the end

of the 60 day post-partum period. There is no infant. While pregnant income was compared to

200% of the FPL. Now it is compared to the MA limit. Recipient is ineligible for MA due to

excess income and/or resources, FHP ineligible due to excess income, FPBP ineligible due to

excess income.

FAMILY HEALTH PLUS (FHP) DISCONTINUANCE TURNING 65

X83 (X0205) Discontinue FHP, Turning 65, Medicaid Ineligible Due to Excess Income

(Tad Based) (Budget Required) FHP Recipient is turning 65. Until recipient turned 65 we

compared income and resources to FHP limits, now we compare them to the Medicaid income.

Recipient is no longer eligible for FHP, Medicaid ineligible due to excess income. If the

recipient incurs medical bills in the amount of the excess income, or the income goes down,

they may reapply.

Worker must enter:

Medicaid

X84 (X0206) Discontinue FHP, Turning 65, Medicaid Ineligible Due to Excess Resources

(Tad Based) (Budget Required) FHP Recipient is turning 65. Until recipient turned 65

we compared income and resources to FHP limits, now we compare them to the Medicaid

income and resource limits. Recipient is no longer eligible for FHP, Medicaid ineligible due

to excess resources. Also, we have not received documentation that the recipient has spent

down the excess resources by establishing or adding to a burial trust/fund, if the recipient incurs

medical bills in the amount of the excess resource, or the resources goes down, they may

reapply.

X85 (X0207) Discontinue FHP, Turning 65, Medicaid Ineligible Due to Excess Income and

Resources

(Tad Based) (Budget Required) FHP Recipient is turning 65. Until recipient turned 65 we

compared income and resources to FHP limits, now we compare them to the Medicaid income

and resource limits. Recipient is no longer eligible for FHP, Medicaid ineligible due to excess

income and resources. Also, we have not received documentation that the recipient has spent

down the excess resources by establishing or adding to a burial trust/fund. If the recipient incurs

medical bills in the amount of the excess resources and expects to have bills equal to or more

than the excess income or the income and resources goes down, they may reapply.

Worker must enter:



FAMILY HEALTH PLUS/EMPLOYER SPONSORED HEALTH INSURANCE

C35 (C0177) Discontinue FHP-PAP, ESHI is not cost effective, Ineligible for FHP due to


(No fill) Recipient is ineligible for Family Health Plus-PAP due to equivalent health insurance.


Message # 2 FHP Public Employee

QUALIFIED INDIVIDUAL

*E81 (C0101) QI-1 Annual Fund Exhausted

(TAD Based) Recipient will no longer receive payment for Medicare Part B premium. The

funding has been exhausted for the year.

X18 (C0019) Discontinue Payment of Medicare Part B Premiums, QI-1

(Fill) (Budget Required) Recipient’s MA payment of Medicare Part B premium payment will

be discontinued. This change is due to excess income, not enrolled in or eligible for Medicare

Part A or other reason(s). Changes will be reflected in the recipients Social Security benefit

check within 90 days.



Net Income Amount

QI-1 Income Limit

Message # 2 Not Enrolled In or Eligible for Medicare Part A From SSA

Message # 3 Other

Reason for discontinuance

X70 (C0102) QI-1, Over Income

(Fill) (Budget Required) Recipient’s MA coverage for QI-1 will end due to excess income, MA

will no longer pay Medicare Part B Premiums.

Worker must enter:

Net Income Amount

QI-1 Income Limit

EQUIVALENT HEALTH INSURANCE / PUBLIC EMPLOYEE

V39 (C0206) Discontinue FHP Due to Equivalent Health Insurance or federal employee

(Fill) Recipient is ineligible for FHP due to equivalent health insurance or federal employee.

Worker Must Choose One of The Following:



INCARCERATION

*C53 (C0282) Discontinue MA/FHP, Incarceration Out of State or Federal Penitentiary Within

NYS

(TAD Based) Discontinuance-Recipient’s MA/FHP coverage will be discontinued. This

is because recipient is incarcerated in an Out of State or Federal Penitentiary within NYS.

*C58 (C0283) Discontinue Payment of Health Insurance Premiums of Inmate of NYS or Local



INCARCERATION (cont’d)

Correctional Facility

(TAD Based) Discontinuance-Recipient’s payment of Health Insurance Premiums. This

is because recipient is an Inmate of a NYS or Local Correctional Facility.

*C59 (C0289) Discontinue Medicare Savings Program of Inmate if NYS or Local Correctional

Facility

(TAD Based) Discontinuance-Recipient’s Medicare Savings Program. This is because recipient

is an Inmate of a NYS or Local Correctional Facility.

*C69 (C0292) Discontinue MA/FHP, Incarcerated Individual Released to Custody of

United States Immigration and Customs Enforcement (ICE)

(TAD Based) Discontinuance-Recipient’s MA/FHP coverage will be discontinued. This

is because recipient was Released into the Custody of United States Immigration and

Customs Enforcement (ICE).

LIVING ARRANGEMENT

*C65 (C0197) Discontinue MA/FHP/FHP-PAP/MSP, Not a Resident of District, County to County Move

(TAD Based) Recipient moved from one county to another.

*E60 (C0007) Unable to Locate

(TAD Based) Recipient’s whereabouts are unknown. If recipient receives this notice and is still

in need of MA/FHP/FPBP they may contact the LDSS office.

*E61 (C0005) Not a Resident Of District

(TAD Based) Recipient is not a resident of the county, if the recipient is still in need of

MA/FHP they may contact the LDSS in the county they are now residing in.

*E62 (C0002) Between 21-65, In a Psychiatric Institution

(TAD Based) Recipient is between 21-65 years of age, receiving inpatient psychiatric care in an

institution.

*E63 (C0004) Not a State Resident

(TAD Based) Recipient is not a resident of New York State.

*E79 (C0001) Medicaid Not Provided in Current Living Arrangement

(TAD Based) Recipient lives in a public institution that provides medical care. Example of an

Institution not covered by MA/FHP/FPBP is Veteran's (VA) Hospitals.

U65 (C0006) Not a Resident of District (MA Extension) Note: Message #1 and #3 re: TMA are not available for CT 24

(Fill) Recipient is no longer living in the county, but is eligible for MA in their new district.

Recipient must file an application in the new district.


Message # 1- (Upstate Only) You are currently receiving a four month extension.

Eligible “To” Date (MMDDYY) (Date must be equal to or greater than today’s date) (this

message not available for CT 24)



LIVING ARRANGEMENT (cont’d)

Message # 2- (Statewide) You were determined eligible for MA during your pregnancy.

Eligible “To” Date (MMDDYY) (Date must be equal to or greater than today’s date)

Message # 3 (Upstate Only) You are currently receiving Transitional Medical Assistance

(this message not available for CT 24)

Message # 4 (Statewide) Your baby is eligible to receive Medical Assistance. Eligible

“To” Date (MMDDYY) (date must be equal to or greater than today’s date)

U77 (C0140) Concurrent Benefits, Intra-State, No Aid Continuing

(Fill) Recipient’s identity matches a person who is already receiving MA/FHP/FPBP benefits in

NYS. Worker must enter:

Location of Concurrent Benefits

U78 (C0141) Concurrent Benefits, Inter- State, Aid Continuing (Fill) Recipient’s identity matches a person who is already receiving MA/FHP/FPBP benefits in

another State.

Worker must enter:



*H10 (C0051) Spousal Impoverishment, Failure to Provide Resource Information, No Undue

Hardship

(TAD Based) Recipient failed to provide documentation of their spouse’s resource(s) necessary

to determine eligibility. Undue hardship does not exist.

*H11 (C0052) Spousal Impoverishment, Failure to Provide Resource Information, Undue

Hardship

(TAD Based) Recipient failed to provide documentation of their spouse’s resource(s) necessary

to determine eligibility. Undue hardship does exist, but recipient refuses to sign forms allowing

us to seek the amount of the resource.

X13 (C0054) Spousal Impoverishment, Excess Resources For Institutionalized Spouse

(Fill) Recipient and/or spouse have countable resources which are over the

resource limit and did not have medical bills that are equal to or more than the amount over the

resource standard.

Worker must enter:

Total Countable Resources For Household

Community Spouse Resource Allowance

Resource Limit for Institutionalized Spouse

TRANSITIONAL MEDICAL ASSISTANCE (TMA)

*H30 (C0033) Discontinue TMA, No Dependent Child Under 21

(TAD Based) TMA will discontinue because there is no longer a dependent child under 21

living in the household. Recipient may continue to be eligible for MA/FHP. A renewal

package will be sent and must be completed and returned by the due date.

*H31 (C0034) TMA Discontinuance, Fraud (Statewide)



TRANSITIONAL MEDICAL ASSISTANCE (TMA) (Cont’d)

(TAD Based) TMA will discontinue because the recipient was convicted of Public Assistance

fraud by a court of law.

*H32 (C0035) TMA Discontinuance, Receiving PA, MA Continues (Upstate)

(TAD Based) TMA will discontinue because the recipient is now receiving Public Assistance.

MA will continue on the PA case.

HEALTH INSURANCE

X14 (C0098) No Longer Eligible for MA Payment of AHIP Premiums

(Fill) (Budget Required)

Recipient is no longer eligible for health insurance payments under the Aids Health Insurance

Program. This is because the recipient failed to complete the eligibility process, has excess

income, is MA eligible, eligible for COBRA, has moved out of the state, has failed to verify

required information or has failed to provide information from an RFI match.


Message # 1 Failed to complete the MA eligibility process


Message # 3 Eligible for MA

Message # 4 Eligible for COBRA

Message # 5 Moved out of State

Message # 6 Failure to verify

Message # 7 Failed to provide documentation of computer match income

Worker must enter:

Line Number for whom documentation was not provided

Resource(s)

X25 (C0264) Discontinue MA Payment of Health Insurance Premiums

(Fill) Recipient’s MA payment of health insurance premiums will be discontinued. This is

because it is no longer cost effective, participation in an insurance plan has been discontinued

or other reason(s).


Message # 1 Not Cost Effective

Message # 2 No Longer Insured

X50 (C0031) Discontinue Payment of COBRA, Continuation of Group Health Insurance

Premiums

(Fill) (Budget Required) Recipient is no longer eligible for payment of group health insurance

under COBRA, this is because the recipient is no longer entitled, has excess income or excess

resources, no longer cost effective, has less than 75 employees or other reason(s).


Message # 1 Not Entitled to COBRA Continuation

Reason not entitled


Net Income

MA Income Limit






MA Resource Limit

Message # 4 No Longer Cost Effective

Message # 5 Only Available for 75 or More Employees

Message # 6 Other



Premiums, Prior Conditional Acceptance

(Fill) (Budget Required) Recipient’s MA payment of COBRA prior conditional acceptance is

being discontinued. This is because the recipient is no longer entitled, has excess income or

excess resources, no longer cost effective, has less than 75 employees or other reason(s).



Reason Not entitled


Net Income Amount

MA Income Limit



MA Resource Limit



Message # 6 Other


X52 (C0020) Medicare Buy-In Program, QMB Ineligible

(Fill) (Budget Required) MA will no longer pay for recipients Medicare premiums, deductibles

and coinsurance. This is because the recipient has excess income or is not enrolled in or

eligible for Medicare Part A or other reason(s).


Message # 1 Over Net Income Limit

Net Income Amount **

Net Income Limit (100%FPL)

Message # 2 Not Enrolled In or Eligible for Medicare Part A from SSA

Must select one of the above options

Message # 3 Other


**MA/SLIMB Budget requires net income + Insurance premium

X53 (C0071) Medicare Buy-In Program, SLIMB Ineligible

(Fill) (Budget Required) Recipients Medicare Part B premiums are being discontinued. This is

because the recipient has excess income, is not enrolled in or eligible for Medicare Part A or

other reason(s).




Net Income Limit (120% FPL)






Message # 3 Other



MEDICAID BUY-IN FOR WORKING PEOPLE WITH DISABILITIES (MBI-WPD)

U03 (C0133) Discontinue MBI-WPD, No Longer Meets Requirements of the Medical

Improvement Group, Medicaid ineligible Due to Excess Income Due to Excess Income,

Equivalent Health Insurance or Federal Employee, S/CC

(Fill) (Budget Required) Recipient is no longer eligible for the MBI-WPD program

under the Medical Improvement Group; no longer meets the requirements. Recipient is

ineligible for Medicaid due to excess income. Recipient was evaluated for FHP,

FHP ineligible due to excess income, equivalent health insurance or Federal Employee.



Gross Income Amount



Net Income Amount

Medicaid Standard



Gross Income Amount

FHP Income Limit

Message # 2 FHP Equivalent Insurance


U06 (C0142) Discontinue MBI-WPD, Medical Improvement Group, Not Working 40 Hrs,

Not Working at Federal Minimum Wage, Medicaid Ineligible Due to Excess Income,

FHP Ineligible Due to Excess Income, Equivalent Health Insurance or Federal

Employee, FP

(Fill) (Budget Required) Recipient is no longer eligible under the MBI-WPD program under

the Medical Improvement Group due to not working 40 hours per month or not earning at

least the Federally required minimum wage. Recipient is ineligible for Medicaid due to excess

income. Recipient was evaluated for FHP, FHP ineligible due to excess income, or equivalent

health insurance or Federal Employee.


Message # 1 Working less than 40 hours

Message # 2 Working for less than the Federal Minimum Wage

Worker must enter:

Net Income Amount







MEDICAID BUY-IN FOR WORKING PEOPLE WITH DISABILITIES (MBI-WPD) (Cont’d)

Gross Income Amount

FHP Income Limit



U07 (C0143) Discontinue MBI-WPD, Medical Improvement Group, Not Working 40 Hrs.

Not Working at Federal Minimum Wage, FNP Parent

(Fill) (Budget Required) Recipient is no longer eligible for the MBI-WPD program under the

Medical Improvement Group due to not working 40 hours per month or not earning at least

the Federally required minimum wage. Recipient is ineligible for Medicaid due to excess

income. Recipient was evaluated for FHP, FHP ineligible due to excess income, or equivalent

health insurance or federal employee.




Worker must enter:

Net Income Amount




Gross Income Amount

FHP Income Limit



U08 (C0131) Discontinue MBI-WPD, No Longer meets Requirements of the Medical

Improvement Group, Medicaid Ineligible Due to Excess Income, FHP Ineligible Due to

Excess Income, Equivalent Health Insurance or Federal Employee, FNP





Worker must enter:

Net Income Amount




Gross Income Amount

FHP Income Limit





Excess Income, Equivalent Health Insurance or Federal Employee FP








Worker must enter:

Net Income Amount





Gross Income Amount

FHP Income Limit




FHP Ineligible Due to Excess Income, Equivalent Health Insurance or

Federal Employee S/CC (D)

(Fill) (Budget Required) Recipient is no longer eligible for the MBI-WPD program under


least the Federally required minimum wage. Recipient is ineligible for Medicaid due to

excess income and/or resources. Recipient was evaluated for FHP, FHP ineligible due to

excess income, equivalent health insurance or federal employee.






Gross Income Amount


Message # 2 Net Income Over Medicaid Standard

Net Income Amount

Medicaid Standard



Gross Income Amount

FHP Income Limit



U18 (C0188) Discontinuance MBI-WPD Due to Excess Income and/or Resources, MA

Ineligible Due to Excess Income and/or Resources

(Fill) (Budget Required) Recipient is no longer eligible under the MBI-WPD program due to

excess income and/or resources. FHP ineligible


Message # 1 Over Income MBI/MA

Net Income Amount


Net Income Amount




MA Income Limit


Message # 2 Over Resources MBI/MA


MA Resource Limit


Message # 3 Over Income and Resources MBI, Over Income and Resources MA

Net Income Amount



MA Resource Limit

Net Income Amount

MA Income Limit



Message # 4 Over Resources MBI and Over Income/Resources MA


MA Resource Limit

Net Income Amount

MA Income Limit



U27 (C0092) Discontinue MBI-WPD Due to Excess Income and/or Resources, Turning 65,

Spenddown Not Met

(Fill) (Budget Required) Recipient is turning 65 and is no longer eligible for MA coverage

under the MBI-WPD Program. The recipient is MA ineligible due to excess income and/or

resources and there is a spenddown requirement, which has not been met.



Net Income Amount

MA Income Limit




MA Resource Limit


Message # 3 Over Income And Resources

Net Income Amount

MA Income Limit


MA Resource Limit






U28 (C0249) Discontinue MBI-WPD Due to No Longer Working, Medicaid Ineligible Due to

Excess Income Spenddown not met, FHP Ineligible Due Excess Income Equivalent

Health Insurance or Federal Employee

(Fill) (Budget Required) Recipient is no longer eligible for Medicaid benefit under the MBI-

WPD program, recipient is no longer working. The recipient is also ineligible for Medicaid due

to excess income and FHP ineligible due excess income, equivalent health insurance or federal

employee.

Worker must enter:

Net Income Amount





Gross Income Amount

FHP Income Limit



ALIENS

*C14 (P0001) Discontinue MA, Non Immigrant/Undocumented Immigrant, 60 Days Post-

Partum, No Infant

(TAD Based) Recipient is no longer pregnant; the 60 day post-partum period has ended. The

recipient is not a citizen, qualified alien or permanently residing in the US under color of the

law (PRUCOL). There was no live birth.

*E02 (C0121) Discontinue Medicaid, Non-Immigrant, Undocumented Immigrant, End of

Medical Emergency (D)

(TAD Based) Recipient no longer has an emergency medical condition. The recipient is not a

citizen, qualified alien or permanently residing in the US under color of the law (PRUCOL).

CONTINUOUS COVERAGE

*E65 (C0155) Moved Out of District, Eligible for Continuous Coverage, Accepted in New

District

(TAD Based) Recipient has moved to a new county and will now be receiving MA from the

new county.

NEWBORN/UNBORN

*E98 (N0012) Newborn Case Opened in Error

(TAD Based) The infant MA case was opened in error.

OTHER

*E90 (C0026) Client Request

(TAD Based) Recipient has requested that the MA/FHP/FPBP case be discontinued.



OTHER (cont’d)

*E95 (C0027) Death

(TAD Based) Our records indicate that the recipient is now deceased.

U66 (C0070) Discontinue MA/FHP/FPBP Currently in Receipt of Assistance Within the Same

District

(Fill) Recipient is in receipt of MA/FHP/FPBP under another case number. Therefore, we are

discontinuing this case.

Worker must enter:

Case number

Y91 MA Eligible After Period of LTC Presumptive Eligibility (Manual Notice Required)

Y99 Other (Manual Notice Required)

NO ELIGIBLE INDIVIDUAL

I94 Used as Case Reason Code When All Case Members Have an Individual Reason Code

SYSTEM GENERATED

941 (C0055) Not a State Resident (SSI Recipient)

According to the SSA office the recipient is no longer a resident of NYS.

942 (C0056) Death (SSI Recipient)

According to the SSA office this person is now deceased.

OMH/OMR ONLY

*E13 (C0084) OMH/OMR Case Type 20 Discharged Into the Community, or an Article 28 or

31 Facility

(TAD Based) Recipient no longer resides in a living arrangement that is under the jurisdiction

of the state, private or residential facility.

*E14 (C0085) OMH/OMR Case Type 22 Discharged Into the Community, or an Article 28 or

31 Facility, Turned 22

(TAD Based) The recipient has reached age 22 while residing in a private or state psychiatric

facility or residential treatment facility. (OMH/OMR Only)

*E15 (C0086) OMH/OMR Only, Lost Eligibility Due to Turning 22 and in a Psychiatric Center

or Residential Treatment Facility

(TAD Based) The recipient has reached age 22 while residing in a private or state run facility.

CLIENT NOTICES SYSTEM MANUAL CNS Section Y – MA Case/Individual Undercare Codes

Revised December 2010 Y-1

Medical Assistance

To perform Undercare transactions on MA/FHP/FPBP cases, the worker chooses one of the following codes:

(Most of these codes can be used at the case or individual level.)

Included are the Discontinuance codes that have been opened up to Undercare (05 & 06 TRANS

TYPE) to be used only at the individual level with I89 at the case level. These reason codes are

identified with a “(D)” at the end of the title.

A “Special Screen” (WCN10A) has been developed for Undercare to accommodate the majority of changes

for excess income and/or resources. This screen is accessed by entry of Reason Code S19 and then the

worker picks from the variables to select the appropriate value combination. Reason Code S19 can be used

at either the Case or Individual level.

NOTE: Since MA uses only Extensive fill and not Limited fill, the word “Fill” will be used in this section.

The term “TAD Based” is also used in this section. TAD Based is defined as a method of notice production

which requires no information to be entered on the CNS Subsystem.

FAILURE TO RECERTIFY

*F10 (C0195) Discontinue MA/RMA/FHP/FHP-PAP, Failed to Return Renewal Form (D)

(TAD Based) Discontinuance-Recipient or their representative has failed to return the renewal

form.

*F13 (C0199) Discontinue Mother on MA/FHP, Failed to Return Renewal Form, 60 Days Post-

Partum, Infant Continues (D)

(TAD Based) Discontinuance - Mother failed to return renewal form. Infant is eligible for full MA

benefits until the end of the month when he/she turns 1 year old as long as the baby continues to

live with the mother.

U14 (C0261) Failed to Return FPBP Renewal Form (D)

(Fill) Discontinuance- Recipient or their representative has failed to return the renewal form.


*E80 (C0067) Discontinue MA/FHP, Failure to Provide Required Information About Non-

Applying Legally Responsible Relative, Income and/or Resources (D)

(TAD Based) Discontinuance- Recipient failed or refused to verify the income and/or resources of

the non-applying legally responsible relative(s).

*C88 (C0300) Discontinue MA/FHP/FHH-PAP/FPBP, Failure to Provide Proof of U.S. Citizenship and

Identity

(TAD Based) Recipient failed to provide documentation proving U.S. Citizenship and identity (D).

S63 (C0248) Discontinue MA/FHP/FPBP, Failure to Provide Information to Clear Up Resource

Information Discrepancy (D)

(Fill) Discontinuance-Recipient failed to submit information explaining discrepancies regarding

income and/or resources reported by the recipient and the investigation by the LDSS office.

Worker must enter:



Due Date

Owner of Resource

FAILURE TO PROVIDE VERIFICATION (Cont’d)

Resource(s) Failed to Verify

Refugee Medical Assistance (RMA)

U20 (C0063/C0064) Discontinue MA/RMA/FHP/FHP-PAP/FPBP Due to Verification of Factors

Which Affect Eligibility, Did Not State Unable to Get Information (D)

(Fill) Discontinuance-Recipient failed to provide documentation to verify continuing eligibility and

did not state unable to get the information.

Worker must select one or more of failed to reasons:

The information required on the Fail to Verify Selection Entry

Screen(WCN140) and the Fail to Verify Variable Entry Screen(WCN141)

(See CNS Manual Section F)

U21 (C0065/C0066) Discontinue MA/RMA/FHP/FHP-PAP/FPBP Due to Verification of Factors

Which Affect Eligibility, Unable to Get Information, But Not a Good Reason (D)

(Fill) Discontinuance-Recipient failed to provide documentation necessary to determine continuing

eligibility and did not have a good reason for not obtaining this information. Worker must select

one or more of failed to reasons:

The Information required on the Failure to Verify Selection Entry Screen

(WCN140) and the Fail to Verify Entry Screen (WCN141) (See CNS

manual Section F)

V17 (C0050) Incorrect or Fraudulent Social Security Number (D)

(Fill) Discontinuance-Recipient submitted an incorrect/fraudulent Social Security number. Worker

must enter:

Individual name or line of person(s) with incorrect Social Security Number

X23 (C0265) Failed to Provide Amount of Income and/or Resources at Renewal (D)

(Fill) Discontinuance - Recipient failed to document income and/or resources at renewal.

Worker must enter:

Income and/or Resources not Verified

X28 (C0274) Discontinue RMA, MA Ineligible Due to Excess Income, FHP Ineligible due to

Over Income, Equivalent Health Insurance or Federal Employee, FPBP Ineligible

Due to Over Income or Eligible but Declines

(Fill) (Budget Required) Recipient will be discontinued for Medicaid coverage under the

Refugee Medical Assistance Program. Ineligible for MA due to excess income. Ineligible

for FHP due to excess income, equivalent insurance or federal employee. FPBP over

income or eligible but declines.

Worker must choose one of the following and enter:

Message#1 Over Income

Gross Income Amount

Family Health Plus Income Limit





OTHER FAILURES

*E09 (C0126) Photo ID Refusal (D)

(TAD Based) Discontinuance - Recipient refused to have Photo ID taken.

*F12 (C0012) Failure to Apply for Social Security Benefits (D)

(TAD Based) Discontinuance-Recipient failed to apply for Social Security benefits.

*F40 (C0009) Failure to Enroll in a Group Health Plan (D) (TAD Based) Discontinuance-Recipient has refused to enroll in a free health insurance plan

offered through their employer.

V13 (C0015) Failure to Apply for or Utilize Benefits (D)

(Fill) Discontinuance-Recipient failed to apply for or use benefits or resources that can reduce or

end the need for MA/FHP.

Worker must enter:

Benefit or resource not applied for

V30 (C0008) Failure to Comply with IV-D Requirements (D)

(Fill) Discontinuance – Recipient did not comply with the Child Support Enforcement Unit to

obtain medical support or proof of paternity from the absent parent. Failure to comply without

good cause is grounds for discontinuance of MA/FHP benefits.


Message # 1- Assign Rights From Health Insurance

Absent Parent’s name


Message # 2 - Assign Rights From Court Ordered Support

Did not assign rights for medical care from Name of Absent parent


Message # 3- Cooperate with CSEU Regarding Paternity

Fail to Provide Information

Did not cooperate in establishing paternity Line number(s) for CT 20 or

name(s) for CT 24 of child (ren) for whom paternity was to be

established

Message # 4-Cooperate with CSEU Regarding Paternity

Fail to Appear As a Witness

Did not appear as a witness in establishing paternity for line number(s)

for CT 20 or name(s) for CT 24

Message #5- Cooperate with CSEU Regarding Child Support

Fail to Provide Information


Appropriate child(ren)’s line number(s) for CT 20 or name(s) for

CT 24

Message #6- Cooperate with CSEU Regarding Child Support



Fail to Appear As a Witness


Appropriate child (ren)’s line number(s) for CT 20 or name(s) for

CT 24

OTHER FAILURES (Cont’d)

V31 (C0014) Failure to Provide Social Security Number (D)

(Fill) Discontinuance-Recipient failed to provide or apply for a Social Security number of all

household members applying.

Worker must enter:

Line number of individuals with no Social Security number provided

V38 (C0072) Failure to Contact Agency as Requested (D) (Fill) Discontinuance-Recipient failed to contact agency with information required to make a

determination for MA.

Worker must enter:

Contact date


U57 (C0183) Discontinue Medicaid Due to Excess Income, FHP Ineligible Due to Excess Income

Equivalent Health Insurance or Federal Employee, FPBP Ineligible Due to Excess Income or

Eligible But Declines, S/CC (D)

(Fill) (Budget Required) Recipient is an S/CC individual who is no longer eligible for MA/FHP.

Recipient is Medicaid ineligible due to excess income, FHP ineligible due to excess income

equivalent health insurance or federal employee. FPBP ineligible due to excess income or eligible

but declines.



Gross Income Amount

FHP Income Limit



U72 (C0136) Excess Income Due to COLA, S/CC (D)

(Fill) (Budget Required) Discontinuance-Due to COLA the recipient’s income is over

the allowable MA income limit.


Net Income Amount

Net Income Limit

V94 (C0099) Discontinue FHP/FHP-PAP Due to Excess Income, FPBP Ineligible Due to Excess

Income or Eligible But Declines (D)

(Fill) (Budget Required) Discontinuance-Recipient is FHP/FHP-PAP ineligible due to excess

Income, FPBP ineligible due to excess income or eligible but declines.

Use For All:

Gross Income Amount

FHP Income Limit



X48 (C0235) Discontinue Medicaid Due to Excess Income, FHP Ineligible Due to Excess Income

Equivalent Health Insurance or Federal Employee, FPBP Ineligible Due to Excess Income or

Eligible But Declines, FNP Parent (D)

EXCESS INCOME/RESOURCES (S/CC, FNP PARENT) (Cont’d)

(Fill) (Budget Required) Recipient is an FNP Parent. Medicaid ineligible due to excess income,

FHP ineligible due to excess income equivalent health Insurance or federal employee, FPBP

ineligible due to excess income or eligible but declines.


Gross Income Amount

FHP Income Limit



EXCESS INCOME/RESOURCES/EXPANDED LEVEL (LIF, ADC-REL, SSI-REL)

*E23 (X0123) Child Under 19, Spenddown to Full Coverage

(TAD Based) (Budget Required) Recipients are children ages 1-19 with income at or below the

MA allowable income limit. They are now eligible for full MA benefits and there is no longer a

spenddown requirement.


(TAD Based) (Budget Required) When a child becomes 6 years old, the Medicaid level changes

from 133% to 100% of the FPL. Now that the net income is over 100% of the FPL, it is now

compared to the Medicaid limit. If the recipient is blind or disabled to qualify for spenddown, the

recipient must tell us about their resources if they have not already done so. Also, if the recipient

incurs medical bills equal to or more than the excess income amount, they may reapply.

*E45 (X0065) Child Turning 6, Excess Income and Resources, Spenddown Not Met (D)

(TAD Based) (Budget Required) When a child becomes 6 years old, the Medicaid level changes

from 133% to 100% of the FPL. Because the net income is over 100% of the FPL, it is now

compared to the Medicaid limit and there is now a resource limit. We have not received

documentation that the recipient has spent down the excess resources by establishing or adding to a

burial trust/ fund. Also, if the recipient incurs medical bills in the amount of the excess resources

or has bills equal to or more than the excess income amount, or if the income or resources go

down, they may reapply.

*E49 (X0066) Child Turning 1, Excess Income, Spenddown Not Met (D)

(TAD Based) (Budget Required) When a child turns age 1, the Medicaid level changes from 200%

to 133% of the FPL. Because the net income is over 133% of the FPL, it is now compared to the

Medicaid limit. If eligibility is based on being certified blind or disabled, resources will be

compared to the Medicaid resource limit. To qualify for spenddown, the recipient must tell us

about their resources if they are certified blind or disabled if they have not already done so. Also,

if the recipient incurs medical bills in the amount of the excess income or the income goes down,

they may reapply.

*E55 (X0060) Child 1-5, Excess Income, Spenddown Not Met (D)



(TAD Based) (Budget Required) The net income is more than 133% of the FPL which is the

income level for a child age 1-5. Now that the net income is over 133% of the FPL, it is now


resources will be compared to the Medicaid Resource Limit. To qualify for spenddown, the


EXCESS INCOME/RESOURCES/EXPANDED LEVEL (LIF, ADC-REL, SSI-REL)(Cont’d)

already done so. Also, if the recipient incurs medical bills in the amount of the excess income or

the income goes down, they may reapply.

*E56 (X0061) Child 1-5, Excess Income and Resources, Spenddown Not Met (D)

(TAD Based) (Budget Required) For a child between the ages of 1-5 net income is compared to

133% of the FPL. Because the income and countable resources are over 133% of the FPL, income

is now compared to the Medicaid limit and there is now a resource limit. We have not received

documentation that the recipient has spent down the excess resources by establishing or adding to a

burial trust/ fund. Also, if the recipient incurs medical bills in the amount of the excess resource or

has bills equal to or more than the excess income amount, or if the income or resources go down,

they may reapply.

*E68 (X0067) Child Turning 1, Excess Income and Resources, Spenddown Not Met (D)

(TAD Based) (Budget Required) When a child turns age 1, the Medicaid level changes from 200%

to 133% of the FPL. Now that the net income and countable resources are over 133% of the FPL,

income is now compared to the Medicaid limit and there is now a resource test. We have not

received documentation that the recipient has spent down the excess resources by establishing or

adding to a burial trust/ fund. Also, if the recipient incurs medical bills in the amount of the excess

resource or has bills equal to or more than the excess income amount, or if the income or resources

go down, they may reapply.

U91 (C0226) Child 6-18, Discontinue Medicaid Due to Excess Income or Income and Resources,

FPBP Ineligible Due to Excess Income, Eligible but Declines or Age Ineligible (D)

(Tad Based) (Budget Required) Discontinuance-Recipient is a child(ren) between the ages of 6-

18, Medicaid ineligible due to excess income or Income and resources, FPBP ineligible due to


EXCESS INCOME/RESOURCES/TRANSFER (LIF, ADC-REL, SSI-REL, S/CC)

S02 (U0010) Transfer by Institutionalized Individual, Reduce From Full to Limited

Coverage

(Fill) (Budget Required) Reduction-Recipient’s coverage will go from full services to

limited care. The recipient and/or spouse have transferred an asset(s) for less than the

value of the resource.

Worker must enter:

Date eligible for Nursing Home Services after penalty period ends

Date of the Transfer

Asset Transferred

Fair Market Value of the resource or the income amount







EXCESS INCOME/RESOURCES/TRANSFER (LIF, ADC-REL, SSI-REL, S/CC) (Cont’d)

S06 (U0017) Intent to Impose a Lien on Real Property-Institutionalized Individual

(Fill) The recipient is an institutionalized individual who will not be returning to the community.

The recipient has interest in Real Property which the MA programs intends to impose a lien on

should the property be sold.

Worker must enter:

The Location of the Real Property for which a Lien is being imposed

Worker must choose one or more of the following exemptions or disregards:

Message # 1 Property is the home and there is intent to return to the home

Message # 2 The Property is used in a trade or business

Message # 3 There is a legal impediment which prevents sale of the property

Message # 4 The Property is the home but continues to be occupied by a dependent

Worker must choose one of the following messages when message # 4 is selected:

Message A- Dependent adult child/stepchild who is not certified blind/disabled or grandchild

Message B- Dependent parent, stepparent, grandparent, aunt, uncle, niece, nephew

Message C- Dependent sibling, stepsibling, half brother/sister, cousin, or in-law

S07 (X0025) Medicaid Level to Excess Income Due to COLA, FHP Ineligible Due to Excess Income,

Failed to Choose a Plan, Chose Spenddown, Equivalent Health Insurance Federal Employee or

Over 65

(Fill) (Budget Required) Recipient is going from Medicaid level to excess income because of an

increase in Social Security benefits due to COLA. FHP ineligible due to excess income, failed to

choose a plan, chose spenddown of income, has equivalent health insurance, is a Federal employee

or is over 65.

Worker must enter:

Net Income Amount




Message # 1 Community Coverage: No LTC

Message # 2 Community Coverage w/ Community-Based LTC





Gross Income Amount

FHP Income Limit

Message # 2 FHP Failed to Choose a Plan







S08 (X0026) Increase in Excess Income Due to COLA

(Fill) (Budget Required) Recipient’s Social Security benefit amount has increased due to COLA.

The increase has caused an increase to the spenddown requirement.

Worker must enter:

Net Income Amount


MA Income Limit

New Monthly Excess Income Amount






S09 (X0036) Institutionalized Individual -Transferred, MA Level to Limited Coverage and

Excess Income Spenddown Met (Fill) (Budget Required) Reduction-Recipient’s coverage will go from full services to limited care

for some services. This is because the recipient has transferred asset(s) for less than the value of

the resource.

Worker must enter:


Net Income Amount

MA Income Limit

Date Eligible for Nursing Home Services

Date of Transfer

Asset Transferred

Fair Market Value of the resource or the income amount


Monthly regional rate of the district in which the individual is

institutionalized

Month, first day of the month and the year in which limited coverage

(Ineligibility for Nursing Home Services) begins (MMDDYY)

S10 (X0011) Change in Figures Used to Calculate Excess Income Amount

(Fill) (Budget Required) There has been a recalculation of the figures used to calculate the

recipient’s excess income amount. The monthly excess income amount and spenddown amount

remains unchanged.

Worker must enter:






S28 (X0018) Spenddown to At or Below MA Level

(Fill) (Budget Required) Recipient no longer has a spenddown requirement; income is at or below

the MA level.









U32 (X0022) Excess Income

(Fill) (Budget Required) Discontinuance- Recipient has excess income over the allowable MA

income level. Also, the recipient did not have paid or unpaid medical expenses not covered by

insurance that are equal to or more than the excess income amount. To qualify for spenddown, the

recipient must tell us the amount of their resources if they have not already done so. If recipient

incurs medical bills in the amount of the excess income, they may reapply.

Worker must enter:

Net Income Amount

MA Income Limit


U33 (X0170) Turning 19, Medicaid Ineligible Due to Excess Income and/or Resources, FHP

Ineligible Due to Excess Income Equivalent Health Insurance or Federal Employee, FPBP

Ineligible Due to Excess Income or Eligible But Declines (Fill) (Budget Required) For a child under age 19 the net income is compared at 100% of the FPL.

When the child turns 19 the income and resources are compared to the Medicaid/FHP income

limits and there is no longer a consideration of expanded budgeting. Recipient is now Medicaid

ineligible due to excess income and/or resources, FHP ineligible due to excess income equivalent

health insurance or Federal Employee, FPBP ineligible due to excess income or eligible but

declines.


Gross Income Amount

FHP Income Limit

Message #2 FHP Public Employee


U40 (X0023) Excess Resources (D)

(Fill) (Budget Required) Discontinuance- Recipient has excess resources over the allowable MA

resource limit. Also, we have not received documentation that the recipient has unpaid medical

expenses not covered by insurance that are equal to or more than the excess resource amount or

that they have spent down resources by establishing or adding to a burial trust/fund. If the

recipient incurs bills in the amount of the excess resources or the resources go down, they may

reapply.

Worker must enter:



U58 (C0184) Discontinue Medicaid Due to Excess Income and/or Resources, FHP Ineligible Due

to Excess Income, Equivalent Health Insurance or Federal Employee, FPBP Ineligible Due to

Excess Income or Eligible but Declined, FP (D)



(Fill) (Budget Required) Recipient is an FP individual ineligible for Medicaid due to excess

income and/or resources, FHP ineligible due to excess income equivalent health insurance or

Federal employee, FPBP ineligible due to income or eligible but declines.



Gross Income Amount

FHP Income Limit




U59 (X0024) Excess Income and Resources (D)

(Fill) (Budget Required) Discontinue- Recipient has excess income and resources over the

allowable MA limits. Also, we have not received documentation that they have spent down

resources by establishing or adding to a burial trust/fund. If the recipient incurs bills in the amount

of the excess resources or expects to have medical bills that are equal to or more than the excess

income amount or if the income or resources go down, they may reapply.

Worker must enter:

Net Income Amount

MA Income Limit

MA Resources Limit



U75 (X0021) No Change in Excess Income Amount

(Fill) (Budget Required) Monthly excess income amount continues unchanged. Recipient will

continue Medicaid coverage with a spenddown.






V94 (C0099) Discontinue FHP/FHP-PAP Due to Excess Income and/or Resources, FPBP

Ineligible Due to Excess Income or Eligible But Declines (D)

(Fill) (Budget Required) Discontinuance-Recipient is FHP ineligible due to excess income and/or

resources, FPBP ineligible due to excess income or eligible but declines.



Gross Income Amount

FHP Income Limit



FHP Resource Limit


Gross Income Amount

FHP Income Limit




FHP Resource Limit


Message # 1 FPBP Over Income, No Need to Notify

Message # 2 FPBP Eligible but Declines

X74 (X0019) Continue Excess Resources, Spenddown Met


(Fill) (Budget Required) Continue MA with spenddown due to excess resources.

Recipient continues to have countable resources over the MA limit. Medical expenses continue

to be equal to or exceed the amount of the resources over the MA resource limit.

Worker must choose one of following messages:





Optional completion of the Provider/ Recipient Letter

X75 (X0020) Increase In Excess Income Amount

(Fill) (Budget Required) Recipient’s Medicaid spenddown requirement has increased due to

excess income. Medical expenses must be equal to or exceed the amount of income over the

Medicaid limit.

Worker must choose one of following messages:





Optional completion of the Provider/ Recipient Letter

X76 (X0126) Decrease in Excess Income Amount

(Fill) (Budget Required) Recipient has had a decrease in excess income amount (Not due to

COLA). There is still a spenddown requirement. (Note: this code should not be used for COLA)






X77 (X0180) Decrease in Excess Income Amount Due to COLA

(Fill) (Budget Required) Recipient has had a decrease in excess income amount due to COLA

(Note: Use this code only when there is a COLA)

Worker must enter:

New Monthly Excess Income Amount

Net Income Amount

MA Income Limit








X80 (X0208) Medicaid to Spenddown Due to Excess Income, FHP Ineligible Due to Excess

Income, Chose Spenddown, Over 65 Federal Employee or Equivalent Health Insurance.


(Fill) (Budget Required) Recipient is going from full Medicaid to spenddown due to excess

income, FHP ineligible due to excess income, equivalent health insurance or is a Federal employee

chose spenddown of income or is over 65.

Worker must enter:

Net Income Amount










Gross Income Amount

FHP Income Limit





INCOME/RESOURCE RELATED POST-PARTUM

S11 (U0008) Limited Prenatal Care to Full MA During Pregnancy or 60 Days Post-Partum

(Tad Based) (Budget Required) Recipient’s MA coverage will increase from limited service to all

covered care and services. Recipient’s income is now below the allowable MA limit.

S25 (X0210) Discontinue Mother, Continue Infant, 60 Days Post-Partum, MA Ineligible Due to

Excess Income and/or Resources, FHP Ineligible Due to Excess Income, FPBP Ineligible Due

to Excess Income or Eligible But Declines (D)

(Tad Based) (Budget Required) Discontinuance-While pregnant and during the 60 days post-

partum period the recipient’s income was compared at 200% of the FPL. Now income and

resources are compared to the MA/FHP limits. Recipient is ineligible for MA due to excess

income and/or resources and is ineligible for FHP due to excess income. FPBP ineligible due to

excess income or has declined. Infant continues until age 1.

X15 (P0003) Discontinue Mother, MA Ineligible Due to Excess Income and/or Resources, FHP

Ineligible Due to Excess Income, FPBP Ineligible Due to Excess Income, 60 Days Post-

Partum, No Infant, FP (D)



(Fill) (Budget Required) Discontinuance-Recipient is an FP individual no longer pregnant and is at

the end of the 60 day post-partum period. There is no infant. While pregnant, income was

compared to 200% of the FPL. Now it is compared to the MA limit. Recipient is ineligible for

MA due to excess income and/or resources, FHP ineligible due to excess income, FPBP ineligible

due to excess income.

Use For All:

Gross Income Amount

INCOME/RESOURCE RELATED POST-PARTUM (Cont’d)

FHP Income Limit


FHP Ineligible Due to Excess Income and/or Resources, FPBP Ineligible Due to Excess

Income, 60 Days Post-Partum, No Infant, S/CC (D)

(Fill) (Budget Required) Recipient is an S/CC individual, 60 days post-partum, while pregnant

income was compared to 200% of the FPL. Income is now compared to the MA/FHP income

limits. Recipient is MA/FHP ineligible due to excess income and/or resources, FPBP ineligible

due to excess income. No Infant.



Gross Income Amount

FHP Income Limit



FHP Resource Limit


Gross Income Amount

FHP Income Limit


FHP Resource Limit

MA TO FAMILY HEALTH PLUS (FHP) CHOSE A PLAN

S27 (X0213) MA to FHP Due to Excess Income, 60 Days Post-Partum, Continue Infant, Chose a

Plan or will be Auto-Assigned

(Fill) (Budget Required) Recipient is at the end of the 60 day post-partum period, MA ineligible

due to excess income, FHP eligible, One Plan or chose a new health plan or staying in same plan or

auto-assigned. Infant continues to age 1.


Message # 1 One Plan or Chose a New Plan

Health Plan Name

Message # 2 Staying in the Same Plan

Health Plan Name

Message # 3 Will be Auto-Assigned

U25 (P0011) MA to FHP Due to Excess Income, 60 Days Post-Partum, No Infant, Chose a Plan,

Stay in Same plan or will be Auto-Assigned, S/CC



(Fill) (Budget Required) Reduction in MA coverage. Recipient is an S/CC individual going from

MA to FHP. MA ineligible due to excess income, FHP eligible, One plan or chose a new plan or

staying in the same plan or Auto-Assign. Used only at the end of the 60 day post-partum period

when there is no live birth.

Use For All:

Net Income Amount

Medicaid Standard


MA TO FAMILY HEALTH PLUS (FHP) CHOSE A PLAN (Cont’d)


Health Plan Name


Health Plan Name


U26 (P0007) MA to FHP Due to Excess Income, 60 Days Post-Partum, No Infant, Chose a Plan,

Stay in Same Plan or will be Auto-Assigned, FP

(Fill) (Budget Required) Reduction in MA coverage. Recipient is an FP individual going from

MA to FHP. MA ineligible due to excess income, FHP eligible, One Plan or chose a new health

plan or staying in same plan. Used only at the end of the 60 day post-partum period, when there is

no live birth.



Health Plan Name


Health Plan Name


U85 (U0081) MA to FHP Due to Excess Income, Chose a Plan, Stay in same Plan or will be Auto-

Assigned, FP

(Fill) (Budget Required) Reduction in MA coverage. Recipient is an FP individual going from MA

to FHP. MA ineligible due to excess income, FHP eligible, One Plan or chose a new health plan or

staying in same plan.



Health Plan Name


Health Plan Name


U86 (U0082) MA to FHP Due to Excess Income, Chose a Plan, Staying in Same Plan or will be

Auto-Assigned, S/CC

(Fill) (Budget Required) Reduction in MA coverage. Recipient is an S/CC individual going from

MA to FHP. MA ineligible due to excess income, FHP eligible, one plan or chose a new health

plan or staying in same plan or Auto-Assign





Health Plan Name


Health Plan Name


U87 (U0098) Spenddown to FHP, Chose a Plan or will be Auto-Assigned

(Fill) (Budget Required) Recipient is going from MA with a spenddown to FHP. This change is

because the recipient has chosen coverage under FHP or because the gross income is now under

100% or 150% of the FPL. Recipient chose a health plan.



Message # 1 Spenddown, still FHP eligible

Message # 2 Spenddown, now FHP eligible

Gross income Amount

FHP Income Limit



Health Plan Name


U89 (U0106) MA to FHP Due to Excess Income, Chose a Plan, Staying in Same Plan or will be

Auto-Assigned, FNP Parent

(Fill) (Budget Required) Recipient is an FNP Parent(s) going from MA to FHP. MA ineligible due

to excess income. Recipient must choose a new health plan or may remain in the health plan they

are currently enrolled in.


Message # 1 Chose a New Plan

Health Plan Name

Message # 2 Staying in Same Plan

Health Plan Name

U90 (U0112) Turning 19, Medicaid to FHP Due to Excess Income, Chose a Plan, Staying in Same

Plan or will be Auto-Assigned

(Fill) (Budget Required) Reduction in coverage. Recipient is a child turning 19, going from

Medicaid to FHP due to excess income, FHP eligible, One plan or chose a new plan or staying in

the same plan.



Health Plan Name


Health Plan Name


X81 (X0220) MA to FHP Due to COLA, Chose a Plan or will be Auto Assigned

(Fill) (Budget Required) Reduction in coverage. Recipient is going from MA to FHP, due to

COLA. MA ineligible due to excess income, FHP eligible, chose a plan or staying in the same

plan.



Worker must enter:

Net Income Amount

MA Income Limit

Gross Income Amount

FHP Income Limit


Message # 1 Chose a New Plan

Health Plan Name



Health Plan Name


REFUGEE MEDICAL ASSISTANCE

S92 (X0084) RMA with Spenddown to FHP, Chose a Plan

(Fill) (Budget Required) Recipient is going from the Refugee Medical Assistance Program to Family

Health Plus. Eligibility period has ended. Not eligible for MA due to excess income. ESHI is offered,

ESHI is not cost effective or ESHI is not offered


Employer Sponsored Health Insurance is Offered

Employer Sponsored Health Insurance is not Cost-Effective

Employer Sponsored Health Insurance is Not Offered

C47 (X0082) RMA with Spenddown to Medicaid Standard, Decrease in Income

(Tad Based) (Budget Required) Medicaid coverage will continue, however there is no longer a

spenddown. Eligible for ongoing Medicaid because net income is less then the Medicaid Standard of

need.

C49 (U0188) RMA to FPBP, S/CC

(Tad Based) (Budget Required) Coverage will be changed from Medicaid with a spenddown under

the Refugee Medical Assistance Program to Family Planning Benefit Program. FHP Ineligible due to

over income or equivalent Insurance.

FAMILY HEALTH PLUS (FHP) TO MA

U37 (U0113) FHP to MA, Pregnant and MA Eligible, Chose MA

(Fill) (Budget Required) Recipient is going from FHP to MA, is pregnant and has net income

below the MA income limit. Recipient chose MA.

Must choose a plan:


Health Plan Name

Message # 2 Fee for Service

Message # 3 Voluntarily Selected a New Plan

Current Health Plan

New Plan Selected



U95 (X0202) Turning 65, FHP to MA with Excess Income, Spenddown Not Met

(Fill) (Budget Required) Recipient is turning 65, and is no longer eligible for FHP, income is now

compared to MA income limit. Recipient is MA eligible and now has a spenddown requirement,

spenddown not met.






FAMILY HEALTH PLUS (FHP) TO MA (Cont’d)

V80 (U0099) FHP to Medicaid with a Spenddown Due to Over Gross Income or Chose

Spenddown, Spenddown Not Met, Under 65

(Fill) (Budget Required) Recipient is under 65 years of age, going from FHP to Medicaid with a

spenddown requirement, FHP ineligible due to excess income or chose spenddown. The

spenddown requirement has not been met.






X86 (U0080) FHP to MA, S/CC

(Fill) (Budget Required) Recipient is an S/CC individual going from FHP to MA. Income is now

under the PA standard of need. Persons financially eligible for MA are not eligible for FHP.







Message # 1 Fee For Services

Message # 2 Mandatory Managed Care District, Must Choose a Plan

Message # 3 Staying In the Same Plan

Health Plan Name


Current Plan Enrolled

New Plan Selected

X88 (U0120) FHP to MA, FNP Parent or FP

(Fill) (Budget Required) Recipient is an FNP Parent(s) or FP individual going from FHP to MA.

Income is now under the MA income limit. Persons financially eligible for MA are not eligible for

FHP.









Message # 1 Fee For Services

Message # 2 Mandatory Managed Care District, Must Choose a Plan

Message # 3 Staying In the Same Plan

Health Plan Name


Current Plan Enrolled

New Plan Selected

FAMILY HEALTH PLUS (FHP)

*C07 (U0122) Add Person(s) to FHP Case

*Note: Must be used at the individual level Only with Case Level Code I89 either by itself or

with other No Fill Codes.

(TAD Based) An individual is being added to an existing FHP case.

U38 (U0115) Continue FHP, Pregnant, MA Eligible But Did Not Choose MA or FHP (Tad Based)(Budget Required) Recipient is pregnant and is currently FHP eligible. Income is now

below the MA income limit. Did not choose MA or FHP, will continue as FHP.

U39 (U0114) Continue FHP, Pregnant, MA Eligible But Chose FHP

(Tad Based)(Budget Required) Recipient is pregnant and is currently FHP eligible with income

below the MA income limit, chose to stay in FHP.

FAMILY HEALTH PLUS-PREMIUM ASSISTANCE PROGRAM (FHP-PAP)

C35 (C0177) Discontinue FHP-PAP, ESHI is not cost effective, Ineligible for FHP due to


(No fill) Recipient is ineligible for Family Health Plus-PAP due to equivalent health insurance.


Message # 2 FHP Public Employee

C45 (U0193) Add Person to the FHP- PAP case

(No fill) (Budget Required) Add a person to an existing Family Health Plus- PAP case.

X31 (U0186) FHP to FHP-PAP

(Fill) (Budget Required) Reduction in benefits. Change case from Family health Plus to Family

health plus-PAP.

Worker must enter:

Health Plan Name

Health Plan Effective Date

X32 (U0190)FHP-PAP to FHP

(Fill) (Budget Required) Increase in benefits. Change case from Family Health Plus-PAP to Family

Health Plus.

Worker must choose message#1 Plan or New Plan

Health Plan Name



X37 (U0195) FHP to FHP-PAP Employer Buy-In

(Fill) (Budget Required) Recipient is now eligible to enroll in a health insurance plan offered by

Employer.

Worker must enter:

Health Plan Name

X33 (U0191) FHP-PAP to MA, FP, FNP Parent

(Fill) (Budget Required) Increase in benefits for FP/FNP Parent. Change from Family Health Plus-

PAP to MA.


Massage #1 Community Coverage No LTC

FAMILY HEALTH PLUS-PREMIUM ASSISTANCE PROGRAM (FHP-PAP) (Cont’d)

Message #2 Community Coverage and Community LTC

Message #3 No Longer Eligible for LTC

Message #4 None of the Above


Message #1 Lost ESI- No Medicaid Plan

Message #2 Keep ESI- FFS

Message #3 Lost ESI- Mandatory Medicaid

Message #4 Lost ESI- MED Plan no Change

Message #5 Lost ESI- Choose Plan Mandatory

Health Plan Name


X34 (U0192) FHP-PAP to MA, S/CC

(Fill) (Budget Required) Increase in benefits for Single Childless Couple. Change from Family

Health Plus-PAP to MA.


Massage #1 Community Coverage No LTC

Massage #2 Community Coverage and Community LTC

Massage #3 No Longer Eligible for LTC

Massage #4 None of the Above


Massage #1 Lost ESI- No Medicaid Plan

Massage #2 Keep ESI- FFS

Massage #3 Lost ESI- Mandatory Medicaid

Massage #4 Lost ESI- MED Plan no Change

Massage #5 Lost ESI- Choose Plan Mandatory

Health Plan Name


FAMILY HEALTH PLUS (FHP) DISCONTINUANCE TURNING 65

X83 (X0205) Discontinue FHP, Turning 65, Medicaid Ineligible Due to Excess Income (D)

(Fill) (Budget Required) Discontinuance-FHP Recipient is turning 65. Until recipient turned 65

we compared income and resources to FHP limits, now we compare them to the Medicaid income

limit. Recipient is no longer eligible for FHP, Medicaid ineligible due to excess income. If the



recipient incurs medical bills in the amount of the excess income, or the income goes down, they

may reapply. Worker must enter:

Net Income Amount



X84 (X0206) Discontinue FHP, Turning 65, Medicaid Ineligible Due to Excess Resources (D)

(Fill) (Budget Required) Discontinuance-FHP Recipient is turning 65. Until recipient turned 65

we compared income and resources to FHP limits, now we compare them to the MA income limit.

Recipient is no longer eligible for FHP, Medicaid ineligible due to excess resources. Also, we

have not received documentation that the recipient has spent down the excess resources by

FAMILY HEALTH PLUS (FHP) DISCONTINUANCE TURNING 65 (Cont’d)

establishing or adding to a burial trust/fund. If the recipient incurs medical bills in the amount of

the excess resources, or the resources go down, they may reapply.

Worker must enter:




X85 (X0207) Discontinue FHP, Turning 65, Medicaid Ineligible Due to Excess Income and

Resources (D)

(Fill) (Budget Required) Discontinuance - FHP Recipient is turning 65. Until recipient turned 65

we compared income and resources to FHP limits, now we compare them to the Medicaid income

limit. Recipient is no longer eligible for FHP, Medicaid ineligible due to excess income and

resources. Also, we have not received documentation that the recipient has spent down the excess

resources by establishing or adding to a burial trust/fund. If the recipient incurs medical bills in the

amount of the excess resources and expects to have bills equal to or more than the excess income

or the income and resources go down, they may reapply.

Worker must enter:

Net Income Amount





EQUIVALENT HEALTH INSURANCE

V39 (C0206) Discontinue FHP Due to Equivalent Health Insurance or Federal Employee

(Fill) Recipient is ineligible for FHP due to equivalent health insurance or Federal Employee.



FAMILY HEALTH PLUS (FHP) TO FAMILY PLANNING BENEFIT PROGRAM (FPBP)

V79 (U0137) FHP/ FHP-PAP to FPBP Due to Excess Income, Non-ESHI, Federal Employee or

ESHI Not Cost Effective



(Fill) (Budget Required) Recipient’s coverage will change from FHP/FHP-PAP to FPBP.

Recipient is now ineligible for FHP due to excess income non employer-sponsored health

insurance, federal employee or employer sponsored health insurance not cost effective.



Gross Income Amount

FHP Income Limit

Message #2 FHP Non- Employer Sponsored Health Insurance


Message #4 FHP Employer Health Insurance Not Cost Effective

MA TO FAMILY PLANNING BENEFIT PROGRAM (FPBP)

*F82 (U0138) Child 10-18, Medicaid to FPBP Due to Excess Income

(TAD Based) (Budget Required) Reduction in coverage from full MA to FPBP. Child (ren)

between the ages of 10-18, no longer eligible for Medicaid due to income over 100% of the FPL.

*F83 (U0142) Child 10-18, Medicaid to FPBP Due to Excess Income, 60 Days Post-Partum

(TAD Based) (Budget Required) Reduction in coverage from full Medicaid to FPBP. Child(ren)

between the ages of 10-18, no longer Medicaid eligible due to income over 100% of the FPL,

FPBP eligible at the end of 60 day post-partum period.

V76 (U0139) Over 19, Medicaid to FPBP Due to Excess Income, FHP Ineligible Due to Equivalent

Health Insurance or Federal Employee. (Tad Based)(Budget Required) Reduction in coverage from full Medicaid to FPBP. Recipient is

over 19 and is no longer eligible for Medicaid due to excess income.


Message #1: FHP Equivalent Health Insurance

Message #2: FHP Federal Employee

V77 (U0140) Medicaid to FPBP Due to Excess Income, FHP Ineligible Due to Excess Income


(Fill) (Budget Required) Reduction in coverage from MA to FPBP. Recipient is an S/CC

individual(s), Medicaid ineligible due to excess income, FHP ineligible due to excess income

equivalent health insurance or federal employee.


Gross Income Amount

FHP Income Limit



V78 (U0141) Over 19, Medicaid to FPBP Due to Excess Income and/or Resources, FHP Ineligible

Due to Excess Income Equivalent Health Insurance or Federal Employee, 60 Days Post-

Partum, Infant Continues

(Fill) (Budget required) Reduction in coverage. Recipient is over the age of 19, ineligible for

Medicaid due to excess income and/or resources, FHP ineligible due to excess income equivalent



health insurance or federal employee. Recipient is 60 days post-partum, infant continues until age

1.



Gross Income Amount

FHP Income Limit



V93 (U0164) Medicaid to FPBP Due to Excess Income, FHP Ineligible Due to Excess Income

Equivalent Health Insurance or Federal Employee, FNP Parent

(Fill) (Budget Required) Reduction in coverage. Recipient is an FNP Parent going from Medicaid

to FPBP. Medicaid ineligible due to excess income, FHP ineligible due to excess income,

equivalent health insurance or is a federal employee.

MA TO FAMILY PLANNING BENEFIT PROGRAM (FPBP) (Cont’d)



Gross Income Amount

FHP Income Limit



V95 (U0165) Medicaid to FPBP Due to Excess Income and/or Resources, FHP Ineligible Due to

Excess Income, Equivalent Health Insurance or Federal Employee, FP or MA-SSI Related

(Fill) (Budget Required) Reduction in coverage. Recipient is an FP individual going from

Medicaid to FPBP due to excess income and/or resources, FHP ineligible due to excess income,

equivalent health insurance or federal employee.



Gross Income Amount

FHP Income Limit



FAMILY PLANNING BENEFIT PROGRAM (FPBP)

*C12 (U0156) Add FPBP Person(s) to MA Case

*Note: Must be used at the individual level Only with Case Level Code I89 with or without other

No Fill Codes.

(TAD Based) Add a FPBP person to an existing MA case.

*C15 (U0059) Continue FPBP Unchanged

(TAD Based) Recipient’s Family Planning Benefit Program case continues unchanged.

*C20 (U0157) Add Person(s) to FPBP Case


No Fill Codes.

(TAD Based) Add a person(s) to an existing FPBP case.



V84 (C0190) Discontinue FPBP Due to Excess Income, Over 19 (D)

(Fill) (Budget Required) Discontinuance-Recipient is over 19 years of age, FPBP ineligible due to

excess income.

Worker must enter:

Net Income Amount

FPBP Income Limit

FAMILY PLANNING BENEFIT PROGRAM (FPBP) To MA

*F48 (U0074) Child 10-18, FPBP to MA, Income Now Below 100% FPL

(TAD Based) (Budget Required) Recipient’s net income is now below the allowable income limit

for persons between the ages of 10-18, coverage will increase from FPBP to full MA.

FAMILY PLANNING BENEFIT PROGRAM (FPBP) To MA (Cont’d)

V88 (U0132) FPBP to MA, S/CC

(Tad Based) (Budget Required) Recipient is an S/CC individual going from FPBP to MA,

recipient’s net income is now under the Medicaid Standard.

V89 (U0075) FPBP to MA, FP

(Tad Based) (Budget Required) Recipient is an FP individual going from FPBP to MA, recipient’s

net income is now under the MA income limit.

FAMILY PLANNING BENEFIT PROGRAM (FPBP) TO FAMILY HEALTH PLUS (FHP)

V86 (U0133) FPBP to FHP, MA Ineligible Due to Excess Income, Chose a Plan or will be Auto-

Assigned FP

(Fill) (Budget Required) Recipient is an FP individual going from FPBP to FHP. Recipient’s gross

income is below the FHP income limit and above the MA income limit, recipient has chosen a

health plan.

Work must chose one of the following messages:

Message # 1Plan or New Plan

Plan name


V87 (U0135) FPBP to FHP, MA Ineligible Due to Excess Income, Chose a Plan or will be Auto-

Assigned, S/CC

(Fill) (Budget Required) Recipient is an S/CC individual going from FPBP to FHP. Recipient’s

gross income is under the FHP income limit, MA ineligible due to excess income, Chose a plan or

plan will be Auto-Assigned.

Worker must chose one of the following messages and enter:

Message # 1 One Plan District or Chose a Plan

Health plan


RESOURCE ATTESTATION



*C26 (U0161) Community Coverage without LTC to Community Coverage with Community

Based LTC

(TAD Based) Recipient’s MA coverage is being increased from Community Coverage with no

LTC to Community Coverage with Community based LTC. The recipient has requested an

increase and has submitted proof of current income and resources. Worker did not review the past

36 months (60 months for trust) therefore the recipient will not be covered for certain nursing

facility services.

*C27 (U0162) Community Coverage with Community Based-LTC to All Covered Care and

Services, FP

(TAD Based) Recipient’s MA coverage is being increased from Community Coverage with

Community Based LTC to all covered care and services. The recipient has requested an increase

and has submitted proof of resources for the past 36 months (60 months for trust).

RESOURCE ATTESTATION (Cont’d)

*C60 (U0072) Community Coverage without Community Based-LTC to All Covered Care and

Services, FP

(TAD Based) Recipient’s MA coverage is being increased from Community Coverage without

Community Based LTC to all covered care and services. The recipient has requested an increase

and has submitted proof of resources for the past 36 months (60 months for trust) and proof of

income.

S64 (U0150) All Covered Care and Services to Community Coverage without LTC Due to Failure

to Provide Documentation of Income and/or Resources, No Spenddown

(Fill) (For Recertification Only) Recipient’s coverage is being reduced from full coverage to

limited coverage due to failure to verify income and/or resources.

Worker must enter:

Income and/or Resource(s) Not Verified

S65 (U0152) Continue MA Unchanged, Limited Benefit Package Due to Income and Resource

Documentation

(Fill) Recipient’s coverage will continue unchanged.



Message # 2 Community Coverage With Community Based LTC

S86 (U0160) Community Coverage with Community-Based LTC to Community Coverage

without LTC, Due to Failure to Provide Documentation of Income and/or Resources at

Renewal, No Spenddown

(Fill) Reduction- Recipient’s MA coverage will be reduced from Community Coverage with

Community Based LTC to Community Coverage without LTC. Recipient failed to provide

documentation of income and/or resources at renewal.

Worker must enter:

Income and/or Resource(s) Not Verified

S87 (U0061) Continue MA Unchanged with No LTC, (Attestor or Current Documenter Failed to

Verify)



(Fill) Recipient has requested an increase in MA coverage, but has failed to verify income and/or

resources therefore, coverage will continue unchanged.

Worker must enter:

Income/Resource(s) Not Verified “From” Date

Income/Resource(s) Not Verified “To” Date

Income/Resource(s) Not Verified


Attestor Not Eligible for LTC

Current Documenter Not Eligible for Nursing Facility Services


*H10 (C0051) Spousal Impoverishment, Failure to Provide Resource Information, No Undue

Hardship (D)

SPOUSAL IMPOVERISHMENT (Cont’d)

(TAD Based) Recipient failed to provide documentation of their spouse’s resource(s) necessary to

determine eligibility. Undue hardship does not exist.

*H11 (C0052) Spousal Impoverishment, Failure to Provide Resource Information, Undue

Hardship (D)

(TAD Based) Recipient failed to provide documentation of their spouse’s resource(s) necessary to

determine eligibility. Undue hardship does exist, but recipient refuses to sign forms allowing

worker to seek the amount of the resource.

X13 (C0054) Spousal Impoverishment, Excess Resources for Institutionalized Spouse (D)

(Fill) (Budget Required) Recipient and/or spouse have countable resources which are over the

resource limit and they do not have medical bills that are equal to or more than the amount over the

resource standard.

Worker must enter:

Total Countable Resources For Household

Community Spouse Resource Allowance

Resource Limit for Institutionalized Spouse

*C53 (C0282) Discontinue MA/FHP, Incarceration Out of State or Federal Penitentiary Within NYS

(D)

(TAD Based) Discontinuance-Recipient’s MA/FHP coverage will be discontinued. This is because

recipient is incarcerated in an Out of State or Federal Penitentiary within NYS.

*C55 (U0173) Suspend MA Coverage of Inmate of NYS/Local Correctional Facility (Upstate)

(TAD Based) (FOR USE WITH SINGLE INDIVIDUALS ONLY) Recipient’s MA coverage

suspended due to incarceration at a NYS/Local Correctional Facility (Upstate).

*C56 (U0176) Reopening: Case Closed as Incarcerated in Error (Upstate)

(TAD Based) (Reopening) Recipient’s original case was closed in error. Recipient is not

incarcerated.

*C58 (C0283) Discontinue Medicaid Payment of Health Insurance Premiums of Inmate of NYS or



Local Correctional Facility (D)

(TAD Based) Discontinuance-Recipient’s payment of Health Insurance Premiums. This is because

recipient is an Inmate of a NYS or Local Correctional Facility.

INCARCERATION

*C59 (C0289) Discontinue Medicare Savings Program of Inmate of NYS or Local Correctional

Facility (D)

(TAD Based) Discontinuance-Recipient’s Medicare Savings Program. This is because recipient is

an Inmate of a NYS or Local Correctional Facility.

*C66 (U0175) FHP to MA, Incarcerated Individual Released (Upstate)

(TAD Based) Recipient is no longer incarcerated. MA will be reinstated.

*C67 (U0178) Reinstate MA, Incarcerated Individual Released (Upstate)

INCARCERATION (Cont’d)

(TAD Based) Recipient is no longer incarcerated. Reinstate MA Coverage.

*C68 (U0184) Reinstate FPBP, Incarcerated Individual Released (Upstate)

(TAD Based) Recipient is no longer incarcerated. Reinstate FPBP Coverage.

*C69 (C0292) Discontinue MA/FHP, Incarcerated Individual Released to Custody of United States

Immigration and Customs Enforcement (ICE), (D)

(TAD Based) Discontinuance-Recipient’s MA/FHP coverage will be discontinued. This is

because recipient was Released into the Custody of United States Immigration and Customs

Enforcement (ICE).

LIVING ARRANGEMENT

*C33 (U0076) All Covered Care and Services to CC With CBLTC, No Longer Institutionalized, No

SD, Renewal (TAD Based) (For Renewal Only) Recipient’s coverage is being reduced from full coverage to

community coverage with community based Long Term Care, no longer institutionalized

individual, no spenddown.

*E60 (C0007) Unable to Locate (D)

(TAD Based) Discontinuance –Recipient’s whereabouts are unknown. If recipient receives this

notice and is still in need of MA/FHP/FPBP they may contact the LDSS office.

*E61 (C0005) Not a Resident Of District (D)

(TAD Based) Discontinuance-Recipient is not a resident of the county. If the recipient is still in

need of MA/FHP they may contact the LDSS in the county they are now residing in.

*E62 (C0002) Between 21-65, In a Psychiatric Institution (D)

(TAD Based) Discontinuance-Recipient is between 21-65 years of age, receiving inpatient

psychiatric care in an institution.

*E63 (C0004) Not a State Resident (D)

(TAD Based) Discontinuance -Recipient is not a resident of New York State.



*E79 (C0001) MA Not provided in Current Living Arrangement (D)

(TAD Based) Discontinuance-Recipient lives in a public institution that provides medical care.

Example of an Institutions not covered by MA/FHP/FPBP is Veteran's (VA) Hospitals.

*E85 (U0060) Moved Out of Household, No Forwarding Address (D)

(TAD Based) Discontinuance-Recipient has moved out of the household and there is no

forwarding address.

S12 (U0121) All Covered Care and Services to CC With CBLTC, No Longer Institutionalized,

Exc Inc, SD Not Met

(Fill) Recipient’s coverage is being reduced from full coverage to community coverage with

community based Long Term Care, no longer Institutionalized individual, Excess Income,

Spenddown not met.

Worker must enter:

LIVING ARRANGEMENT (Cont’d)

Net Income Amount

MA Income Limit


U65 (C0006) Not a Resident of District (MA Extension) (D)

(Note: Message #1 and #3 re: TMA is not available for CT 24)

(Fill) Discontinuance-Recipient is no longer living in the county, but is eligible for MA in their

new district. Recipient must file an application in the new district.


Message # 1- (Upstate Only) You are currently receiving a four month

extension. Eligible “To” Date (MMDDYY) (Date must be equal to or

greater than today’s date) (this message not available for CT 24)

Message # 2- (Statewide) You were determined eligible for MA during your

pregnancy. Eligible “To” Date (MMDDYY) (Date must be equal to or

greater than today’s date)

Message # 3 (Upstate Only) You are currently receiving Transitional

Medical Assistance (this message not available for CT 24)

Message # 4 (Statewide) Your baby is eligible to receive Medical

Assistance. Eligible “To” Date (MMDDYY) (date must be equal to or

greater than today’s date)

U77 (C0140) Concurrent Benefits, Intra-State, No Aid Continuing (D)

(Fill) Discontinuance-Recipient’s identity matches a person who is already receiving

MA/FHP/FPBP benefits in NYS.

Worker must enter:


U78 (C0141) Concurrent Benefits, Inter- State, Aid Continuing (D)

(Fill) Discontinuance - Recipient’s identity matches a person who is already receiving

MA/FHP/FPBP benefits in another State.

Worker must enter:




HEALTH INSURANCE

*C08 (U0006) COBRA Continuation

(TAD Based) Recipient continues to be eligible for MA payment of group health insurance

premiums under the COBRA Continuation coverage program.

*C09 (U0007) QMB Continuation

(TAD Based) Recipient continues to be eligible for MA payment of Medicare premiums,

deductibles and coinsurance.

*C10 (U0018) SLIMB Continuation

(TAD Based) Recipient continues to be eligible for MA Payment of Medicare Part B premiums as

a SLIMB.


*C23 (U0068) Continue Payment of Medicare Part B Premium, QI-1

(TAD Based) Recipient continues to be eligible for MA payment of Medicare Part B premiums as

a QI-1.

*C32 (U0117) Continue MA Payment of Health Insurance Premiums.

(TAD Based) Recipient continues to be eligible for MA payment of Medicaid premiums

*E81 (C0101) Discontinue QI-1 Coverage, Annual Fund Exhausted (D)

(TAD Based)(Budget Required) Discontinuance-Recipient will no longer receive payment for

Medicare Part B premium, funding has been exhausted for the year.

S17 (U0019) Change from SLIMB/QI-1 to QMB Coverage

(Fill) (Budget Required) Recipient’s income has decreased to at or below the QMB income

level, in addition to MA payment of Medicare Part B Premiums recipient is now eligible for

payments of Medicare Part A deductibles and coinsurance.

Worker must enter:

Medicare Part A and Part B from Date

QMB Income Limit (100% FPL)

S18 (U0020) Change from QMB to SLIMB Coverage

(Fill) (Budget Required) Recipient’s income has increased and is over the QMB income limit, but

less than the SLIMB income limit. Recipient will continue to be eligible for payment of Medicare

Part B, but is no longer eligible for MA payment of Part A deductibles or coinsurance.

Worker must enter:

QMB Income Limit (100%FPL)

SLIMB Income Limit (120% FPL)

S21 (U0077) Change from QMB to QI-1 Coverage

(Fill) (Budget Required) Recipient’s income is over the QMB income limit, but less than the QI-1

income limit. Recipient will continue to be eligible for payment of Medicare Part B premium as a

QI-1 individual, but payment of Medicare Part A and Part B deductibles and co-insurance will be

discontinued through QMB.



Medicare Part A and B From Date

QMB Income Limit (100% FPL)

QI-1 Income Limit

X14 (C0098) No Longer Eligible for MA Payment of AHIP Premiums (D)

(Fill) (Budget Required) Discontinuance-Recipient is no longer eligible for health insurance

payments under the Aids Health Insurance Program. This is because the recipient failed to

complete the eligibility process, has excess income, is MA eligible, eligible for COBRA, has

moved out of the state, has failed to verify required information or has failed to provide

information from an RFI match.


Message # 1 Failed to complete the MA eligibility process


Message # 3 Eligible for MA

Message # 4 Eligible for COBRA


Message # 5 Moved out of State

Message # 6 Failure to verify

Message # 7 Failed to provide documentation of computer match income

Worker must enter:

Line Number of individual for whom documentation was not provided

Resource(s)

X18 (C0019) Discontinue Payment of Medicare Part B Premiums, QI-1(D)

(Fill) (Budget Required) Discontinuance-Recipient’s MA payment of Medicare Part B premium

payment will be discontinued. Changes will be reflected in the recipient’s Social Security benefit

check within 90 days, this change is due to excess income, not enrolled in Medicare Part A or other

reasons.



Net Income Amount

QI-1 Income Limit

Message # 2 Not enrolled or eligible for Part A

Message # 3 Other


X25 (C0264) Discontinue Payment of Health Insurance Premiums (D)

(Fill) Discontinuance-Recipient’s MA payment of health insurance premiums will be discontinued.

This is because it is no longer cost-effective, participation in the insurance plan has been

discontinued or other reason(s).


Message # 1 Not Cost Effective

Message # 2 No Longer Insured

Message # 3 Other





Premiums (D)

(Fill) (Budget Required) Discontinuance-Recipient is no longer eligible for payment of group

health insurance under COBRA. This is because the recipient is no longer entitled, has excess

income and resources, it is no longer cost effective, has less than 75 employees or other reason(s).



Reason not entitled


Net Income

MA Income Limit



MA Resource Limit




Message # 6 Other

Reason not entitled

X51 (C0032) Discontinue Payment of COBRA Continuation of Group Health Insurance

Premiums, Prior Conditional Acceptance (D)

(Fill) (Budget Required) Discontinuance-Recipient’s MA payment of COBRA prior conditional

acceptance is being discontinued. This is because the recipient is no longer entitled, has excess

income or excess resources, it is no longer cost effective, has less than 75 employees or other

reason(s).


Message # 1 Not Entitled to COBRA Continuation Because

Reason Not entitled


Net Income Amount

MA Income Limit



MA Resource Limit



Message # 6 Other


X52 (C0020) Medicare Buy-In Program, QMB Ineligible (D)

(Fill) (Budget Required) Discontinuance-MA will no longer pay for recipients Medicare

premiums, deductibles and coinsurance. This is because the recipient has excess income or is not

enrolled in or eligible for Medicare Part A or other reason(s).






Net Income Limit (100%FPL)



Message # 3 Other



X53 (C0071) Medicare Buy-In Program, SLIMB Ineligible (D)

(Fill) (Budget Required) Discontinuance-Recipients Medicare Part B premiums are being

discontinued. This is because the recipient has excess income, is not enrolled in or eligible for

Medicare Part A or other reason(s).




Net Income Limit (120% FPL)




Message # 3 Other



X70 (C0102) Discontinue QI-1, Over Income (D)

(Fill) (Budget Required) Discontinuance-Recipient’s MA coverage for QI-1 will end due to excess

income, MA will no longer pay Medicare Part B Premiums.

Worker must enter:

Net Income Amount

QI-1 Income Limit

MEDICAID BUY-IN FOR WORKING PEOPLE WITH DISABILITIES (MBI-WPD)


Improvement Group, Medicaid ineligible Due to Excess Income Due to Excess Income,








Gross Income Amount



Net Income Amount

Medicaid Standard





Gross Income Amount

FHP Income Limit



U05 (U0124) Continue MBI-WPD, Medically Improved With a Severe Impairment

(Fill) (Budget Required) Recipient has shown medical improvement but continues to have a severe

medically determinable impairment(s); MA will continue.

Worker must enter one of the following messages:

Message # 1 Community Coverage no Long Term Care

Message # 2 Community Coverage with Community Based Long Term Care

Message # 3 No Longer Eligible for Long Term Care

Message # 4 None Of the Above





Employee, FP

(Fill) (Budget Required) Recipient is no longer eligible under the MBI-WPD program under


least the Federally required minimum wage. Recipient is ineligible for Medicaid due to excess

income. Recipient was evaluated for FHP, FHP ineligible due to excess income, equivalent

health insurance or Federal Employee.




Worker must enter:

Net Income Amount





Gross Income Amount

FHP Income Limit



U07 (C0143) Discontinue MBI-WPD, Medical Improvement Group, Not Working 40 Hrs.

Not Working at Federal Minimum Wage, FNP Parent

(Fill) (Budget Required) Recipient is no longer eligible for the MBI-WPD program under the

Medical Improvement Group due to not working 40 hours per month or not earning at least

the Federally required minimum wage. Recipient is ineligible for Medicaid due to excess

income. Recipient was evaluated for FHP, FHP ineligible due to excess income, equivalent

health insurance or federal employee.






Worker must enter:

Net Income Amount




Gross Income Amount

FHP Income Limit



U08 (C0131) Discontinue MBI-WPD, No Longer meets Requirements of the Medical


Excess Income, Equivalent Health Insurance or Federal Employee, FNP






Worker must enter:

Net Income Amount




Gross Income Amount

FHP Income Limit





Excess Income, Equivalent Health Insurance or Federal Employee FP





Worker must enter:

Net Income Amount





Gross Income Amount

FHP Income Limit





U11 (U0002) MBI-WPD to MA with Spenddown, Spenddown Not Met, Turning 65

(Fill) (Budget Required) Recipient’s coverage is being reduced from MA under the MBI-WPD

program to MA with a spenddown requirement. Recipient is turning 65 and has monthly income

over the MA income level.

Worker must enter:

Net Income Amount

MA Income Limit




Message # 2 Community Coverage with Community Based LTC



U12 (X0226) MBI-WPD to MA, Excess Income, Spenddown Not Met


(Fill)(Budget Required) Recipient’s coverage is being reduced from MA under the MBI-WPD

program to MA with a spenddown requirement. Recipient’s net income is over 250% of the FPL,

the income and resources are now being compared to the MA limits.

Worker must enter:

Net Income Amount

250% Federal Poverty Level

MA Income Limit










Federal Employee S/CC (D)

(Fill) (Budget Required) Recipient is no longer eligible for the MBI-WPD program under


least the Federally required minimum wage. Recipient is ineligible for Medicaid due to

excess income and/or resources. Recipient was evaluated for FHP, FHP ineligible due to

excess income, equivalent health insurance or federal employee.






Gross Income Amount




Message # 2 Net Income Over Medicaid Standard

Net Income Amount

Medicaid Standard



Gross Income Amount

FHP Income Limit



U17 (U0125) MBI-WPD to MA

(Fill) (Budget Required) Recipient’s coverage will change from MBI-WPD to MA with full

coverage because they are now either unemployed or income is now below the MA income level.


Message # 1 No Longer Employed

Net Income Amount

MA Income Limit


Message # 2 Income

Net Income Amount

MA Income Limit




Message # 3 No Longer Eligible


U18 (C0188) Discontinuance MBI-WPD Due to Excess Income and/or Resources, MA Ineligible

Due to Excess Income and/or Resources

(Fill) (Budget Required) Recipient is no longer eligible under the MBI-WPD program due to

excess income and/or resources. FHP ineligible


Message # 1 Over Income MBI/MA

Net Income Amount


Net Income Amount

MA Income Limit


Message # 2 Over Resources MBI/MA


MA Resource Limit


Message # 3 Over Income and Resources MBI, Over Income and Resources MA

Net Income Amount



MA Resource Limit



Net Income Amount

MA Income Limit



Message # 4 Over Resources MBI and Over Income/Resources MA


MA Resource Limit

Net Income Amount

MA Income Limit



U27 (C0092) Discontinue MBI-WPD Due to Turning 65, MA Ineligible Due to Excess Income

and/or Resources, Spenddown Not Met (D)

(Fill) (Budget Required) Discontinuance–Recipient is turning 65 and is no longer eligible for MA

coverage under MBI-WPD. The recipient is MA ineligible due to excess income and/or resources

and there is a spenddown requirement, spenddown has not been met.




Net Income Amount

MA Income Limit




MA Resource Limit


Message # 3 Over Income And Resources

Net Income Amount

MA Income Limit


MA Resource Limit



U28 (C0249) Discontinue MBI-WPD Due to No Longer Working, Medicaid Ineligible Due to

Excess Income, Spenddown not met FHP Ineligible Due Excess Income, Equivalent Health

Insurance or Federal Employee (D)

(Fill) (Budget Required) Recipient is no longer eligible for Medicaid benefit under the MBI-WPD

program, recipient is no longer working. The recipient is also ineligible for Medicaid due to

excess income and FHP ineligible due excess income, equivalent health insurance or federal

employee.

Worker must enter:

Net Income Amount







Gross Income Amount

FHP Income Limit



U29 (U0003) MBI-WPD to MA with Spenddown Due to No Longer Working, Spenddown Not

Met, FHP Ineligible Due to Choosing Spenddown or has Equivalent Health Insurance

(Fill) (Budget Required) The Recipient is no longer working and is therefore no longer eligible for

MA benefits under the MBI-WPD program. The recipient is MA ineligible due to excess income,

spenddown has not been met. The recipient was also evaluated for FHP, chose spenddown of

income or has equivalent health insurance.

Worker must enter:

Net Income Amount

MA Income Limit






Message # 3 No Longer Eligible





U30 (U0154) MBI-WPD to Medicaid with a Spenddown Due to Non-Financial Reasons,

Spenddown not met FHP Ineligible Due to Excess Income, Chose Spenddown, Equivalent

Health Insurance, Federal Employee or Over 65

(Fill) (Budget Required) Recipient coverage is being reduced from Medicaid coverage under the

MBI-WPD program to Medicaid coverage with a spenddown requirement for Non-Financial

reasons. Recipient is also ineligible for FHP due to excess income, chose spenddown of income,

has equivalent health insurance, federal employee or is over 65.

Worker must choose one of the following messages;

Message # 1 No Longer Working

Message # 2 Over 65

Use for All:

Worker must enter:

Net Income Amount





Gross Income Amount

FHP Income Limit










Message # 3 No Longer Eligible For LTC


U50 (U0127) MA to MBI-WPD, Client Request

(Fill) (Budget Required) Recipient’s coverage will change from MA to MA under the MBI-WPD

program. This is because the recipient has requested the change to MBI-WPD and meets the

requirements for the program.







U53 (X0222) MA With Spenddown to MBI-WPD

(Fill) (Budget Required) Recipient’s coverage will change from Medicaid with a spenddown

requirement to Medicaid under the MBI-WPD program. This is because the net income and

countable resources are below the allowable levels.






ALIENS

*C14 (P0001) Discontinue MA, Non Immigrant/Undocumented Immigrant, Post-Partum No Infant

(D)

(TAD Based) Discontinuance-Recipient is no longer pregnant, and the 60 day post-partum period

has ended. The recipient is not a citizen, qualified alien or permanently residing in the US under

color of the law (PRUCOL). There was no live birth.

*E03 (C0122) Discontinue MA, Non Immigrant/Undocumented Immigrant, 60 Days Post-Partum,

Infant Continues (D)

(TAD Based) Discontinuance-Recipient is not a citizen, qualified alien or permanently residing in

the U.S. under color of the law (PRUCOL), the 60 day post-partum period has ended. No

emergency medical condition exists. The infant will continue until age one.

*E02 (C0121) Discontinue Medicaid, Non-Immigrant, Undocumented Immigrant, End of Medical

Emergency (D)

(TAD Based) Recipient no longer has an emergency medical condition. The recipient is not a

citizen, qualified alien or permanently residing in the US under color of the law (PRUCOL).



CONTINUOUS COVERAGE

*C17 (U0035) Continuous Coverage

(TAD Based) Recipients coverage will continue or be extended, this is because certain children up

to age nineteen must remain eligible for twelve continuous months from the date they are

determined eligible or until they reach nineteen, whichever is earlier.

*E64 (U0036) Continuous Coverage, Moved out of District

(TAD Based) Certain children under 19 years of age who are MA eligible must receive continuous

benefits for one year even if their circumstances change. Families who move from one county to

another will continue coverage until the application is filed in the new county and should apply in

the new county as soon as they are able. After the one year period, if recipient has not already

done so, they will have to reapply for MA for the child (ren) in the new county.

*E65 (C0155) Moved Out of District, Eligible for Continuous Coverage, Accepted in New District

(D)

(TAD Based) Discontinuance-Recipient has moved to a new county and will now be receiving MA

from the new county.

NEWBORN/UNBORN

*E97/I89 (N0008) Newborn Added to Case in Error (Upstate Only) (D)

(TAD Based) Discontinuance - A newborn was added to the case incorrectly. Worker will delete

the newborn.

*E99/I89 (N0005) Newborn Deceased (D)

(TAD Based) Discontinuance-A newborn that was added to a case or converted from unborn to

newborn and is now deceased, coverage is being authorized from the baby’s birth until the date

of the baby’s death.

920/I98 (N0003) Newborn Added to Case (System Generated)

Based on a match to a Medicaid mother a newborn will be added to the case.

921/I96 (N0004) Unborn Name Conversion (System Generated) An unborn on the system that can be matched with a mother who just gave birth will be changed

to newborn with their correct name and birth date.

TRANSITIONAL MEDICAL ASSISTANCE

*C02 (C0042) Discontinue TMA, No Earnings in 1 or More of the Last 3 Months (Upstate)

(TAD Based) Discontinuance-Recipient has had no earnings in one or more of the last three

months and did not have a good reason for this. A renewal package will be sent to apply for

Medical Assistance or Family Health Plus. If the recipient wants us to determine eligibility for

these programs, they must complete the forms and return them by the due date.

*C04 (C0046) Discontinue TMA, End of 12 Months

(TAD Based) Discontinuance-TMA is a 12 month program, recipients have received the full 12

months. A renewal package will be sent to apply for Medical Assistance or Family Health Plus. If

the recipient wants us to determine eligibility for these programs, they must complete the forms

and return them by the due date.



*E08 (U0030) MA to TMA, First 6 Months

(TAD Based) Recipient’s MA will continue under TMA for 12 months as long as a caretaker

relative of a dependent child (ren) under the age of 21 is in the household.

*Triggers the mailer process.

Y78 Beginning of TMA Eligibility Extension after PA Ineligibility Resulting From Unemployment

(Manual Notice Required) Triggers Mailer Process

Y79 Beginning of TMA Eligibility Extension after PA Ineligibility Resulting From Loss of 30 +1/3

(Manual Notice Required) Triggers Mailer Process

HOME EQUITY INTEREST

*C30 (Y0007) Community Coverage without LTC, Home Equity Interest Exceeds Limit, No Undue


(TAD Based) Recipient will get community coverage with no long term care. The recipient has

requested an increase in MA coverage, but the LDSS office worker has determined that the home

equity interest exceeds the equity limit of $758,000. There is no spenddown requirement.

*C31 (U0069) Continue MA Unchanged, Home Equity Interest Exceeds Limit, No Undue


(TAD Based) Recipient’s coverage will continue unchanged. The recipient has requested an

increase in MA coverage but the LDSS office worker has determined that the home equity interest

exceeds the equity limit of $7508,000 and no undue hardship exists. There is no spenddown

requirement.

S29 (U0070) Continue MA Unchanged Due, Home Equity Interest Exceeds Limit, No Undue

Hardship, 6-Month Excess Income and Resource Spenddown Met (Fill) (Budget Required) Recipient’s MA coverage will continue unchanged with a spenddown

requirement. Recipient requested an increase in MA coverage of LTC. The worker has determined

that the home equity interest exceeds the limit and no undue hardship exists. Recipient has met the

6 month excess income and resource requirement.

Worker must enter:

6 Month Coverage Start Date

Net Income Amount

MA Income Limit


MA Resource Limit



SHORT- TERM REHABILATIVE CARE

S33 (U0155) Accept Short-Term Rehabilitative Nursing Home Care (Undercare Only)

(Fill) (Budget Required) Recipient’s MA has been approved for short-term rehabilitative nursing

home care.

Worker must enter:

Rehabilitation Begin Date (MMDDYY)



Rehabilitation End Date (MMDDYY)

First Month Contribution Amount

Second Month Contribution Amount

Net Monthly Income Amount

MA Income Level

Excess Income Amount

S34 (U0158) Deny, Short-Term Rehabilitative Nursing Home Care (Undercare Only)

(Fill) Recipient’s request is being denied for short-term rehabilitative nursing home care.

Recipient has already received one admission for rehabilitative care in the past 12 months.


Rehabilitation Begin Date (MMDDYY)

Rehabilitation End Date (MMDDYY)

Message # 1 Already Received Nursing Home Care in the Last Year

Message # 2 Other:

Reason for Denial

PAY-IN

*E22 (X0088) Failed to Meet or Pay-In Excess Income for 3 Consecutive Months (D)

PAY-IN (Cont’d)

(TAD Based) Discontinuance-Recipient has failed to meet the excess income liability for three or

more consecutive months. Also, no paid or unpaid medical bills have been submitted that are

equal to or more than the excess income amount.

S15 (X0089) Pay-In Credit Due to Uncovered Expenses

(Fill) Notification of credit due from bills submitted for uncovered medical services.

Worker must enter:

Date of Service

Description of service

Amount of Medical Bill

Amount Recipient paid into the agency for the period stated

Month(s) of 02 Coverage

Month/Year (MMYY) which partial credit applies

Excess which applies to partial month

Month(MMYY) when full excess income amount should again be paid

Full excess income amount

S16 (X0090) Pay-In Refund Due to Uncovered Expenses

(Fill) Notification of refund due recipient. Recipient has already paid the excess amount for this

period.

Worker must enter:

Date of Service

Description of service

Amount of Medical bill

Amount Recipient paid into the agency for the period stated



OTHER

*C05 (U0001) Continue MA/FHP/FHP-PAP Unchanged

(TAD Based) Recipient’s MA/FHP/FHP-PAP will continue unchanged.

*C06 (U0009) Add Person(s) to MA Case


No Fill Codes.

(TAD Based) Used by worker to add an individual to the MA case.

*C11 (U0012) Stenson, Continue Unchanged

(TAD Based) The recipient is no longer eligible for Supplemental Security Income (SSI), based on

information from the State Data Exchange (SDX). Recipient will continue to be entitled to full

MA benefits.

*C13 (U0005) Continue Coverage, Infant up to Age 1 Guarantee,

(TAD Based) Continue infant until the end of the month when he/she turns 1 year. Mother

received MA during pregnancy.

*C16 (U0038) Continue Coverage, 4 Month Extension Due to Increase in Spousal or Child Support

OTHER (Cont’d)

(TAD Based) Recipient is eligible for a four month extension of MA benefits because the

recipient’s income is over the LIF income limit due to receipt of or increase in child or spousal

support.

*E90 (C0026) Client Request (D)

(TAD Based) Discontinuance-Recipient has requested that the MA/FHP/FPBP case be

discontinued.

*E95 (C0027) Death (Individual) (D)

(TAD Based) Discontinue-Our records indicate that the recipient is now deceased.

U66 (C0070) Discontinue MA/FHP/FPBP, Currently in Receipt of Assistance (D)

(Fill) Discontinuance-Recipient is receiving MA/FHP/FPBP under another case number.

Worker must enter:

Case number currently active

Y77 Undercare Case Maintenance (Manual Notice Required)

Y99 Other (Manual Notice Required)

USED WITH INDIVIDUAL REASON CODES

I89 Used as a Case Reason Code When Some or All Case Members Have an Individual Reason

Code

USED WITH INFORMATIONAL LETTERS



I90 Used as a Case Reason Code When Some or All Case Members Have an Individual Reason

Code

SPENDDOWN MET

T01 (S0001) Spenddown Met with Bills/Receipts or Combination Bills, Receipts and Pay- In

(Fill) Recipient is eligible with a spenddown; the spenddown has been met with bills/receipts, or a

combination of bills/receipts and pay-in to meet the spenddown for 1-6 months.






Message # 1 Medical Bills/Receipts to Meet Excess Income-Outpatient

Coverage

Total Amount Bills/Receipts

Outpatient Coverage Start Date (MMYY)

Outpatient Coverage End Date (MMYY)

Month Applied to (MMYY)

*Note: Message # 1A is only completed as appropriate

Credit Amount

SPENDDOWN MET (Cont’d)

Month Applied to (MMYY)

Message # 2 Medical Bills/Receipts to Meet 6 Month Excess Income-

Full Coverage


6 Month Coverage From Date(MMYY)

Message # 3 Combined Bills/Receipts & Pay-In Amount Excess Income

Outpatient Coverage

Total Bills/Receipts

Total Amount Paid

Bills/Receipts/Payment Applied to 1st Month (MMYY)

Bills/Receipts/Payment Applied to Last Month (MMYY)

Message # 4 Combined Bills/Receipts & Pay-In 6 Month Excess

Income-Full Coverage


Total Amount Paid In

6 Month Full Coverage from 1st day of Month(MMYY)

Optional completion of the Provider/Recipient letter

If the worker chooses to send a CNS P/R letter, the following entries are required:

Recipient Line Number

Provider Name

Provider Address

*Note: Canadian address requires additional entry of “X” and 3 lines in the

address field

Medical Assistance Authorization From Date



Medical Assistance Authorization To Date

Authorized For (Worker must Select One) :

Outpatient Care Only

All Available Benefits (Inpatient/Outpatient)

Unpaid Bills:

Bill Date

Date of Service

Patient Name/Account Number

Amount

Partial Bill:

Amount Patient Responsible For

Bill Date

Date of Service

Patient Name/Account Number

Amount

*Note: Workers can use an entire unpaid bill, partial bill or both

Optional completion of the Provider/Recipient letter

T02 (S0002) Spenddown Met Pay-In Only

(Fill) Recipient is eligible with a spenddown. Spenddown requirement has been met with pay-in

for 1-6 months.


SPENDDOWN MET (Cont’d)





Message # 1 Payment to Meet Excess Income – Outpatient Coverage

Total Amount Paid

Outpatient Coverage From 1st Day (MMYY)

Outpatient Coverage To Last Day (MMYY)

Message # 2 Payment To Meet Excess Income- 6 Month Inpatient

Coverage Only

Total Amount Paid In

6 Month Coverage from 1st Day (MMYY)

OTHER INFORMATIONAL LETTERS (00 Transaction Types)

Reason Codes T06 and T07 require the worker to use a “00” transaction and are released through

CNS only, no WMS transaction is needed. Once the CNS pending notice is created, it is then sent out

through Selection #7 on the CNS Menu Screen: Notice Authorization Release.

T06 (S0007) SSN Failed Verification/Validation (Active Case)

(Fill) Based on comparison of information received from the Social Security Administration office,

the SSN number given to the LDSS does not match. Therefore, the recipient must submit the correct

SSN number.

Worker must enter:



Line Number(s) or Name(s) of individual who needs

verification/validation

T07 (S0009) SSN Failed SSN Verification/Validation (Application)

(Fill) Based on comparison of information received from the Social Security Administration

Office, the SSN number given to the LDSS does not match. Therefore, the recipient must submit

the correct SSN number.

Worker must enter:

Name(s) of individual who needs verification/validation

T11 (S0011) MBI-WPD to MA, Turning 65

(TAD Based) Recipient has turned 65; therefore, the recipient is no longer eligible for the MBI-

WPD program. Because the net income and countable resources are below the MA income levels,

MA benefits will continue.

T12 (S0012) MBI-WPD to MA, No Longer Working (TAD Based) Employment is a condition of the MBI-WPD program; the recipient is no longer

employed but has income and resources below the MA income limit. MA benefits will continue.

CLIENT NOTICES SYSTEM MANUAL CNS Section Z: MA Case/Individual Chronic Care Codes

Revised April 01, 2008 Page Z - 1

Medical Assistance To perform an Opening or Undercare transactions on MA – Chronic Care cases, the worker chooses one of the following codes. NOTE: Since MA uses only Extensive fill and not Limited fill, the word “Fill” will be used in this section. The term “TAD Based” is also used in this section. TAD Based is defined as a method of notice production which requires no information to be entered on the CNS Subsystem. INTENT TO ESTABLISH LIABILITY TOWARD CHRONIC CARE INCOME ONLY V52 (U0014) Individual -Income Contribution Only (Fill) (Budget Required) The applicant, who is residing in a medical institution, has been approved

for MA coverage of institutional services. The applicant has a monthly contribution of income only toward the cost of care.

Worker may enter: Income: Month of Institutionalization

• Dependent Household Members Allowance • Medical Expenses to Reduce Income • Payable To: ________________

Income: Ongoing Chronic Care • Dependent Household Members Allowance • Medical Expenses to Reduce Income • Payable To: ________________

V53 (U0041) Spousal – Income Contribution Only (Fill) (Budget Required) The applicant, who is residing in a medical institution, has been approved



• Medical Expenses to Reduce Income • Payable To: ________________

Income: Ongoing Chronic Care • Medical Expenses to Reduce Income • Payable To: ________________

Worker may enter: Resources

• Medical Bills To Reduce Resources RESOURCE ONLY V62 (U0055) Spousal – Resource Contribution Only (Fill) (Budget Required) The applicant, who is residing in a medical institution, has been approved

for MA coverage of institutional services. The applicant has excess resources only to contribute toward the cost of care.



Worker may enter:

Income: Month of Institutionalization • Medical Expenses To Reduce Income

Income: Ongoing Chronic Care • Medical Expenses To Reduce Income


• Medical Bills To Reduce Resources • Remaining Excess Resources or Not Applicable • Payable To: ________________

V63 (U0056) Individual – Resource Contribution Only (Fill) (Budget Required) The applicant, who is residing in a medical institution, has been approved



• Dependent Household Members Allowance • Medical Expenses to Reduce Income

Income: Ongoing Chronic Care • Dependent Household Members Allowance • Medical Expenses to Reduce Income



INCOME AND RESOURCE V54 (U0023) Spousal – Income/Resource Contribution (Fill) (Budget Required) The applicant, who is residing in a medical institution, has been approved

for MA coverage of institutional services. The applicant has a monthly contribution of income and excess resources toward the cost of care.








V55 (U0040) Individual – Income/Resource Contribution (Fill) (Budget Required) The applicant, who is residing in a medical institution, has been approved



• Dependent Household Members Allowance • Medical Expenses to Reduce Income • Payable To: ________________

Income: Ongoing Chronic Care • Dependent Household Members Allowance • Medical Expenses to Reduce Income • Payable To: ________________



NO LIABILITY V60 (U0047) Individual – No Liability Toward Cost of Care (Fill) (Budget Required) The applicant, who is residing in a medical institution, has been approved

for MA coverage of institutional services. The applicant has no contribution toward the cost of care.


• Dependent Household Members Allowance • Medical Expenses to Reduce Income

Income: Ongoing Chronic Care • Dependent Household Members Allowance • Medical Expenses to Reduce Income

V61 (U0048) Spousal – No Liability Toward Cost of Care (Fill) (Budget Required) The applicant, who is residing in a medical institution, has been approved



• Medical Expenses to Reduce Income • Remaining Available Monthly Income

Income: Ongoing Chronic Care • Medical Expenses to Reduce Income


• Medical Bills To Reduce Resources



WAIVER RECIPIENT V56 (U0033) Spousal – Previously Wavier Recipient, Income and Resource Contribution (Fill) (Budget Required) The applicant, who is receiving home and community-based waiver

services, has been approved for MA coverage of institutional services. The applicant has a monthly contribution of income and excess resources toward the cost of care.






V57 (U0052) Spousal – Previously Wavier Recipient, Income Contribution Only (Fill) (Budget Required) The applicant, who is receiving home and community-based waiver

services, has been approved for MA coverage of institutional services. The applicant has a monthly contribution of income only toward the cost of care.





• Medical Bills To Reduce Resources V58 (U0053) Spousal – Previously Wavier Recipient, Resource Contribution Only (Fill) (Budget Required) The applicant, who is receiving home and community-based waiver

services, has been approved for MA coverage of institutional services. The applicant has excess resources only to contribute toward the cost of care.


• Medical Expenses to Reduce Income Income: Ongoing Chronic Care

• Medical Expenses to Reduce Income Worker may enter:

Resources • Medical Bills To Reduce Resources • Remaining Excess Resources or Not Applicable • Payable To: ________________



V59 (U0054) Spousal – Previously Wavier Recipient, No Liability Toward Cost of Care (Fill) (Budget Required) The applicant, who is receiving home and community-based waiver

services, has been approved for MA coverage of institutional services. The applicant has no monthly contribution toward the cost of care.


• Medical Expenses to Reduce Income Income: Ongoing Chronic Care

• Medical Expenses to Reduce Income Worker may enter:

Resources • Medical Bills To Reduce Resources

INTENT TO ESTABLISH LIABILITY TOWARD CHRONIC CARE – PREVIOUSLY PRIVATE PAY INCOME ONLY V64 (U0085) Individual- Income Contribution Only (Fill) (Budget Required) The applicant, who is residing in a medical institution, has been approved


Worker may enter: Income: Ongoing Chronic Care

• Dependent Household Members Allowance • Medical Expenses To Reduce Income • Payable To: ________________

V65 (U0086) Spousal- Income Contribution Only (Fill) (Budget Required) The applicant, who is residing in a medical institution, has been approved



• Medical Expenses To Reduce Income • Payable To: ________________


• Medical Bills To Reduce Resources RESOURCE ONLY V74 (U0095) Spousal – Resource Contribution Only (Fill) (Budget Required) The applicant, who is residing in a medical institution, has been approved for MA coverage of institutional services. The applicant has excess resources only to contribute towards the cost of care.




• Medical Expenses To Reduce Income Worker may enter:

Resources • Medical Bills To Reduce Resources • Remaining Excess Resources • Payable To: ________________

V75 (U0096) Individual – Resource Contribution Only (Fill) (Budget Required) The applicant, who is residing in a medical institution, has been approved



• Dependent Household Members Allowance • Medical Expenses To Reduce Income


• Medical Bills To Reduce Resources • Remaining Excess Resources • Payable To: ________________

INCOME AND RESOURCE V66 (U0087) Spousal – Income/Resource Contribution (Fill) (Budget Required) The applicant, who is residing in a medical institution, has been approved






V67 (U0088) Individual – Income/Resource Contribution (Fill) (Budget Required) The applicant, who is residing in a medical institution, has been approved





• Dependent Household Members Allowance • Medical Expenses To Reduce Income • Payable To: ________________



NO LIABILITY V72 (U0093) Individual – No Liability Toward Cost of Care (Fill) (Budget Required) The applicant, who is residing in a medical institution, has been approved



• Dependent Household Members Allowance • Medical Expenses To Reduce Income

V73 (U0094) Spousal – No Liability Toward Cost of Care (Fill) (Budget Required) The applicant, who is residing in a medical institution, has been approved




Resources • Medical Bills To Reduce Resources

WAIVER RECIPIENT V68 (U0089) Spousal – Previously Wavier Recipient, Income and Resource Contribution (Fill) (Budget Required) The applicant, who is receiving home and community-based waiver

services, has been approved for MA coverage of institutional services. The applicant has a monthly contribution of income and excess resources toward the cost of care.







V69 (U0090) Spousal – Previously Wavier Recipient, Income Contribution Only (Fill) (Budget Required) The applicant, who is receiving home and community-based waiver

services, has been approved for MA coverage of institutional services. The applicant has a monthly contribution of income only toward the cost of care.




• Medical Bills To Reduce Resources V70 (U0091) Spousal – Previously Wavier Recipient, Resource Contribution Only (Fill) (Budget Required) The applicant, who is receiving home and community-based waiver

services, has been approved for MA coverage of institutional services. The applicant has excess resources only to contribute toward the cost of care.



Resources • Medical Bills To Reduce Resources • Remaining Excess Resources • Payable To: ________________

V71 (U0092) Spousal – Previously Wavier Recipient, No Liability Toward Cost of Care (Fill) (Budget Required) The applicant, who is receiving home and community-based waiver

services, has been approved for MA coverage of institutional services. The applicant has no monthly income contribution toward the cost of care.



Resources • Medical Bills to Reduce Resources

TRANSFERS AND LIENS S68 (X0227) Accept Limited Coverage Due to Transfer, Individual in Community, Excess

Income, Spenddown Not Met, FHP Ineligible Due to Excess Income, Chose Spenddown, Equivalent Health Insurance or Over 65

(Fill) (Budget Required) Applicant is ineligible for full MA due to a prohibited transfer. The applicant is also ineligible for FHP due to excess income, chose spenddown, equivalent health insurance or over 65 years of age. The applicant is eligible for reduced MA coverage with a spenddown of excess income. The spenddown requirement has not been met.

Worker must enter: Net Income Amount



MA Income Limit Monthly Excess Income Amount

Worker must choose one of the following messages and enter: Message # 1 FHP Over Income

• Gross Income Amount • FHP Income Limit

Message # 2 FHP Chose Spenddown of Income Message # 3 FHP Equivalent Health Insurance Message # 4 FHP Over 65

Worker must enter the following: Date Eligible For Nursing Home Sevices after penalty period ends Date of Transfer Asset Transferred Fair Market Value of the resource or income amount Amount of Compensation Received Monthly regional rate of nursing facility services in the district in which the individual is

institutionalized Month, first day of the month and the year in which limited coverage (Ineligibility for

Nursing Home Services) begins (MMDDYY) S69 (Y0029) Accept Limited Coverage Due to Transfer, Individual in Community, No Excess (Fill) (Budget Required) Applicant is ineligible for full MA due to a prohibitive transfer. The

applicant is eligible for reduced MA coverage. There is no excess. Worker must enter:

Date eligible for Nursing Home Services after penalty period ends Date of Transfer Asset Transferred Fair Market Value of the resource or income amount Amount of Compensation Recieved Monthly regional rate of nursing facility services in the district in which the individual is


Nursing Home Services) begins (MMDDYY) S70 (Y0010)Accept Institutionalized Individual, Limited Coverage Due to Prohibited Transfer,

No Excess (Fill)(Budget Required) Applicant is ineligible for full MA due to a prohibited transfer. The

applicant is eligible for reduced MA coverage. There is no excess. Worker must enter:

Date Eligible for Nursing Home Services after penalty period ends Date of Transfer Asset Transferred Fair Market value of the resource or income amount Amount of Compensation Recieved Monthly regional rate of nursing facility services in the district in which the individual is

institutionalized



Month, first day of the month and the year in which limited coverage (Ineligibility for Nursing Home Services) begins (MMDDYY)

S71 (Y0035) Accept Institutionalized Individual, Limited Coverage Due to Prohib Transfer,

Exc Inc SD Met (Fill)(Budget Required) Applicant is ineligible for full MA due to a prohibited transfer. The

applicant is eligible for reduced MA coverage with a spenddown of excess income. The spenddown requirement has been satisfied for a least one month and up to five months.

Worker must enter: Net Income Amount MA Income Limit Monthly Excess Income Amount Date Eligible for Nursing Home Services after penalty period ends Date Of Transfer Asset Transferred Fair Market Value of the resource or income amount Amount of Compensation Received Monthly regional rate of nursing facility services in the district in which the individual is


Nursing Home Services) begins (MMDDYY) S72 (Y0031) Accept Institutionalized Individual, Limited Coverage Due to Prohibited Transfer, Excess Inc and Res, 6 Month Excess Income and Resources Spenddown Met (Fill)(Budget Required) Applicant is ineligible for full MA due to a prohibited transfer. The

applicant is eligible for reduced MA coverage with a spenddown of excess income and resources. Spenddown of income and resources met for 6 months.

Worker must enter: Net Income Amount MA Income Limit Total Countable Resources MA Resource Limit Monthly Excess Income Amount Excess Resource Amount Spenddown Met “From” Date Date Eligible For Nursing Home Services after penalty period ends Date of Transfer Asset Transferred Fair Market Value of the resource or income amount Amount of Compensation Received Monthly regional rate of nursing facility services in the district in which the individual is

institutionalized Month, first day of the month and the year in which limited coverage (ineligibility for




S73 (X0033) Accept Limited Coverage Due to Transfer, Individual in Community, Excess Income, Spenddown Met

(Fill) (Budget Required) Applicant is ineligible for full MA due to a prohibited transfer. The applicant is also ineligible for FHP due to excess income, chose spenddown, has equivalent health insurance, or is over 65. The applicant is eligible for reduced MA coverage with a spenddown of excess income. The spenddown requirement has been satisfied for at least one and up to five months.

Worker must enter: Spenddown Met “From” Date Spenddown Met “To” Date Net Income Amount MA Income Limit Monthly Excess Income Amount Date Eligible for Nursing Home Services after penalty period ends Date of Transfer Asset Transferred Fair Market Value of the resource or income amount Amount of Compensation Received Monthly regional rate of nursing facility services in the district in which the individual is


Nursing Home Services) begins (MMDDYY) S74 (X0035) Accept Limited Coverage Due to Transfer, Individual in Community, Excess

Income, 6 Month Spenddown Met (Fill) (Budget Required) Applicant is ineligible for full MA due to a prohibited transfer. The

applicant is eligible for reduced MA coverage with a spenddown of excess income. The spenddown requirement has been satisfied for six months.

Worker must enter: Spenddown Met “From” Date Net Income Amount MA Income Limit Monthly Excess Income Amount Date Eligible for Nursing Home Services after penalty period ends Date of Transfer Asset Transferred Fair Market Value of the resource or income amount Amount of Compensation Received Monthly regional rate of nursing facility services in the district in which the individual is


Nursing Home Services) begins (MMDDYY) S75 (Y0030) Accept Institutionalized Individual, Limited Coverage Due to Prohibited Transfer,

Excess Resources, Spenddown Met



(Fill) (Budget Required) Applicant is ineligible for full MA due to a prohibited transfer. The applicant is eligible for reduced MA coverage with a spenddown of excess resources. Resources have been spent down to MA level.

Worker must enter: Spenddown Met “From” Date Spenddown Met “To” Date Total Countable Resources Resource Limit Excess Resource Amount Date Eligible for Nursing Home Services after penalty period ends Date of Transfer Asset Transferred Fair Market Value of the resource or income amount Amount of Compensation Received Monthly regional rate of nursing facility services in the district in which the individual is


Nursing Home Services) begins (MMDDYY) S76 (X0034) Accept Limited Coverage Due to Transfer, Individual in Community, Excess

Resources, Spenddown Met (Fill) (Budget Required) Applicant is ineligible for full MA due to a prohibited transfer. The

applicant is eligible for reduced MA coverage with a spenddown of excess resources. Resources have been spent down to MA level.

Worker must enter: Spenddown Met “ From” Date Spenddown Met “To” Date Total Countable Resources MA Resource Limit Excess Resource Amount Date Eligible for Nursing Home Services after penalty period ends Date of Transfer Asset Transferred Fair Market Value of the resource or income amount Amount of Compensation Received Monthly regional rate of nursing facility services in the district in which the individual is


Nursing Home Services) begins (MMDDYY) ANCILLARY COVERAGE ONLY

S83 (Y0044) Accept Instit Indiv Ancillary Coverage Only Due to Fail to Provide Documentation of Resources, Excess Income, Spenddown Not Met

(Fill) (Budget Required) Applicant is accepted for ancillary coverage because they failed to provide resource documentation. Reduced MA coverage is available for other care and services not



included in the facility’s rate (example: eyeglasses, hearing aides, dentures and acute hospital care), but they must meet the excess income spenddown requirement. The Spenddown has no been met.

Worker must enter: Net Income Amount MA Income Limit Monthly Excess Income Amount Resources Failed to Verify

S84 (Y0034) Accept Institutionalized Individual, Ancillary Coverage Only Due to Failure

to Provide Documentation of Resources (No Excess) (Fill) (Budget Required) Applicant is accepted for ancillary coverage because they failed to

provide resource documentation. Reduced MA coverage is available for other care and services not included in the facility’s rate (example: eyeglasses, hearing aides, dentures and acute hospital care). There is no excess.

Worker must enter: Resources Failed to Verify

HOME EQUITY INTEREST *C30 (Y0007) Community Coverage without LTC, Home Equity Interest Exceeds Limit, No Undue

Hardship, No Spenddown (TAD Based)(Budget Required) ) Applicant is eligible for Community Coverage without LTC. It

has been determined that the applicant(s) home equity interest exceeds the limit allowed, and that undue hardship does not exist. There is no spenddown requirement.

S91 (Y0037) Community Coverage without LTC, Home Equity Interest Exceeds Limit, No Undue

Hardship, Excess Income, Spenddown Met (Fill) (Budget Required) Applicant is eligible for Community Coverage without LTC with a

spenddown requirement. It has been determined that the applicant(s) home equity interest exceeds the limit allowed, and that undue hardship does not exist. The applicant has met the spenddown requirement for at least one month, but no more than five months.

Worker must enter: Outpatient Coverage “From” Date Outpatient Coverage “To” Date Net Income Amount MA Income Limit Monthly Excess Income Amount

X91 (Y0033) Community Coverage without LTC, Home Equity Interest Exceeds Limit, No Undue

Hardship, Excess Income and/or Resources, Excess Income and/or Resources 6-Month Spenddown Met

(Fill) (Budget Required) Applicant is eligible for Community Coverage without LTC with a spenddown requirement. It has been determined that the applicant(s) home equity interest exceeds the limit allowed, and that undue hardship does not exist. The applicant has met the spenddown of



income for 1-5 months or for 6 months and/or resources have been spent down to MA level. Worker must choose one of the following messages and enter:

Message # 1 Over income • Net Income Amount • MA Income Limit • Monthly Excess Income Amount • 6 Month Coverage “From” Date

Message # 2 Over Resources • Total Countable Resources • MA Resource Limit • Excess Resource Amount • MA Coverage “From” Date • MA Coverage “To” Date

Message # 3 Over Income and Resources • Net Income Amount • MA Income Limit • Total Countable Resources • MA Resource Limit • Monthly Excess Income Amount • Excess Resource Amount • 6 Month Coverage “From” Date

RECALCULATION OF CONTRIBUTION TOWARD CHRONIC CARE V11 (U0147) Recalculation of Contribution Toward Chronic Care Due to COLA, Individual

(Upstate Only) (Fill) (Budget Required) Recalculation-The recipient’s monthly income contribution will change

effective January 1ST due to the COLA adjustment for the individual only. Worker must enter:

Previous Total Income Contribution Per Month Total Income Contribution Per Month

V12 (U0148) Recalculation of Contribution Toward Chronic Care Due to COLA, Spousal

(Upstate Only) (Fill) (Budget Required) Recalculation-The recipient’s monthly income contribution will change

effective January 1ST due to the COLA adjustment. Worker must enter:

Previous Total Income Contribution Per Month Total Income Contribution Per Month

V40 (U0015) Recalculation of Contribution Toward Chronic Care, Spousal, Income Only (Fill) (Budget Required) Recalculation, The institutionalized individual’s monthly income

contribution toward the cost of care will be changing. Worker must enter:



Previous Total Income Contribution Per Month Medical Expense to Reduce Income Remaining Available Monthly Income Total Income Contribution Per Month Payable To: ________________ Recalculation Due To: ________________

V41 (U0022) Recalculation of Contribution Toward Chronic Care, Individual, Income Only (Fill) (Budget Required) Recalculation, The institutionalized individual’s monthly income contribution toward the cost of care will be changing. Worker must enter:

Previous Total Income Contribution Per Month Dependent Household Member Allowance Medical Expenses to Reduce Income Total Income Contribution Per Month Payable To: ________________ Recalculation Due To: ________________

V42 (U0042) Recalculation of Contribution Toward Chronic Care, Individual, Resource Only (Fill) (Budget Required) Recalculation, The institutionalized individual will have a contribution of excess resources toward the cost of care. There continues to be no income contribution required. Worker will enter:

Dependent Household Member Allowance Medical Expenses to Reduce Income Medical Bills to Reduce Resources Remaining Excess Resources Payable To or Not Applicable: ________________ Recalculation Due To: ________________

V43 (U0045) Recalculation of Contribution Toward Chronic Care, Spousal, Resource Only (Fill) (Budget Required) Recalculation, The institutionalized individual will have a contribution of excess resources toward the cost of care. There continues to be no income contribution required. Worker must enter:

Medical Expenses to Reduce Income Remaining Available Monthly Income Medical Bills to Reduce Resources Remaining Excess Resources Payable To or Not Applicable: ________________ Recalculation Due To: ________________

V44 (U0050) Recalculation of Contribution Toward Chronic Care, Spousal, No Change (Fill) (Budget Required) Recalculation, The institutionalized individual’s monthly income contribution toward the cost of care will remain unchanged. Worker must enter:

Medical Expenses to Reduce Income Remaining Available Monthly Income



Total Income Contribution Per Month Payable To: ________________ Recalculation Due To: ________________

V45 (U0051) Recalculation of Contribution Toward Chronic Care, Individual, No Change (Fill) (Budget Required) Recalculation, The institutionalized individual’s monthly income contribution toward the cost of care will remain unchanged. Worker must enter:

Dependent Household Member Allowance Medical Expenses to Reduce Income Total Income Contribution Per Month Payable To: ________________ Recalculation Due To: ________________

V46 (U0024) Recalculation of Contribution Toward Chronic Care, Spousal, Income and

Resources (Fill) (Budget Required) Due to recalculation of the institutionalized individual’s monthly income

and resources, the income contribution toward the cost of care will be changing, and there will be a contribution of Excess Resources.

Worker must enter: Previous Total Income Contribution Per Month Medical Expenses to Reduce Income Remaining Available Monthly Income Total Income Contribution Per Month Payable To: ________________ Medical Bills To Reduce Resources Remaining Excess Resources Payable To or Not Applicable: ________________ Recalculation Due To: ________________

V47 (U0026) Recalculation of Contribution Toward Chronic Care, Individual, Income and

Resources (Fill) (Budget Required) Due to recalculation of the institutionalized individual’s monthly income

and resources, the income contribution toward the cost of care will be changing, and there will be a contribution of Excess Resources.

Worker must enter: Previous Total Income Contribution Per Month Dependent Household Member Allowance Medical Expenses to Reduce Income Total Income Contribution Per Month Payable To: ________________ Medical Bills To Reduce Resources Remaining Excess Resources Payable To or Not Applicable: ________________ Recalculation Due To: ________________



V48 (U0046) Recalculation of Contribution Toward Chronic Care, Spousal, No Liability (Fill) (Budget Required) Recalculation of the institutionalized individual continues with no contribution required towards the cost of care. Worker must enter:

Medical Expenses to Reduce Income Remaining Available Monthly Income Recalculation Due To: ________________

V49 (U0049) Recalculation of Contribution Toward Chronic Care, Individual, No Liability (Fill) (Budget Required) Recalculation of the institutionalized individual continues with no contribution required towards the cost of care. Worker must enter:

Dependent Household Member Allowance Medical Expenses to Reduce Income Recalculation Due To: ________________

V50 (U0057) Recalculation of Contribution Toward Chronic Care, Individual, No Change in

Income, Excess Resources (Fill) (Budget Required) Due to recalculation of the institutionalized individual’s monthly income,

the contribution toward the cost of care will remain unchanged. However, there is an excess resource contribution toward the cost of care.

Worker must enter: Dependent Household Member Allowance Medical Expenses to Reduce Income Total Income Contribution Per Month Payable To: ________________ Medical Bills To Reduce Resources Remaining Excess Resources Payable To or Not Applicable: ________________ Recalculation Due To: ________________

V51 (U0058) Recalculation of Contribution Toward Chronic Care, Spousal, No Change in

Income, Excess Resources (Fill) (Budget Required) Due to recalculation the institutionalized individual’s monthly income,

the contribution toward the cost of care will remain unchanged. However, there is an excess resource contribution toward the cost of care.

Worker must enter: Medical Expenses to Reduce Income Remaining Available Monthly Income Total Income Contribution Per Month Payable To: ________________ Medical Bills To Reduce Resources Remaining Excess Resources Payable To or Not Applicable: ________________ Recalculation Due To: ________________

TRANSFERS AND LIENS



S02 (U0010) Transfer by Institutionalized Individual, Reduce From Full to Limited Coverage (Fill) (Budget Required) Reduction-Recipient’s coverage will go from full services to limited care. The recipient and/or spouse have transferred an asset(s) for less than the Fair Market value of the resource. Worker must enter:

Date eligible for Nursing Home Services after penalty period ends Date of the Transfer Asset Transferred Fair Market Value of the resource or the income amount Amount of Compensation Received Monthly regional rate of the nursing facility services in district in which the

individual is institutionalized Month, first day of the month and the year in which limited coverage

(Ineligibility for Nursing Home Services) begins (MMDDYY) S06 (U0017) Intent to Impose a Lien on Real Property-Institutionalized Individual (Fill) The recipient is an institutionalized individual who will not be returning to the community.

The recipient has interest in Real Property which the MA program intends to impose a lien on should the property be sold.

Worker must enter: The Location of the Real Property for which a Lien is being imposed

Worker must choose one or more of the following exemptions or disregards: Message # 1 Property is the home and there is intent to return to the home Message # 2 The Property is used in a trade or business Message # 3 There is a legal impediment which prevents sale of the property Message # 4 The Property is the home but continues to be occupied by a

dependent Worker must choose one or more of the following messages when message # 4 is selected:

Message A- Dependent adult child/stepchild who is not certified blind/disabled, or grandchild

Message B- Dependent parent, stepparent, grandparent, aunt, uncle, niece, nephew

Message C- Dependent sibling, stepsibling, half brother/sister, cousin, or in-law

S09 (X0036) Institutionalized Individual- Transfer, MA to Limited Coverage and Excess Income, Spenddown Met (Fill) (Budget Required) Reduction-Recipient’s coverage will go from full coverage to limited

coverage. This is because the recipient has transferred asset(s) for less than the value of the resource.

Worker must enter: Monthly Excess Income Amount Net Income Amount MA Income Limit Date Eligible for Nursing Home Services after Pending Penalty Period Ends Date of Transfer



Asset Transferred Fair Market Value of the resource or the income amount Amount of Compensation Received Monthly regional rate of nursing facility services in the district in which the


(Ineligibility for Nursing Home Services) begins (MMDDYY) U54 (X0040) Transfer of Assets, Institutionalized Individual, Excess Income, Spenddown Not Met (Fill) (Budget Required) Discontinue MA due to the transfer of assets. Due to excess income, the

recipient is not eligible for ancillary services (i.e. eyeglasses, acute hospital care). The recipient’s ancillary medical bills do not equal or exceed the excess income amount based on a household of

one using community budgeting. Worker must enter:

Net Income Amount MA Income Limit Monthly Excess Income Amount Date eligible for Nursing Home Services after penalty period ends Date of the Transfer Asset Transferred Fair Market Value of the resource or the income amount Amount of Compensation Received Monthly regional rate of nursing facility services in the district in which the


(Ineligibility for Nursing Home Services) begins (MMDDYY) U55 (X0181) Transfer of Assets, Institutionalized Individual, Excess Resources, Spenddown Not Met (Fill) (Budget Required) Discontinuance-Recipient is an institutionalized individual with excess resources and the spenddown has not been met. Worker must enter:

Total Countable Resources Excess Resource Amount Date eligible for Nursing Home Services after penalty period ends Date of the Transfer Asset Transferred Fair Market Value of the resource or the income amount Amount of Compensation Received Monthly regional rate of nursing facility services in the district in which the


(Ineligibility for Nursing Home Services) begins (MMDDYY) U56 (X0182) Transfer of Assets, Institutionalized Individual, Excess Income and Resources, Spenddown Not Met 4r (Fill) (Budget Required) Discontinuance-Recipient is an institutionalized individual with



excess income and resources, the spenddown requirement has not been met. Worker must enter:

Net Income Amount MA Income Limit Total Countable Resources Monthly Excess Income Amount Excess Resource Amount Date eligible for Nursing Home Services after penalty period ends Date of the Transfer Asset Transferred Fair Market Value of the resource or the income amount Amount of Compensation Received Monthly regional rate of nursing facility services in the district in which the


(Ineligibility for Nursing Home Services) begins (MMDDYY)

CLIENT NOTICES SYSTEM MANUAL CNS Section AA: MA Case/Individual Medicaid Cancer Treatment Program (MCTP) Codes

Revised March 2008 Page AA - 1

Medical Assistance To perform denials/discontinuance/openings/undercare transactions for the Medicaid Cancer Treatment Program (MCTP), the worker chooses one of the following codes. These transactions can only be done in District 99. NOTE: Since MA uses only Extensive fill and not Limited fill, the word “Fill” will be used in this section. The term “TAD Based” is also used in this section. TAD Based is defined as a method of notice production which requires no information to be entered on the CNS Subsystem. MEDICAID CANCER TREATMENT PROGRAM (DISTRICT 99 ONLY) OPENINGS *C19 (Y0049) Accept MCTP (TAD Based) Accept recipient for MA coverage under the MCTP program. DENIALS *B70 (D0130) Deny MCTP, Not in Need of Treatment (TAD Based) Recipient denied for MA coverage under the MCTP program. This is because the recipient is not in need of treatment. *B71 (D0131) Deny MCTP, Not a Resident of State (TAD Based) Recipient denied for MA coverage under the MCTP program. This is because the recipient is not a Resident of New York State. *B72 (D0133) Deny MCTP, Other Health Insurance (TAD Based) Recipient denied for MA coverage under the MCTP program. This is because the recipient has other health insurance. V81 (D0132) Deny MCTP, Failed to Verify, Did Not State Unable to Get Information (Fill) Applicant failed to provide documentation necessary to determine eligibility and did not state unable to get information. Worker must enter:

• Documentation needed UNDERCARE *B78 (U0149) Continue MA/MCTP Unchanged (TAD Based) The recipient’s MA coverage under the MCTP program is unchanged. U24 (X0225) Spenddown to MCTP (Fill) Recipient’s coverage will change from MA with a spenddown to coverage under the

MCTP Program. This is because the recipient preferred to receive MA benefits through this program.

Worker must enter: MCTP Effective Date

CLIENT NOTICES SYSTEM MANUAL CNS Section AA: MA Case/Individual Medicaid Cancer Treatment Program (MCTP) Codes

Revised March 2008 Page AA - 2

DISCONTINUANCES *B73 (C0216) Discontinue MCTP, Client Request (TAD Based) Recipient has requested that the MCTP case be discontinued. *B74 (C0217) Discontinue MCTP, Failed to Renew (Recertify) (TAD Based) Recipient or their representative has failed to return the renewal form. *B75 (C0218) Discontinue MCTP, Other Health Insurance (TAD Based) Discontinue Recipient for MA coverage under the MCTP program. This is because the recipient has other health insurance. *B76 (C0219) Discontinue MCTP, Moved out of State (TAD Based) Discontinue Recipient for MA coverage under the MCTP program. This is because the recipient is no longer a resident of New York State. *B77 (C0221) Discontinue MCTP, Death (TAD Based) Discontinue Recipient due to death. V82 (C0220) Discontinue MCTP, Treatment Ended (Fill) Discontinue Recipient for MA coverage under MCTP. This is because the recipients treatment has ended. Worker must enter:

• Date Treatment Ended

CLIENT NOTICES SYSTEM MANUAL CNS MA Insert Language - Matrices

Last Revised Page BB -1

PA REASON CODE - MA LANGUAGE MATRICES When a PA case is Denied or Discontinued, the Reason Code selected for the transaction determines the notice language. The selected PA reason code also determines the MA language, which is automatically generated for the PA notice. The following Matrices enable the worker to identify which MA Insert Reason Code is associated with the PA Reason Code. The worker can then find the corresponding language for the MA Insert Reason Code at the end of this section. PA NOTICE – MA INSERT LANGUAGE GENERATION OF MA COVERAGE TO-DATE AT PA CLOSING Receipt of PA no longer automatically entitles a recipient to MA. Therefore, WMS will generate an MA Coverage TO-Date equal to today’s date plus 10 days when a PA Case is closed and Notice Indicator of “A” or “T” is entered or “N” is entered and MA Coverage exists at least ten days in the future. PA REASON CODE – MA LANGUAGE MATRICES The matrices have been redesigned to reflect the usage of Categorical Codes to generate MA Extensions and MA Insert Language. LOGIC USED TO GENERATE AN MA INSERT RC FOR PA DENIALS WHEN BOTH A PA CASE LEVEL RC (CRC) AND INDIVIDUAL LEVEL RC (IRC) ARE ENTERED IN WMS Case RC – No Separate Determination: If the CRC generates any MA Insert RC other than 753 or 793 for an individual then that Insert RC generated by the CRC takes precedence over the Insert RC generated by any IRC present for that individual. Exception: when the IRC is E95 the Insert RC generated by E94 (756) will be generated for that individual. Case RC – Separate Determination (753, 793): When the CRC generates Insert RC 753 or 793 for an individual, WMS defaults to the Insert RC generated by the IRC for that individual if an IRC is present. Case RC I92: Default to IRC LOGIC USED TO GENERATE AN MA INSERT RC FOR PA CLOSINGS WHEN BOTH A PA CASE LEVEL RC (CRC) AND INDIVIDUAL LEVEL RC (IRC) ARE ENTERED IN WMS: For no individual in the case does Case RC generate a Rosenberg Extension or a Continuous Coverage Extension or a PCP Guarantee Extension: CRC takes precedence over all IRCs. Exception: WMS Defaults to IRC if:

• IRC is E94.



For no individual in the case does Case RC generate a Rosenberg Extension or a Continuous Coverage Extension; Case RC does generate PCP Guarantee Extension for one or more individuals in the case: CRC takes precedence over all IRCs. Exceptions: WMS defaults to IRC if:

• IRC does not generate a Rosenberg Extension nor a Continuous Coverage Extension nor a PCP Guarantee Extension; or

• IRC is E94. For no individual in the case does Case RC generate a Rosenberg Extension or a PCP Guarantee Extension; Case RC does generate a Continuous Coverage Extension for one or more individuals in the case: CRC takes precedence over all IRCs. Exceptions: WMS defaults to IRC if:

• IRC does not generate a Rosenberg Extension nor a Continuous Coverage Extension; or • IRC is E94.

Case RC Generates an MA Extension: WMS defaults to IRC unless:

• IRC generates an MA extension and IRC is not E94. • CRC generates 6 or 4 month extension. When CRC generates a 6 month (E31, M92 or M93) or a

4 month (E32) extension, WMS will not default to IRC unless IRC is E95, F63, E60 or E90. (If no 6 or 4 month extension is generated, standard CRC logic is used).

• CRC is E34. Case Level Reason Code I92: WMS default to IRC unless:

• No IRC is present AND Categorical Code = 41. A 1 month extension and MA Insert RC 760 will be generated for that individual.

THE FOLLOWING PAGES SHOW THE FOUR MATRICES:

• Pa Denial Case Reason Codes – MA Insert Reason Codes • PA Closing Case Reason Codes – MA Insert Reason Codes • PA Denial Individual Reason Codes – MA Insert Reason Codes • PA Closing Individual Reason Codes – MA Insert Reason Codes



PA DENIAL CASE Reason Codes – MA INSERT Reason Codes Column headings explained in Notes below.

PA RC SEP DET CAT CD SEP DET IN S RC NO-SEP DET INS EXCEPT E10 NONE NA 754 E30 09 761 NA E30 OTHER THAN 09 753 753 <21 E34 ALL 756 NA NA E60 NONE NA 754 E61 NONE NA 754 E63 NONE NA 754 E64 NONE NA 754 F16 ALL 753 NA NA F33 OTHER THAN 09 753 754 <21 F81 01-08 10-12 753 754 <21 I92 See Individual Codes

M15 ALL 753 NA NA M25 OTHER THAN 09 753 754 <21 M35 ALL 753 NA NA M37 ALL 753 NA NA M48 ALL 753 NA NA M66 NONE NA 754 M67 NONE NA 754 M88 OTHER THAN 09 753 754 <21 M90 ALL 793 NA NA M91 ALL 793 NA NA M94 ALL 753 NA NA M95 ALL 753 NA NA N10 NONE NA 754 N13 01-08 10-12 15 48 753 754 <21 N14 ALL 753 NA NA N15 15 48 753 754 N16 15 48 753 754 N17 15 48 753 754 N19 ALL 753 NA NA U40 09 761 NA 21-65 U40 OTHER THAN 09 753 754 <21 U41 OTHER THAN 09 753 754 <21 U42 OTHER THAN 09 753 754 <21 U44 OTHER THAN 09 753 754 <21 V21 OTHER THAN 09 753 754 <21 V23 OTHER THAN 09 753 754 <21 V24 OTHER THAN 09 753 754 <21 V25 OTHER THAN 09 753 754 <21 W10 OTHER THAN 09 753 754 <21 W11 ALL 753 NA NA W40 ALL 753 NA NA Y92 MANUAL NOTICE – no MA IRC generated Y95 MANUAL NOTICE – no MA IRC generated Y99 MANUAL NOTICE – no MA IRC generated

Notes:



SEP DET CAT CD – Categorical Codes which generate a separate determination Insert RC

• OTHER THAN – indicates all Categorical Codes other than those specified SEP DET INS RC – Insert RC generated for individual(s) entitled to a separate determination

NO-SEP DET INS – Insure RC generated for individuals not entitled to a separate determination EXCEPT – individuals who otherwise would not get a separate determination Insert RC because of their Categorical Code get 753 if identified here <21 – individuals less than 21 years old on Denial date (incl. unborns) NA – not applicable



PA CLOSINGS CASE Reason Codes – MA Insert Reason Codes Column headings explained in Notes below. PA RC MA EXT CAT CD MA EXT

INS RC NO-EXT INS RC

EXCEPT CONT EXT

PCP GUAR

E30 OTHER THAN 09 758 761 <21 NA Y E31*

* 01-08 13 26 10 11 12 15 48

764 764/758

761 <21 NA Y

E32* 01-08 13 48 15 26 10 11 12

763/758 758

761 <21 NA Y

E34 ++

ALL 756 NA NA NA Y

E38 OTHER THAN 09 26 758 761 <21 NA Y E39 OTHER THAN 09 758 761 <21 NA Y E40 OTHER THAN 09 758 761 <21 NA Y E50 OTHER THAN 09 821 761 <21 707 Y E51 OTHER THAN 09 758 761 <21 NA Y E52 OTHER THAN 09 758 761 <21 NA Y E53 OTHER THAN 09 758 761 <21 NA Y E54 OTHER THAN 09 821 761 <21 707 Y E60 NONE NA 761 NONE N Y E66 NONE NA 761 NONE N N F11 OTHER THAN 09 758 761 <21 NA Y F16 ALL 756 NA NA NA NA F19 OTHER THAN 09 758 761 <21 NA Y F33 OTHER THAN 09 758 761 <21 NA Y F38 15 48 771 761 U, <1 Y Y F81 01-08 10 11 12 758 761 <21 NA Y G61 NONE NA 761 NONE Y N I92 41 758 OTHERWISE DEFAULTS TO IRC

M10 15 48 821 761 U, <1 707 Y M11 15 48 771 761 U, <1 Y Y M12 15 48 821 761 U, <1 707 Y M15 ALL 758 NA NA NA NA M25 OTHER THAN 09 758 761 <21 NA Y M48 ALL 821 NA NA 707 NA M61 NONE 757 761 NONE Y N M62 NONE 757 761 NONE Y N M63 NONE NA 761 NONE N N M68 NONE NA ALL NONE N N M88 OTHER THAN 09 758 795 <21 NA Y M90 NONE NA 794 NONE N Y M91 NONE NA 794 NONE N Y

M92* *

01-08 13 10 11 12 15 26 48

764 764/758

761 <21 NA Y

M93* *

01-08 13 10 11 12 15 26 48

764 764/758

761 <21 NA Y

M94 ALL 758 NA NA NA NA M95 ALL 758 NA NA NA NA N13 01-08 10-12 15 48 758 761 <21 NA Y N14 ALL 758 NA NA NA NA N15 15 48 771 761 U, <1 Y Y N16 15 48 771 761 U, <1 Y Y



PA RC MA EXT CAT CD MA EXT INS RC

NO-EXT INS RC

EXCEPT CONT EXT

PCP GUAR

N17 15 48 771 761 U, <1 Y Y N19 ALL 758 NA NA NA NA N51 OTHER THAN 09 758 761 <21 NA Y N53 OTHER THAN 09 758 761 <21 NA Y U40 09 761 NA 21-65 NA NA U40 OTHER THAN 09 758 761 <21 NA Y U41 OTHER THAN 09 758 761 <21 NA Y U42 OTHER THAN 09 758 761 <21 NA Y U43 NONE NA 761 NONE NA N U44 OTHER THAN 09 758 761 <21 NA Y U16 OTHER THAN 09 758 761 <21 NA Y V20 OTHER THAN 09 758 761 <21 NA Y V22 OTHER THAN 09 758 761 <21 NA Y V23 OTHER THAN 09 758 761 <21 NA Y V24 OTHER THAN 09 758 761 <21 NA Y V25 OTHER THAN 09 758 761 <21 NA Y W10 OTHER THAN 09 758 761 <21 NA Y W11 ALL 758 NA NA NA NA W40 ALL 758 NA NA NA NA Y95 NONE NA 761 NA Y NA Y98 OTHER THAN 09 758 761 <21 NA Y Y99 ALL 758 NA NA NA NA

Notes: MA EXT CAT DC – Categorical Codes which generate an extension OTHER THAN – Indicates all other Categorical Codes other than those listed MA EXT INS RC – Insert RC for Individual(s) receiving extension NO-EXT INS RC – Insert RC for Individuals not receiving extension



EXCEPT – individuals who otherwise would not get an extension because of their Categorical Code get extension if identified here: U – Unborns <21 – individuals less than 21 years of age at time of closing (including unborns). <1 – individuals less than 1 year of age NA – not applicable CONT EXT: Y – if otherwise ineligible for an extension or if only eligible for a PCP Guarantee extension, then based on the CRC a Continuous MA extension is given. N – Not Given – No Continuous extension is given regardless of IRC. NA occurring in this column indicates that based on the CRC the individual would be eligible for another extension (other than PCP Guarantee). However, if the CRC defaults to the Individual RC, then NA does not preclude a Continuous extension. When a Continuous Coverage Extension case is generated the MA Opening Reason Code will be 715 (Continuous Eligibility or Continuous Coverage WMS will generate an Individual Categorical Code of 53 and will have the Auth TO-Date set equal to the Continuous Save Date (CSD). If more than one CSD is present to the Auth TO-Date will be set to the shortest CSD. The MA Insert RC 858 or (859 when PA Closing RC M62 is entered) will be system generated. PCP GUAR: Y – if otherwise ineligible for extension, extension given to individual if Managed Care Guarantee Thru Date exceeds Cov TO-Date. N – Not Given – No PCP Guarantee extension is given regardless of the IRC. NA occurring in this column indicates that the individual would be eligible for a non-PCP Guarantee would not be generated. However, if the PA Case RC defaults to the Individual RC, then the NA does not preclude a PCP extension. PCP Guarantee Extensions generate COV Code 31 (PCP Cov Only) or 333 (PCP guarantee/HR) with an MA COV TO-Date of the PA Case Closing. Cov Codes 31 and 33 will be generated for the balance of the period ending with the PCP Guar Date. The MA Opening code is 710. MA Insert RC 765 will be generated. All MA extensions are for 1 month and the MA Opening RC is 700 unless otherwise indicated. No MA Insert RC nor extension will be generated for any individual with MA Cov Cd = 04. ++ WMS will generate MA extension case with Case Type = 22, Coverage TO-Date = 12/31/49 (2049), Categorical Code = 12 and will change Coverage code to 01 if 16 exists and to 30 if 32 exists. The MA Extension Opening RC = 093. * For Categorical codes listed in the first line of the EXT CAT CD column: to receive a 6 month (CRC E32, M92, M93/MA Opening RC 088) or 4 month (CRC E32/MA Opening RC 090) extension, the PA case must have been active for at least 3 of the past 6 months prior to the PA case closing. If it fails the 3 of 6 check, the MA Insert RC defaults to 758 and a 1 month MA extension case is generated. CRC E31, M92, M93 – For Categorical codes listed in the second line of EXT CAT CD column: to receive the 6 month (088) extension, the PA case must have been active for at least 3 of the past 6 months prior to the PA case closing AND the case must include at least two individuals, at least one of whom must be under age 21. If both conditi8ons are not met, the MA Insert RC CRC E31, M92, M93 – For Categorical Code 09: to receive the 6 month (088) extension, the PA case must have been active for at least 3 of the past 6 months prior to the PA case closing AND the 09 individual must be under age 21 AND the case must include at least one individual with a Categorical code other than 09. If the



conditions are not met, MA Insert RC 761 will be generated for that individual unless he is an “Except” individual in which case 758 will be generated for him. ^ I92 defaults to the IRC; if no IRC exists and the Categorical Code is 41 for that individual, generate a 1 month extension and MA RC 760. The system hierarchy logic when searching for EXCEPT individuals is: 1. An unborn (MA Insert RC 758 is generated). 2. An infant up to age 1 (MA Insert RC 760 is generated). 3. An individual under age 21 (MA Insert RC 758 is generated). WMS will not allow entry of a Reason Code in the MA Extension field on screen WKUM01 of the PA Closing except for Suppression Code 195 with V20, V22, V23, V24 or V25. See Suppression Code explanation in the CNS Manual for details.



PA DENIAL INDIVIDUAL Reason Codes – MA Insert Reason Codes Column headings explained in Notes below. PA RC SEP DET CAT CD SEP DET INS RC NO-SEP DET INS EXCEPT

E21 15 48 753 754 E72 ALL 753 NA E73 ALL 753 NA E90 ALL 753 NA E94 ALL 756 NA E95 ALL 753 NA F12 OTHER THAN 09 753 754 <21 F17 15 48 753 754 F21 15 48 753 754 F35 ALL 753 NA F40 01-08 15 48 753 754 <21 F44 OTHER THAN 09 26 753 755 <21 F45 OTHER THAN 09 26 753 755 <21 F46 OTHER THAN 09 29 753 755 <21 F60 ALL 753 NA F63 NONE NA 754 F75 ALL 753 NA F76 ALL 753 NA F84 ALL 753 NA F88 OTHER THAN 09 26 753 755 <21 F92 15 48 753 802 F93 15 48 753 754 M33 OTHER THAN 09 753 754 <21 M97 ALL 753 NA M98 NONE NA 754 M99 NONE NA 754 MX1 OTHER THAN 09 26 753 755 <21 MX2 OTHER THAN 09 26 753 755 <21 MX3 OTHER THAN 09 26 753 755 <21 N20 ALL 753 NA N42 ALL 753 NA N49 ALL 753 NA N50 ALL 753 NA N66 NONE NA 754 P93 NONE NA 804 U44 OTHER THAN 09 753 754 <21 V30 15 48 753 754 WA1 ALL 753 NA WA2 ALL 753 NA WA3 ALL 753 NA WAX ALL 753 NA WD1 ALL 753 NA WD2 ALL 753 NA WD3 ALL 753 NA WDX ALL 753 NA WE1 ALL 753 NA WE2 ALL 753 NA WE3 ALL 753 NA



PA RC SEP DET CAT CD SEP DET INS RC NO-SEP DET INS EXCEPT WH1 OTHER THAN 09 26 753 754 <21 WH2 OTHER THAN 09 26 753 754 <21 WH3 OTHER THAN 09 26 753 754 <21 WH4 OTHER THAN 09 26 753 754 <21 WHX OTHER THAN 09 26 753 754 <21 WP1 OTHER THAN 09 26 753 754 <21 WP2 OTHER THAN 09 26 753 754 <21 WP3 OTHER THAN 09 26 753 754 <21 WP4 OTHER THAN 09 26 753 754 <21 WP5 OTHER THAN 09 26 753 754 <21 WP6 OTHER THAN 09 26 753 754 <21 WP7 OTHER THAN 09 26 753 754 <21 WP8 OTHER THAN 09 26 753 754 <21 WR1 ALL 753 NA WR2 ALL 753 NA WR3 ALL 753 NA WR4 ALL 753 NA WRX ALL 753 NA WS1 OTHER THAN 09 26 753 754 <21 WS2 OTHER THAN 09 26 753 754 <21 WS3 OTHER THAN 09 26 753 754 <21 WS4 OTHER THAN 09 26 753 754 <21 WS5 OTHER THAN 09 26 753 754 <21 WS6 OTHER THAN 09 26 753 754 <21 WS7 OTHER THAN 09 26 753 754 <21 WS8 OTHER THAN 09 26 753 754 <21 Y98 MANUAL NOTICE – no MA IRC generated Y99 MANUAL NOTICE – no MA IRC generated

Notes: SEP DET CAT CD – Categorical Codes which generate a separate determination Insert RC OTHER THAN – indicates all Categorical Codes other than those specified SEP DET INS RC – Insert RC generated for individual(s) entitled to a separate determination NO-SEP DET INS – Insert RC generated for individuals not entitled to a separate determination EXCEPT – individuals who otherwise would not get a separate determination Insert RC because of their Categorical Code get 753 if identified here: <21 – individuals less than 21 years old on Denial date (including unborns)



PA CLOSING INDIVIDUAL Reason Codes – MA Insert Reason Codes Column headings explained in Notes below.

PA RC

MA EXT CAT CD

MA EXT INS RC

NO-EXT INS RC

EXCEPT

CONT EXT

PCP GUAR

E21 15 48 771 761 U, <1 Y Y E72 ALL 758 NA NA NA NA E73 ALL 758 NA NA NA N

(Though Ins RC is generated, no MA extension case is generated for E73.) E90 ALL 758 NA NA NA NA E94+ ALL 756 NA NA NA NA F12 OTHER THAN 09 758 761 <21 NA Y F17 15 48 771 761 U, <1 Y Y F21 15 48 771 761 U, <1 Y Y F35 ALL 758 NA NA NA NA F40 01-08

15 48 758 771

761 <21 NA Y

F44 OTHER THAN 09 26 758 762 <21 NA Y F45 OTHER THAN 09 26 758 762 <21 NA Y F46 OTHER THAN 09 26 758 762 <21 NA Y F60 ALL 758 NA NA NA NA F61 ALL 758 NA NA NA NA F63 NONE NA 761 NONE N N F66 NONE NA 761 NONE N N F75 ALL 758 NA NA NA NA F76 ALL 758 NA NA NA NA F84 ALL 758 NA NA NA NA F92 15 48 771 803 U, <1 Y Y F93 15 48 771 761 U, <1 Y Y GX1 OTHER THAN 09 26 758 762 <21 NA Y GX2 OTHER THAN 09 26 758 762 <21 NA Y GX3 OTHER THAN 09 26 758 762 <21 NA Y M33 OTHER THAN 09 26 758 762 <21 NA Y M97 ALL 758 NA NA NA NA M98 NONE NA 761 NONE N N M99 NONE NA 761 NONE N N MX1 OTHER THAN 09 26 758 762 <21 NA Y MX2 OTHER THAN 09 26 758 762 <21 NA Y MX3 OTHER THAN 09 26 758 762 <21 NA Y N20 ALL 758 NA NA NA NA N41 ALL 758 NA NA NA NA N42 ALL 758 NA NA NA NA N49 ALL 758 NA NA NA NA N50 ALL 758 NA NA NA NA N66 NONE NA 761 NONE Y N P93 NONE NA 805 NONE Y Y U44 OTHER THAN 09 758 761 <21 NA Y V30 15 48 771 761 U, <1 Y Y WA1 ALL 758 NA NA NA NA WA2 ALL 758 NA NA NA NA WA3 ALL 758 NA NA NA NA WAX ALL 758 NA NA NA NA WD1 ALL 758 NA NA NA NA



PA RC

MA EXT CAT CD

MA EXT INS RC

NO-EXT INS RC

EXCEPT

CONT EXT

PCP GUAR

WD2 ALL 758 NA NA NA NA WD3 ALL 758 NA NA NA NA WDX ALL 758 NA NA NA NA WE1 ALL 758 NA NA NA NA WE2 ALL 758 NA NA NA NA WE3 ALL 758 NA NA NA NA WH1 OTHER THAN 09 26 758 761 <21 NA Y WH2 OTHER THAN 09 26 758 761 <21 NA Y WH3 OTHER THAN 09 26 758 761 <21 NA Y WH4 OTHER THAN 09 26 758 761 <21 NA Y WHX OTHER THAN 09 26 758 761 <21 NA Y WP1 OTHER THAN 09 26 758 761 <21 NA Y WP2 OTHER THAN 09 26 758 761 <21 NA Y WP3 OTHER THAN 09 26 758 761 <21 NA Y WP4 OTHER THAN 09 26 758 761 <21 NA Y WP5 OTHER THAN 09 26 758 761 <21 NA Y WP6 OTHER THAN 09 26 758 761 <21 NA Y WP7 OTHER THAN 09 26 758 761 <21 NA Y WP8 OTHER THAN 09 26 758 761 <21 NA Y WR1 ALL 758 NA NA NA NA WR2 ALL 758 NA NA NA NA WR3 ALL 758 NA NA NA NA WR4 ALL 758 NA NA NA NA WRX ALL 758 NA NA NA NA WS1 OTHER THAN 09 26 758 761 <21 NA Y WS2 OTHER THAN 09 26 758 761 <21 NA Y WS3 OTHER THAN 09 26 758 761 <21 NA Y WS4 OTHER THAN 09 26 758 761 <21 NA Y WS5 OTHER THAN 09 26 758 761 <21 NA Y WS6 OTHER THAN 09 26 758 761 <21 NA Y WS7 OTHER THAN 09 26 758 761 <21 NA Y WS8 OTHER THAN 09 26 758 761 <21 NA Y Y98 OTHER THAN 09 758 761 <21 NA Y Y99 ALL 758 NA NA NA NA Notes: MA EXT CAT CD – Categorical Codes which generate an extension. OTHER THAN – indicates all other Cat Codes other than those listed. MA EXT INS RC – Insert RC for individual(s) receiving extension. NO-EXT INS RC – Insert RC for Individuals not receiving extension EXCEPT – individuals who otherwise would not get an extension because of their Cat Code get extension if identified here. U – unborns <21 – individuals less than 21 years of age at time of closing (include unborns). <1 – individuals less than 1 year of age. All MA extensions are for 1 month unless otherwise indicated. No MA Insert RC nor extension will be generated for an individual with MA Cov Cd = 04.



CONT EXT: Y – if otherwise ineligible for an extension or if only eligible for a PCP Guarantee extension, then based on the CRC a Continuous MA extension is given. N – Not Given – No Continuous extension is given regardless of IRC. NA occurring in this column indicates that based on the IRC the individual would be eligible for another extension (other than PCP Guarantee). However, if the CRC had defaulted to this IRC, then NA does not preclude a Continuous extension. When a Continuous Coverage Extension case is generated the MA Opening Reason Code will be 715 (Continuous Eligibility or Continuous/PCP Guarantee). For individuals who qualify for Continuous Coverage WMS will generate an Individual Categorical Code of 53 and will have the Auth TO-Date set equal to the Continuous Save Date (CSD). If more than one CSD is present the Auth TO-Date will be set to the shortest CSD. The MA Insert RC 858 (859 when PA Closing RC M62 is entered) will be system generated. PCP GUAR: Y – if otherwise ineligible for extension, extension given to individual if Managed Care Guarantee Thru Date exceeds Cov TO-Date. N = Not Given – No PCP Guarantee extension is given regardless of the IRC. NA occurring in this column indicates that the individual would be eligible for a non-PCP MA extension based on the PA Individual Closing RC; therefore a PCP Guarantee extension would not be generated. However, if the PA Case RC had defaulted to the this Individual RC, then NA does not preclude a PCP extension. PCP Guarantee Extensions generate Cov Code 31 (PCP Cov Only) or 33 (PCP Guarantee/HR) with an MA COV TO-Date equal to individuals who have Cov Code 30 (PCP Full Cov) or 32 (PCP/HR) at the time of the PA Case Closing and who will not receive any other MA Extension and who have a PCP Guar Date beyond the Cov TO-Date of the PA Case Closing. Cov Codes 31 and 33 will be generated for the balance of the period ending with the PCP Guar Date. The MA Opening code is 710. MA Insert RC 765 will be generated. NA – Not Applicable N – Not Given – No PCP Guarantee extension is given even if the Case RC would give one. + - For this individual Only: WMS will generate an extension case with MA Coverage = 01 if 16 exists and = 30 if 32 exists. Categorical Code will be set to 12. If all individuals in the case have this Individual RC or none of the individuals without this RC receive an extension, Case Type will = 22, Coverage TO-Date will = 12/31/49 (2049) and MA Ext Opening RC will = 093; otherwise, a standard 1 month extension case will be generated. The system hierarchy logic when searching for EXCEPT individuals is: 1. An unborn (MA Insert RC 758 is generated). 2. An infant up to age 1 (MA Insert RC 760 is generated). 3. An individual under age 21 (MA Insert RC 758 is generated).



TMA (MA) Certain Medicaid Only (Case Type 20) cases are entitled to Transmittal Medical Assistance (TMA). The Undercare (Transaction Types 05, 06) Reason Code E08 – MA TMA Acceptance – 1st Six Months should be entered when appropriate. The following non-overrideable edits apply to E08:

• The MA Coverage TO Date must be at least 6 months in the future. • There must be at least two individuals in the case at least one of whom is under 21. • The case must have been active under LIF for at least 3 of the past 6 months. (The 3 of 6 month

test will be performed by WMS based on that case number only.) • E08 is not valid with Individual Categorical Codes 21, 22, 25, 39, 42 or 43.

RC E08 triggers the TMA mailer process as MA Code 088 will continue to do. In non-Phase 5 CNS Undercare districts a manual notice is required for E08. Note: TMS continues to be generated form closings of appropriate PA cases when PA Case RC E31 is

entered. If for some reason TMA was not generated (e.g., PA worker was unaware of TMA eligibility and/or E31 was not entered), but the MA worker knows that the case should receive TMA, RC Y78 should be entered in Phase 5 districts, 088 in non-Phase 5 districts. Either RC will trigger the TMA mailer process.



When a PA Closing or Denial Reason Code is entered on WMS, whether at the Case level or at the Individual level, the WMS/CNS interface will generate the appropriate MA language for the PA notice. The system generated MA Insert Reason Codes are as follows: PA/MA DISCONTINUANCE 761 Discontinuance for Same Reason as PA Medical Assistance is being discontinued for the same reason as the PA case. 762 Discontinuance, Failure to Participate in a Drug/Alcohol Program The PA/MA case is being discontinued for failure to participate in a drug/alcohol treatment

program. The recipient may reapply at any time for MA if he/she does participate in a drug/alcohol treatment program.

767 Discontinuance, HR Failure to Comply with a PA Employment Requirement The HR PA/MA case is being discontinued for failure to comply with a PA employment

regulation. 769 Discontinuance, ADC-U Failure to comply with a PA Employment Requirement The ADC-U PA/MA case is being discontinued for failure to comply with a PA employment

regulation. 790 Discontinuance, HR Failure to Sign PA Consent Form to Release Drug/Alcohol Treatment

Records The HR PA/MA recipient is being discontinued for failure to sign the PA consent form to release

Drug/Alcohol treatment records to the district. 791 Discontinuance, Lump sum – Not Eligible for MA PA/MA discontinued for receipt of lump sum. The MA recipient can reapply when

income/resource levels are below the MA limits. 792 Failure to Sign Citizenship – Alien Declaration PA/MA Discontinuance – Failure to sign citizenship/alien declaration. The MA recipient can

reapply if pregnant or has an emergency medical condition. 794 PA/MA Discontinuance – Client’s Request Recipient requested that both PA and MA case be closed. PA DISCONTINUANCE/MA EXTENSIONS 707 PA Discontinuance, MA Opening PA discontinuance, MA Opening after PA closing. 752 PA Discontinuance, MA suspension Recipient’s PA is being discontinued due to incarceration, their MA will be suspended. 756 PA Discontinuance, MA Continues Unchanged PA discontinued. MA determination was made to continue MA unchanged.



757 Continue MA, County Transfer PA discontinued. MA Continues due to county transfer. 758 PA Discontinuance, MA Continues Unchanged Pending Decision PA discontinued. MA continues until a separate MA determination is made. 760 PA Discontinuance, MA Continuation of Newborn PA discontinued. Infant continues to be MA eligible until age one as long as the infant lives with

the mother. 763 PA Discontinuance, MA Continues, Support Extension PA discontinued due to receipt of or increase in spousal or child support. MA continues until the

end of the fourth month following the PA closing. 764 PA Discontinuance, TMA Acceptance, First Six Months PA Discontinued, due to increased earnings, new employment or loss of earned income disregard.

The MA case is accepted for Transitional Medical Assistance (TMA) for six months following the PA closing as long as there is a dependent child in the household. Message explains the case may remain open for six additional months following the six month extension. This is as long as the recipient completes and returns the TMA mailers, continues to be employed, has a dependent child under age 21 living in the household and the earned income remains below certain levels.

765 PA Discontinuance, MA/PCP Extension PA discontinued. Recipient is in a PCP Managed Care Plan (Coverage Code 30 or 32) and

eligible for guaranteed eligibility. Recipient is only eligible for MA coverage of medical services available through the Managed Care Provider until the end of the PCP extension period.

771 PA Discontinuance, Two Month MA Post-partum Extension Public Assistance discontinued. Medical Assistance continues until the end of the month

following the 60th day after the pregnancy ends. 788 PA Discontinuance, MA Continues Unchanged Pending Decision PA discontinued due to suspension of SSI/SSD benefits because of failure to comply with Social

Security Administration’s drug/alcohol treatment requirement. MA continues until a separate determination is made. MA should continue for SSI recipients whose SSI benefits are suspended. If financially eligible, MA should continue for SSD recipients. If the individual is not in an SSA sanction period for failure to comply with SSA’s drug alcohol treatment requirements the individual should be discontinued from MA due to failure to comply with HR’s drug alcohol requirements – see MA only closing code F43 (C0024).

820 PA Discontinuance/Deletion, MA Separate Determination PA discontinuance/deletion. MA separate determination notice will be sent. 821 PA Discontinuance, If Receiving MA, Continue Unchanged PA discontinuance. If in receipt of MA, Continue Unchanged. 823 PA Closing/Deletion – MA Continue on SSI Case PA discontinuance or deletion. MA will continue on the SSI case.



827 PA Discontinuance, MA Extension PA discontinuance. Extension for child support in lieu of TA.

PA DISCONTINUANCE WHILE PA CLOCKING DOWN When a PA case is closed while clocking down, these system-generated Insert Reason Codes will generate the respective Alerts on the MA Authorization Document (DSS-3209). 772 PA CL Updated – MA System Modified Occurs when the PA closing causes WMS to automatically perform Undercare Maintenance on

the previously generated MA extension case. 773 PA CL RC Changed – Eval Ext (worker should evaluate the extension) If previously generated MA extension case has had UM performed on it by the worker, WMS

will not automatically update it. 774 PA CL Updated – MA System Modified Occurs when the PA closing causes WMS to automatically close the MA extension case. 966 PA CL RC Changed – Eval Ext (worker should evaluate the extension) Occurs when the MA extension case is clocking down. PA/MA DENIALS 754 Combined PA/MA Denial Denial, Medical Assistance is being denied for the same reason as the PA case. 755 Denial, Failure to Participate in a Drug/Alcohol Program Denial, the PA/MA case is being denied for failure to participate in a drug/alcohol treatment

program. The applicant may reapply at any time for MA if he/she does participate in a drug/alcohol treatment program.

766 HR Failure to Comply with a PA Employment Requirement Denial, the HR PA/MA case is being denied for failure to comply with a PA employment

regulation. 768 ADC-U Failure to Comply with a PA Employment Requirement Denial, the ADC-U PA/MA case is being denied for failure to comply with PA employment

regulations. 793 PA/MA Denial, Client’s Request Applicant requested that both PA and MA case be closed. 795 Failure to Sign PA Consent Form to Release Drug/Alcohol Treatment Records The HR PA/MA recipient is being denied for failure to sign the PA consent form to release

Drug/Alcohol treatment records to the district.



797 Failure to Sign Citizenship – Alien Status PA/MA Denial – Failure to sign citizenship/alien declaration. The MA recipient can reapply if

pregnant or has an emergency medical condition. PA DENIALS/MA ACTION 753 PA Denial, MA Separate Determination The PA application is denied. A separate MA determination will be made on the case. 789 PA Denial, MA Separate Determination PA denied due to suspension of SSI/SSA benefits because of failure to comply with Social

Security Administration’s drug/alcohol treatment requirements. (See closing language for insert paragraph 788 – A separate MA determination will be made on the case.)

CNS FILL REASON CODE SCREEN DISPLAYS INDEX

10/08/08

1

OPENINGS

Community Coverage

S82 - Community Coverage without LTC......................................................................pg.55

S83 - Ancillary Coverage Only, Institutionalized individual, Due to failed to

Provide Documentation of Resources, Excess Income Spenddown Not

Met........................................................................................................................ pg.56

S84 - Ancillary Coverage Only, Institutionalized Individual, Due to Failure

to Provide Documentation of Resources, No Excess............................................pg.57

Family Health Plus Employer Sponsored Health Insurance

S37 - Accept FHP, MA Ineligible Due to Excess Income, ESHI is offered,

ESHI is Not Cost Effective or ESHI is not offered FNP Parent...........................pg.36


ESHI is Not Cost Effective or ESHI is not offered FP.........................................pg.37


ESHI is Not cost Effective, ESHI is not offered S/CC ........................................pg.37

Family Health Plus Premium Assistance Program (FHP-PAP)

S93- Accept FHP/FHP-PAP, FP……………………………………………………....pg.60

S94- Accept FHP/FHP-PAP, FNP Parent……………………………………………..pg.61

S95- Accept FHP/FHP-PAP, S/CC……………………………………………………pg.61

S96- Accept FHP/PAP Employer Buy-In (EBI) ……………………………...………pg.62

Retro Coverage

S57 - Approve Retro, Deny Ongoing MA Due to Excess Income and/or

Resources, FHP Ineligible Due to Excess Income and/or Resources,

Equivalent Health Insurance, Federal Employee or Over 65, S/CC ....................pg.38

S58 – Approve Ongoing, Deny retro MA Due to excess income and/or

resources, S/CC.....................................................................................................pg.39


Resources, FHP Ineligible Due to Excess Income and/or Resources,

Equivalent Health Insurance, Federal Employee or Over 65, FNP

Parent ....................................................................................................................pg.40

S60 - Approve Ongoing, Deny Retro MA Due to Excess, FNP Parent ........................pg.41


Resources, FHP Ineligible Due to Excess Income, Equivalent Health

Insurance, Federal Employee or Over 65, FP ......................................................pg.54

S81 - Approve Ongoing, Deny Retro MA Due to Excess Income, FP ..........................pg.55

Family Planning Benefit Program

S61 – Accept FPBP, MA Ineligible Due to Excess Income and/or Resources,

FHP Ineligible Due to Excess Income, Non-ESHI, Federal Employee,

or ESHI- Non Cost Effective, FP.........................................................................pg.41

S66 - Accept FPBP, MA Ineligible Due to Excess Income and/or Resources,


or ESHI- Non Cost Effective, S/CC .....................................................................pg.43


10/08/08

2

Family Planning Benefit Program (con’t)

S67- Accept FPBP, MA Ineligible Due to Excess Income and/or Resources,

FHP Ineligible Due to Excess Income Non-ESHI, Federal Employee,

or ESHI- Non Cost Effective, FNP Parent............................................................pg.44

Prenatal

S35 - Prenatal Care, Between 100% and 200% .............................................................pg.36

MBI-WPD (Medicaid Buy-In for working people with Disabilities)

S32 - Accept MBI-WPD, No Premium Payment ..........................................................pg.33

Medicare Buy-In Program

X54 – Accept Medicare Buy-In Program, QMB...........................................................pg.154

Health Insurance

X26 - Accept MA payment of insurance premiums......................................................pg.144

Excess Income and/or Resources

S20AA - Excess Income, Spenddown Met, FHP Ineligible Due to Excess

Income, Chose Spenddown, Equivalent Health Insurance,

Federal Employee or Over 65.........................................................................pg.08

S20AB - Coverage, Excess Income, FHP Ineligible Due to Excess Income,

Chose Spenddown, Equivalent Health Insurance or Over 65, Adults

Only ................................................................................................................pg.09

S20AC - Excess Income, 6 Month Spenddown Met, FHP Ineligible Due to

Excess Income, Chose Spenddown, Equivalent Health Insurance,

Federal Employee or Over 65 ........................................................................pg.10

S20AD - Excess Resources, Spenddown Met ......................... ....................................pg.12

S20AE - Excess Income and Resources, Both Met, FHP Ineligible Due to

Excess Income, Chose Spenddown, Equivalent Health Insurance,

Federal Employee or Over 65 ........................................................................pg.13

S20AF - Excess Income and Resources, Resource Spenddown Met, FHP

Ineligible Due to Excess Income, Chose Spenddown, Equivalent Health

Insurance, Federal Employee or Over 65 .......................................................pg.15

S20AG - Excess Income and Resources, Resource and 6 Month Spenddown Met,

FHP Ineligible Due to Excess Income, Chose Spenddown, Equivalent

Health Insurance, Federal Employee or Over 65 ...........................................pg.16

S20BA - Child 1-5 at 133%, Excess Income, Spenddown Met ....................................pg.18

S20BC - Child 1-5 at 133%, Excess Income, 6 Month Spenddown Met .....................pg.19

S20BE - Child 1-5 at 133%, Excess Income and Resources, Both Met .......................pg.21

S20BG - Child 1-5 at 133%, Excess Income and Resources, Resource and 6

Month Spenddown Met ..................................................................................pg.22

S20CA - Child 6-18 at 100%, Excess Income, Spenddown Met ..................................pg.24

S20CC – Child 6-18 at 100%, Excess Income, 6 Month Spenddown Met ...................pg.25

S20CE – Child 6-18 at 100%, Excess Income and Resources, Both Met .....................pg.27

S20CG – Child 6-18 at 100%, Excess Income and Resources, Resource and 6

Month Spenddown Met...................................................................................pg.28


10/08/08

3

Aliens

S77 - Non-Immigrant/Undocumented Immigrant, Emergency, Excess Income,

Monthly or 6 Month Spenddown Met ..................................................................pg.52

S78 - Non-Immigrant/Undocumented Immigrant, Emergency, Excess Resources,

Spenddown Met ....................................................................................................pg.53

S79 - Non-Immigrant/Undocumented Immigrant, Emergency, Excess Income

and Resources, Either Both Met or Resource and 6 Month Spenddown

Met ........................................................................................................................pg.53

Transfers

S68 - Accept Limited Coverage Due to Transfer, Individual in Community,

Excess Income, Spenddown Not Met, FHP Ineligible Due to Excess

Income, Chose Spenddown, Equivalent Health Insurance or Over 65 ................pg.44


No Excess .............................................................................................................pg.45

S70 - Accept Institutionalized Individual Limited Coverage Due to Prohibited

Transfer, No Excess .............................................................................................pg.46


Transfer, Excess Income, Spenddown Met .........................................................pg.46


Transfer, Excess Income and Resources, Resource and 6 Month

Spenddown Met ....................................................................................................pg.47


Excess Income, Spenddown Met ..........................................................................pg.48

S74 - Accept Limited Coverage Due to Transfer, Individual in Community, Excess

Income, 6 Month Spenddown Met .......................................................................pg.49


Transfer, Excess Resources, Spenddown Met ......................................................pg.50


Excess Resources, Spenddown Met .....................................................................pg.51

Home Equity Interest

S91 - Accept Community Coverage Without LTC, Home Equity Interest

Exceeds Limit, No Undue Hardship, Exc Inc SD Met.........................................pg.59

X91- Accept CC Without LTC, Home Equity Interest Exceeds Limit, No

Undue Hardship,6-Mo Exc Inc and /or Res SD Met...........................................pg.163

DENIALS

Failure to Provide Verification

U20 - Verification of Factors Which Affect Eligibility, Did Not State Unable

to Get Information.................................................................................................pg.75

U21 - Verification of Factors Which Affect Eligibility, Unable to Get

Information, But Not a Good Reason....................................................................pg.76

V17 - Incorrect or Fraudulent Social Security Number................................................pg.127

X23 - MA/FHP, Failed to Provide Amount of Resource(s) at Application..................pg.142


10/08/08

4

Failure to Choose a Health Plan for FHP

X45 - Deny MA Due to Excess Income and/or Resources, Failed to Choose a

Health Plan for FHP, FP ...................................................................................pg.149


Health Plan for FHP, S/CC ...............................................................................pg.149


Health Plan for FHP, FNP Parent ......................................................................pg.150

Excess Income/Resources (FNP Parent, S/CC)

U35 - Deny MA Due to Excess Income, FHP Ineligible Due to Excess Income,

Non-ESHI, Federal Employee, or ESHI- Not Cost Effective, FPBP Ineligible

Due to Excess Income or Eligible but Declines, S/CC.......................................pg.105

U49 - Deny MA Due to Excess Income, FHP Ineligible Due to Excess Income,

Non-ESHI, Federal Employee, or ESHI- Not Cost Effective, FPBP Ineligible

Due to Excess Income or Eligible but Declines, FNP Parent.............................pg.107

Excess Income/Resources/Transfer ( LIF, ADC-Rel, SSI-Rel, S/CC)

U32 - Excess Income…………………….....................................................................pg.102

U34 - Deny MA Due to Excess Income and/or Resources, FHP Ineligible

Due to Excess Income, Non-ESHI, Federal Employee, or EHSI- Not

Cost Effective, FPBP Ineligible Due to Excess Income or Eligible

but Declines, FP ................................................................................................ pg.104

U40 - Excess Resource………………………..............................................................pg.106

U59 - Excess Income and Resources, ……………………...........................................pg.110

V85 - FPBP Ineligible Due to Excess Income, No Application for MA/FHP..............pg.137

X10 - Inpatient Hospital Bill Does Not Meet 6 Month Excess Income Amount..........pg.140

Living Arrangements

U79 - Concurrent Benefits, Inter-State, Intra-State.......................................................pg.120

U84 - Concurrent Benefits, AFIS-Match Intra-State.....................................................pg.121

Other Failures

V13 - Failure to Apply for or Utilize Benefits and/or Resources .................................pg.125

V14 - Failure to Complete the Declaration of Citizenship/Immigration Status............pg.126

V30 - Failure to Comply with IV-D Requirements.......................................................pg.128

V31 - Failure to Provide Social Security Number.........................................................pg.132

Spousal Impoverishment

X13 - Spousal Impoverishment, Excess Resources for Institutionalized

Spouse.................................................................................................................pg.140

Health Insurance

U80 - Qualified Individual (QI-1), Over Income or Other ...........................................pg.121

X25 - Deny MA Payment of Health Insurance Premiums............................................pg.144

X50 - Deny Payment of COBRA Continuation of Group Health Insurance

Premiums ............................................................................................................pg.151


10/08/08

5

Health Insurance (con’t) X52 - Medicare Buy-In Program, QMB Ineligible ......................................................pg.152

X53 - Medicare Buy-In Program, SLIMB Ineligible ...................................................pg.153


U19 - MBI-WPD Ineligible, Due to Excess Income and/or Resources, MA Ineligible

Due to Excess Income and/or Resources .............................................................pg.75

U60 - MBI-WPD Ineligible, Not Currently Working, MA Ineligible Due to

Excess Income and/or Resources, FHP Ineligible Due to Excess Income

Equivalent Health Insurance or Federal Employee.............................................pg.111

U62 - MBI-WPD Ineligible, Not Certified Disabled, MA Ineligible Due to

Excess Income, FHP Ineligible Due to Excess Income, Equivalent Health

Insurance or Federal Employee FP.....................................................................pg.112



Insurance or Federal Employee S/CC.................................................................pg.113

U70 - MBI-WPD Ineligible, Failure to Submit Proof of Work, MA Ineligible

Due to Excess Income and/or Resources, FHP Ineligible Due to Excess

Income and/or Resources, Equivalent Health Insurance or Federal

Employee.............................................................................................................pg.115



Insurance or Federal Employee, FNP Parent……………..................................pg.118

Aliens

U63 - Non-Immigrant/Undocumented Immigrant, Emergency Medical

Condition, Excess Income and/or Resources, FP................................................pg.112

U73 - Non-Immigrant/Undocumented Immigrant, Emergency Medical

Condition, Excess Income, S/CC........................................................................pg.117

Other

U66 - Currently in Receipt of Assistance Under Another Case ...................................pg.114

DISCONTINUANCE


S63 - Discontinue MA/FHP/FPBP, Failure to Provide Information to Clear

Up Income and/or Resource Information

Discrepancy...........................................................................................................pg.42

U20 - Discontinue MA/RMA/FHP/FHP-PAP/FPBP Due to Verification of

Factors Which Affect Eligibility, Did Not State Unable to Get

Information............................................................................................................pg.75

U21 - Discontinue MA/RMA/FHP/FHP-PAP/FPBP Due to Verification of Factors

Which Affect Eligibility, Unable to Get Information, But Not a Good

Reason...................................................................................................................pg.76

V17 - Incorrect or Fraudulent Social Security Number ...............................................pg.127


10/08/08

6

Failure to Provide Verification (con’t)

X23 - Failed to Provide Amount of Income and/or Resources at

Renewal...............................................................................................................pg.142

Other Failures

V13 - Failure to Apply for or Utilize Benefits..............................................................pg.125



V38 - Failure to Contact Agency as Requested.............................................................pg.133

Excess Income/Resources (S/CC, FNP Parent)

U57 - Discontinue MA Due to Excess Income, FHP

Ineligible Due to Excess Income, Equivalent Health Insurance, or Federal

Employee, FPBP Ineligible Due to Excess Income or Eligible but Declines,

S/CC....................................................................................................................pg.109

U72 – Excess Income Due to COLA, S/CC..................................................................pg.116

X48 - Discontinue MA Due to Excess Income, FHP Ineligible Due to

Excess Income, Equivalent Health Insurance, or Federal Employee,

FPBP Ineligible Due to Excess Income or Eligible but Declines,

FNP Parent ........................................................................................................pg.150

Refugee Medical Assistance

X28- Discontinue RMA, Ineligible for Medicaid due to Excess Income,

Ineligible for FHP due to Income, Equivalent Health Insurance, or

Federal Employee, FHP Ineligible but declines, S/CC………………………...pg.145

Excess Income/Resources/Transfer (LIF, ADC-Rel, SSI-Rel, S/CC)

U32 - Excess Income……………………......................................................................pg.102

U33 - Turning 19, Discontinue MA Due to Excess Income and/or Resources,

FHP Ineligible Due to Excess Income, Equivalent Health Insurance,

or Federal Employee, FPBP Ineligible Due to Excess Income or Eligible

but Declines.........................................................................................................pg.103

U40 - Excess Resources................................................................................................pg.106

U58 - Discontinue MA Due to Excess Income and/or Resources,

FHP Ineligible Due to Excess Income, Equivalent Health

Insurance, or Federal Employee, FPBP Ineligible Due to Excess

Income or Eligible but Declines, FP.................................................................. pg.110

U59 - Excess Income and Resources............................................................................pg.110

Qualified Individual

X18 - Discontinue Payment of Medicare Part B Premium, QI-1 ................................pg.142

X70 - Discontinue QI-1 Coverage, Over Income ......................................................pg.155

Equivalent Health Insurance

V39 - Discontinue FHP Due to Equivalent Health Insurance or Federal

Employee.............................................................................................................pg.134


10/08/08

7

Living Arrangements

U65 - Not a Resident of District (MA Extension).........................................................pg.114

U77 - Concurrent Benefits, Intra-State No Aid Continuing .........................................pg.119

U78 - Concurrent Benefits, Inter-State, Aid..................................................................pg.120


X13 - Spousal Impoverishment, Excess Resources for Institutionalized Spouse.........pg.140

Health Insurance

X14 - No Longer Eligible for MA Payment of AHIP Premiums..................................pg.141

X25 - Discontinue MA Payment of Health Insurance Premiums.................................pg.143

X50 - Discontinue Payment of COBRA, Continuation of Group Health

Insurance Premiums............................................................................................pg.151


Insurance Premiums, Prior Conditional Acceptance..........................................pg.152

X52 - Medicare Buy-In Program, QMB Ineligible.......................................................pg.152

X53 - Medicare Buy-In Program, SLIMB Ineligible....................................................pg.153

.

MBI-WPD (Medicare Buy-In for Working People with Disabilities)

U03 - Discontinue MBI-WPD, No Longer Meets Requirements of the Medical

Improvement Group, MA Ineligible Due to Excess Income, FHP Ineligible

Due to Excess Income, Equivalent Health Insurance or Federal Employee,

S/CC......................................................................................................................pg.67

U06 - Discontinue MBI-WPD, Medical Improvement Group, Not Working

40 Hrs, Not Working at Federal Minimum Wage, MA Ineligible Due

to Excess Income, FHP Ineligible Due to Excess Income, Equivalent

Health Insurance or Federal Employee, FP ..........................................................pg.69

U07 - Discontinue MBI-WPD, Medical Improvement Group, Not Working

40 Hrs, Not Working at Federal Minimum Wage, MA Ineligible Due to


Insurance or Federal Employee, FNP

Parent.....................................................................................................................pg.69




FNP Parent............................................................................................................pg.70




FP..........................................................................................................................pg.70

U16 - Discontinue MBI-WPD, Medical Improvement Group, Not Working 40

Hrs, Not Working at Federal Minimum Wage, MA Ineligible Due to

Excess Income, FHP Ineligible Due to Excess Income Equivalent Health

Insurance or Federal Employee,

S/CC......................................................................................................................pg.73


10/08/08

8

MBI-WPD (Medicare Buy-In for Working People with Disabilities) (con’t)

U18 - Discontinue MBI-WPD Due to Excess Income and/or Resources, MA

Ineligible Due to Excess Income and/or

Resources,..............................................................................................................pg.74

U27 - Discontinue MBI-WPD Due to Turning 65, MA Ineligible Due to Excess

Income and/or Resources, Spenddown Not Met ..................................................pg.99

U28 - Discontinue MBI-WPD Due to No Longer Working, MA Ineligible Due

to Excess Income, Spenddown Not Met, FHP Ineligible Due to Excess

Income, Equivalent Health Insurance or Federal

Employee.............................................................................................................pg.100

Other

U66 - Currently in Receipt of Assistance......................................................................pg.114

UNDERCARE


S63 - Discontinue MA/FHP, Failure to Provide Information to Clear Up

Resource Information Discrepancy......................................................................pg.42

U20 - Discontinue MA/FHP/FPBP Due to Verification of Factors Which

Affect Eligibility, Did Not State Unable to Get Information...............................pg.75

U21 - Discontinue MA/FHP/FPBP Due to Verification of Factors Which

Affect Eligibility, Unable to Get Information, But Not a Good Reason..............pg.76

V17 - Incorrect or Fraudulent Social Security Number ...............................................pg.127

X23 - Failed to Provide Amount of Income and/or Resources at Renewal..................pg.142

Other Failures

V13 - Failure to Apply for or Utilize Benefits..............................................................pg.125



V38 - Failure to Contact Agency as Requested............................................................pg.133

Excess Income/Resources (S/CC, FNP Parent)

U57 - Discontinue MA Due to Excess Income, FHP Ineligible Due to

Excess Income, Equivalent Health Insurance, or Federal Employee,

FPBP Ineligible Due to Excess Income or Eligible but Declines,

S/CC....................................................................................................................pg.109

U72 – Excess Income Due to COLA, S/CC..................................................................pg.116

X48 - Discontinue MA Due to Excess Income, FHP Ineligible Due to

Excess Income, Equivalent Health Insurance, or Federal Employee, FPBP

Ineligible Due to Excess Income or Eligible but Declines, FNP Parent ..........pg.150

Excess Income/Resources/Transfer (LIF, ADC-Rel, SSI-Rel, S/CC)

S02- Transfer by Institutionalized Individual, Reduce from Full to

Limited Coverage……………………………………………………………..…pg.01


10/08/08

9

Excess Income/Resources/Transfer (LIF, ADC-Rel, SSI-Rel, S/CC) (con’t)

S06- Intent to Impose a Lien on Real Property- Institutionalized

Individual………………………………………………………………………..pg.01

S07 - MA Level to Excess Income Due to COLA, FHP Ineligible Due to

Excess Income, Failed to Choose a Plan, Chose Spenddown,

Equivalent Health Insurance, Federal Employee or Over 65................................pg.02

S08 - Increase in Excess Income Due to COLA.............................................................pg.03

S09- Institutionalized Individual- Transfer, MA Level to Limited Coverage

And Excess Income, Spenddown Met…………………………………………...pg.04

S10 - Change in Figures Used to Calculate Excess Income Amount.............................pg.05

S28 - Spenddown to At or Below MA Level..................................................................pg.31

U32 - Excess Income…………………….....................................................................pg.102

U33 - Turning 19, Discontinue MA Due to Excess Income and/or Resources,

FHP Ineligible Due to Excess Income, Equivalent Health Insurance, or

Federal Employee, FPBP Ineligible Due to Excess Income or Eligible

but Declines …………………………………………………………………... pg.103

U40 - Excess Resources, .............................................................................................pg.106

U58 - Discontinue MA Due to Excess Income and/or Resources, FHP Ineligible

Due to Excess Income, Equivalent Health Insurance, or Federal Employee,

FPBP Ineligible Due to Excess Income or Eligible but Declines, FP.................pg.110

U59 - Excess Income and Resources.............................................................................pg.110

U75 - No Change in Excess Income Amount................................................................pg.118

X74- Continue Excess Resources, Spenddown Met…………………………………pg.155

X75- Increase in Excess Income Amount………………………………………...….pg.156

X76 - Decrease in Excess Income Amount...................................................................pg.157

X77 - Decrease in Excess Income Amount Due to COLA...........................................pg.158

X80 - MA to Spenddown Due to Excess Income, FHP Ineligible Due to

Excess Income, Chose Spenddown, Over 65, Equivalent Health

Insurance or Federal Employee...........................................................................pg.159

MA to FHP, Chose a Plan

S27 - MA to FHP Due to Excess Income, 60 Days Post-Partum,

Continue Infant, Chose a Plan, Stay in Same Plan or will be Auto-Assigned......pg.30

U25 - MA to FHP Due to Excess Income, 60 Days Post-Partum, No Infant,

Chose a Plan, Stay in Same Plan or will be Auto-Assigned S/CC........................pg.98

U26 - MA to FHP Due to Excess Income, 60 Days Post-Partum, No Infant,

Chose a Plan, Stay in Same Plan or will be Auto-Assigned FP............................pg.99

U85 - MA to FHP Due to Excess Income, Chose a Plan,

Stay in Same Plan or will be Auto-Assigned FP...............................................pg.122

U86 - MA to FHP Due to Excess Income, Chose a Plan,

Stay in Same Plan or will be Auto-Assigned S/CC………….............................pg.122

U87 - MA Spenddown to FHP, Chose a Plan or will be auto assigned........................pg.123

U89 - MA to FHP Due to Excess Income, Chose a Plan, Stay in Plan or

will be Auto-Assigned FNP Parent.....................................................................pg.123

U90 - Turning 19, MA to FHP Due to Excess Income, Chose a Plan,

Stay in Same Plan or will be Auto-Assigned......................................................pg.124

X81 - MA to FHP Due to COLA, Chose a Plan, or will be Auto-Assigned ................pg.160


10/08/08

10

Refugee Medical Assistance

S92- RMA with Spenddown to FHP, Chose a Plan, SCC……………………...…..…pg.60

X28- Discontinue RMA, Ineligible for Medicaid due to Excess Income,

Ineligible for FHP due to Income, Equivalent Health Insurance, or

Federal Employee, FHP Ineligible but declines, S/CC……………………..….pg.145

FHP to MA

U37 - FHP to MA, Pregnant and MA Eligible, Chose MA...........................................pg.105

U95 - Turning 65, FHP to MA with Excess Income, Spenddown Not Met..................pg.124

V80 - FHP to MA with Spenddown Due to Over Gross Income or Chose

Spenddown, Spenddown Not Met, Under 65....................................................pg.136

X86 - FHP to MA, S/CC...............................................................................................pg.161

X88 - FHP to MA, FNP Parent or FP............................................................................pg.162

FHP –PAP

X31- FHPto FHP-PAP………………………………………………………..………pg.145

X32- FHP-PAP to FHP…………………………………………………………….... pg.146

X33- FHP-PAP to MA, FP, FNP Parent…………………………………………..... pg.146

X34- FHP-PAP to MA, S/CC……………………………………………………….. pg.147

X37- FHP to FHP-PAP, Employer Buy-In ………………………………………… pg.148

Equivalent Health Insurance/Public Employee

V39 - Discontinue FHP Due to Equivalent Health Insurance or Public

Employee.............................................................................................................pg.134

FHP to FPBP

V79 – FHP/FHP-PAP to FPBP Due to Excess Income, Equivalent

Health Insurance, Federal Employee, Non-ESHI or

ESHI-Not Cost Effective ....................................................................................pg.136

MA to FPBP

V76 - Over 19, MA to FPBP Due to Excess Income, FHP Ineligible Due to

Equivalent Health Insurance or Federal Employee.............................................pg.134

V77 - MA to FPBP Due to Excess Income and/or Resources, FHP Ineligible

Due to Excess Income and/or Resources, Equivalent Health Insurance

or Public Employee, S/CC .................................................................................pg.135

V78 - Over 19, MA to FPBP Due to Excess Income and/or Resources,


Federal Employee, 60 Days Post-Partum, Infant continues................................pg.135

V93 - MA to FPBP Due to Excess Income, FHP Ineligible Due to Excess

Income, Equivalent Health Insurance or Federal Employee, FNP

Parent...................................................................................................................pg.139

V95 - MA to FPBP Due to Excess Income and/or Resources, FHP Ineligible

Due to Excess Income, Equivalent Health Insurance or

Federal Employee, FP……………………………………………………….....pg.139


10/08/08

11

FPBP to FHP

V86- FPBP to FHP, MA Ineligible Due to Excess Income,

Choose a Plan or will be Auto –Assigned, FP………………………………... pg.138

V87- FPBP to FHP, MA Ineligible Due to Excess Income,

Choose a Plan or will be Auto-Assigned, S/CC………………………….…… pg.138

Resource Attestation

S64 - All Covered Care and Services to Community Coverage with No LTC

Due to Failure to Provide Documentation of Income and/or Resources,

No Spenddown......................................................................................................pg.42

S65 - Continue MA Unchanged, Limited Benefit Package Due to Resource

Documentation......................................................................................................pg.43

S86 - Community Coverage With CBLTC to Community Coverage With No

LTC, Fail to Prov Doc of Income and/or Resource at Renewal No

SD..........................................................................................................................pg.57

S87 - Continue MA Unchanged with No LTC, Attestor or Current

Documenter Failed toVerify .................................................................................pg.58


X13 - Spousal Impoverishment, Excess Resources for Institutionalized

Spouse.................................................................................................................pg.140

Living Arrangements

U65 - Not a Resident of District (MA Extension).........................................................pg.114

U77 - Concurrent Benefits, Intra-State No Aid Continuing .........................................pg.119

U78 - Concurrent Benefits, Inter-State, Aid..................................................................pg.120

Health Insurance

S17 - Change from SLIMB to QMB Coverage..............................................................pg.07

S18 - Change from QMB to SLIMB Coverage..............................................................pg.07

S21 - Change from QMB to QI-1 Coverage...................................................................pg.30

X14 - No Longer Eligible for MA Payment of AHIP Premiums................ ….............pg.141

X18 - Discontinue Payment of Medicare Part B Premium, QI-1 .................................pg.142

X25 - Discontinue MA Payment of Health Insurance Premiums..................................pg.144


Insurance Premiums.............................................................................................pg.151


Insurance Premiums, Prior Conditional Acceptance...........................................pg.152

X52 - Medicare Buy-In Program, QMB Ineligible........................................................pg.152

X53 - Medicare Buy-In Program, SLIMB Ineligible.....................................................pg.153

X70 - Discontinue QI-1 Coverage, Over Income .......................................................pg.155





S/CC......................................................................................................................pg.67


10/08/08

12

MBI-WPD (Medicaid Buy-In for working people with Disabilities) (con’t) U06 - Discontinue MBI-WPD, Medical Improvement Group, Not Working

40 Hrs, Not Working at Federal Minimum Wage, MA Ineligible Due

to Excess Income, FHP Ineligible Due to Excess Income, Equivalent

Health Insurance or Federal Employee, FP ..........................................................pg.69

U07 - Discontinue MBI-WPD, Medical Improvement Group, Not Working 40 Hrs,

Not Working at Federal Minimum Wage, MA Ineligible Due to Excess Income,


Employee, FNP Parent..........................................................................................pg.69




FNP Parent............................................................................................................pg.70




FP……………………………………………………………………………......pg.70

U11 - MBI-WPD to MA with Spenddown, Spenddown Not Met, Turning 65..............pg.71

U12 - MBI-WPD to MA, Excess Income, Spenddown Not Met...................................pg.72

U16 - Discontinue MBI-WPD, Medical Improvement Group, Not Working 40

Hrs, Not Working at Federal Minimum Wage, MA Ineligible Due to

Excess Income, FHP Ineligible Due to Excess Income Equivalent Health

Insurance or Federal Employee, S/CC..................................................................pg.73

U17 - MBI-WPD to MA.................................................................................................pg.73

U18 - Discontinue MBI-WPD Due to Excess Income and/or Resources, MA

Ineligible Due to Excess Income and/or Resources,.............................................pg.74

U27 - Discontinue MBI-WPD Due to Turning 65, MA Ineligible Due to Excess

Income and/or Resources, Spenddown Not Met ..................................................pg.99

U28 - Discontinue MBI-WPD Due to No Longer Working, MA Ineligible Due to

Excess Income, Spenddown Not Met, FHP Ineligible Due to Excess Income,

Equivalent Health Insurance or Federal Employee............................................ pg.100

U29 - MBI-WPD to MA with Spenddown Due to No Longer Working,

Spenddown Not Met, FHP Ineligible Due to Choosing Spenddown or has

Equivalent Health Insurance...............................................................................pg.100

U30 - MBI-WPD to MA with Spenddown Due to Non-Financial Reasons,

Spenddown Not Met. FHP Ineligible Due to Excess Income, Chose

Spenddown, Equivalent Health Insurance, Federal Employee or Over 65........pg.101

U50 - MA to MBI-WPD, Client Request......................................................................pg.107

U53 - MA with Spenddown to MBI-WPD...................................................................pg.108


S29 - Continue MA Unchanged, Home Equity Interest Exceeds Limit, No Undue

Hardship, 6-Mo Exc Inc and Res SD Met.............................................................pg.32

Short-Term Rehabilitation Care

S33 - Accept Short-Term Rehabilitative Nursing Home Care (Undercare Only)..........pg.34

S34 - Deny Short-Term Rehabilitative Nursing Home Care (Undercare Only).............pg.35


10/08/08

13

Pay-In

S15 - Pay-In Credit Due to Uncovered Expenses...........................................................pg.06

S16 - Pay-In Refund Due to Uncovered Expenses.........................................................pg.06

Other


Spenddown Met

T01 - Spenddown Met with Bills/Receipts or Combination Bills, Receipts

and Pay-In .............................................................................................................pg.62

T02 - Spenddown Met, Pay-In Only...............................................................................pg.64

Other Informational Letters

T06 - SSN Failed Verification/Validation (Active Case)...............................................pg.65

T07 - SSN Failed Verification/Validation (Applications)..............................................pg.65

T11 - MBI-WPD to MA, Turning 65.............................................................................pg.65

T12 - MBI-WPD to MA, No Longer Working...............................................................pg.65

PRESUMPTIVE ELIGIBLITY FOR CHILDREN

OPEN/CLOSE

TRANSACTION TYPE 09

U20 - Verification of Factors Which Affect Eligibility, Did Not State Unable

to Get Information.................................................................................................pg.75

U21 - Verification of Factors Which Affect Eligibility, Unable to Get

Information, But Not a Good Reason.................................................................pg.76


U78 - Concurrent Benefits, Inter-State, No Aid Continuing .......................................pg.120

V13 - Failure to Apply for or Utilize Benefits ……………….. ..................................pg.125

V17 - Incorrect or Fraudulent Social Security Number................................................pg.127

V31 - Failure to Provide Social Security Number........................................................pg.132

CHRONIC CARE

INTENT TO ESTABLISH LIABILITY TOWARD CHRONIC CARE

OPENING/UNDERCARE

Income Only

V52 - Individual – Income Contribution Only..............................................................pg.170

V53 - Spousal – Income Contribution Only..................................................................pg.171

Resource Only

V62 - Spousal – Resource Contribution Only...............................................................pg.175

V63 - Individual – Resource Contribution Only...........................................................pg.176


10/08/08

14

Income and Resource

V54 - Spousal – Income/Resource Contribution...........................................................pg.171

V55 - Individual – Income/Resource Contribution.......................................................pg.172

No Liability

V60 - Individual – No Liability Toward Cost of Care..................................................pg.174

V61 - Spousal – No Liability Toward Cost of Care......................................................pg.175

Waiver Recipient

V56 - Spousal – Previously Waiver Recipient, Income and Resource

Contribution.........................................................................................................pg.172

V57 - Spousal – Previously Waiver Recipient, Income Contribution

Only.....................................................................................................................pg.173

V58 - Spousal – Previously Waiver Recipient, Resource Contribution

Only.....................................................................................................................pg.173

V59 - Spousal – Previously Waiver Recipient, No Liability Toward Cost

of Care.................................................................................................................pg.174

INTENT TO ESTABLISH LIABILITY TOWARD CHRONIC CARE-PREVIOUSLY

PRIVATE PAY

Income only

V64 - Individual – Income Contribution Only..............................................................pg.176

V65 - Spousal – Income Contribution Only..................................................................pg.177

Resource Only

V74 - Spousal – Resource Contribution Only...............................................................pg.181

V75 - Individual – Resource Contribution Only...........................................................pg.182

Income and Resource

V66 - Spousal – Income/Resource Contribution...........................................................pg.177

V67 - Individual – Income/Resource Contribution.......................................................pg.178

No Liability

V72 - Individual – No Liability Toward Cost of Care..................................................pg.180

V73 - Spousal – No Liability Toward Cost of Care......................................................pg.181

Waiver Recipient

V68 - Spousal – Previously Waiver Recipient, Income and Resource

Contribution.........................................................................................................pg.178

V69 - Spousal – Previously Waiver Recipient, Income Contribution Only..................pg.179

V70 - Spousal – Previously Waiver Recipient, Resource Contribution

Only.....................................................................................................................pg.179

V71 - Spousal – Previously Waiver Recipient, No Liability Toward Cost of

Care.....................................................................................................................pg.180


10/08/08

15

Transfer and Liens


Excess Income, Spenddown Not Met, FHP Ineligible Due to Excess

Income, Chose Spenddown, Equivalent Health Insurance or Over 65.................pg.44


No Excess..............................................................................................................pg.45

S70 - Accept Instit. Individual, Limited Coverage Due to Prohib. Transfer,

No Excess..............................................................................................................pg.46

S71 - Accept Instit. Individual, Limited Coverage Due to Prohib.Transfer,

Excess Income, Spenddown Met...........................................................................pg.46


Excess Income and Resources, Resource and 6 Month Spenddown

Met.........................................................................................................................pg.47


Excess Income, Spenddown Met...........................................................................pg.48


Excess Income, 6 Month Spenddown Met............................................................pg.49


Excess Resources, Spenddown Met......................................................................pg.50


Excess Resources, Spenddown Met......................................................................pg.51

Ancillary Coverage Only

S83 - Accept Institutionalized Individual, Ancillary Coverage Only Due To

Failure To Provide Documentation Of Resources, Excess Income,

Spenddown Not Met..............................................................................................pg.56

S84 - Ancillary Coverage Only, Institutionalized Indiv., Due To Failure To

Provide Documentation Of Resources, No Excess...............................................pg.57


S91 - Accept Community Coverage Without LTC, Home Equity Interest

Exceeds Limit, No Undue Hardship, Exc Inc SD Met..........................................pg.59

X91 - Accept CC Without LTC, Home Equity Interest Exceeds Limit, No

Undue Hardship,6-Mo Exc Inc and /or Res SD Met...........................................pg.163

RECALCULATION OF CONTRIBUTIONS TOWARD CHRONIC CARE

Recalculation of Contributions Toward Chronic Care

V11 - Recalculation of Contribution Toward Chronic Care Due to COLA,

Individual (Upstate Only)....................................................................................pg.163

V12 - Recalculation of Contribution Toward Chronic Care Due to COLA,

Spousal (Upstate Only).......................................................................................pg.164

V40 - Recalculation of Contribution Toward Chronic Care, Spousal, Income

Only.....................................................................................................................pg.164

V41 - Recalculation of Contribution Toward Chronic Care, Individual,

Income Only........................................................................................................pg.165


10/08/08

16

Recalculation of Contributions Toward Chronic Care (con’t)


Resource Only.....................................................................................................pg.165

V43 - Recalculation of Contribution Toward Chronic Care, Spousal,

Resource Only.....................................................................................................pg.166

V44 - Recalculation of Contribution Toward Chronic Care, Spousal, No

Change.................................................................................................................pg.166

V45 - Recalculation of Contribution Toward Chronic Care, Individual, No

Change.................................................................................................................pg.167

V46 - Recalculation of Contribution Toward Chronic Care, Spousal, Income

& Resource..........................................................................................................pg.167


Income & Resource.............................................................................................pg.168


Liability..............................................................................................................pg.168


Liability..............................................................................................................pg.169


Change in Income, Excess Resources................................................................pg.169


Change in Income, Excess Resources................................................................pg.170

Transfers and Liens

S02 - Transfer by Institutionalized Individual, Reduce from Full to Limited

Coverage................................................................................................................pg.01

S06 - Intent to Impose a Lien on Real Property–Institutionalized Individual................pg.01

S09 - Institutionalized Individual- Transfer, MA Level to Limited Coverage

and Excess Income, Spenddown Met...................................................................pg.04


S29 - Continue MA Unchanged Due to Excess Income and Resources,

Institutionalized Individual, Home Equity Interest Exceeds Limit,

No Undue Hardship, Resource and 6 Month Spenddown Met..............................pg.32

CNS FILL REASON CODE SCREEN DISPLAYS

February 2011

1

S02/U0010 Case Type: 20

Transaction Types: 05, 06 - Case or Individual Level

Transfer by institutionalized individual, reduce from full to limited coverage



Intent to impose lien on real property, institutionalized individual


February 2011

2

S07/X0025 Case Type: 20


MA level to excess income due to COLA increase

If message 3 is selected (No Longer Eligible LTC) you will also need to complete this

screen:


February 2011

3



Increase in excess income due to COLA increase


screen:


February 2011

4



Reduce MA to limited coverage, excess income, spenddown met, transfer

institutionalized individual


February 2011

5



Change in figures used to calculate excess income amount


screen:


February 2011

6



Pay-In credit due to uncovered expenses



Pay-In refund due to uncovered expenses


February 2011

7



Change from SLIMB to QMB coverage



Change from QMB to SLIMB


February 2011

8

S20-AA/X0001 Case Type: 20


Accept excess income monthly spenddown


February 2011

9

S20-AB/X0006 Case Type: 20


Accept provisional excess income


February 2011

10

S20-AC/X0002 Case Type: 20


Accept excess income, 6-month spenddown met, A of R


February 2011

11


February 2011

12

S20-AD/X0003 Case Type: 20


Accept excess resources, spenddown met


February 2011

13

S20-AE/X0004 Case Type: 20


Accept excess income & resources monthly, both spenddown met


February 2011

14


February 2011

15

S20-AF/X0007 Case Type: 20


Accept excess income/resources, resource spenddown met


February 2011

16

S20-AG/X0005 Case Type: 20


Accept excess income/resources, 6-month and resource spenddown met


February 2011

17


February 2011

18

S20-BA/X0149 Case Type: 20


Accept child 1-5 over 133%, 1-month excess income spenddown met


February 2011

19

S20-BC/X0157 Case Type: 20


Accept child 1-5 over 133%, excess income, 6-month spenddown met


February 2011

20


February 2011

21

S20-BE/X0154 Case Type: 20


Accept child 1-5 over 133%, excess income/resources, 1-month excess

income & resources spenddown met


February 2011

22

S20-BG/X0151 Case Type: 20


Accept child 1-5 over 133%, excess income/resources, 6-month

spenddown met


February 2011

23


February 2011

24

S20-CA/X0228 Case Type: 20


Accept child 6-18 over 100%, 1-month excess income spenddown met


February 2011

25

S20-CC/X0231 Case Type: 20


Accept child 6-18 over 100%, excess income, 6-month spenddown met


February 2011

26


February 2011

27

S20-CE/X0230 Case Type: 20


Accept child 6-18 over 100%, excess income/resources, 1-month excess

income & resources spenddown met


February 2011

28

S20-CG/X0229 Case Type: 20


Accept child 6-18 over 100%, excess income/resources, 6-month spenddown met


February 2011

29

On all “S20” combinations, if message “No Longer Eligible LTC” is selected you will also

need to complete the following screen:


February 2011

30



Change from QMB to QI-1 coverage

S27/X0213 Case Types: 20, 24

Transaction Types: 05, 06 - Individual Level Only

MA to FHP Due to Excess Income, 60 Days Post-Partum, Continue Infant, Chose a Plan,

Stay in Same Plan or will be Auto-Assigned


February 2011

31



Spenddown to MA Level


screen:


February 2011

32



Continue MA Unchanged, Home Equity Interest Exceeds Limit, No Undue Hardship, 6-Mo

Exc Inc and Res SD Met


February 2011

33

S32/Y0013 Case Type: 20


Accept MBI-WPD, no premium payment


screen:


February 2011

34



Accept short-term Rehabilitative Nursing Home Care


February 2011

35



Denied short-term Rehabilitative Nursing Home Care


February 2011

36



Accept pregnant woman with limited coverage between 100-200% of FPL



Accept FHP, MA Ineligible Due to Excess Income, ESHI is offered, ESHI is Not Cost

Effective or ESHI is not offered FNP Parent


February 2011

37



Accept FHP, MA Ineligible Due to Excess Income, ESHI is offered, ESHI is Not Cost

Effective or ESHI is not offered FP

S39/Y0025 Case Type: 24, 20


Accept FHP, MA Ineligible Due to Excess Income, ESHI is offered,

ESHI is Not cost Effective, ESHI is not offered S/CC


February 2011

38



Approve retro – Deny ongoing , MA ineligible due to excess income and/or

resources, FHP ineligible due to excess income and/or resources,

equivalent insurance, Federal employee or over 65, S/CC


February 2011

39



Approve ongoing, Deny Retro MA due to excess income and/or resources, S/CC


February 2011

40

S59/Y0016 Case Types: 20, 24


Approve retro – Deny ongoing MA due to excess income and/or

resources, FHP ineligible due to excess income and/or resources,

equivalent insurance, Federal employee or over 65, FNP parent


February 2011

41



Approve Ongoing, Deny Retro MA Due to Excess, FNP Parent



Accept FPBP, MA Ineligible Due to Excess Income and/or Resources,


or ESHI- Non Cost Effective, FP


February 2011

42

S63/C0248 Case Type: 20, 24

Transaction Types: 05, 06 – Individual Level only


Discontinue - failure to provide information to clear up discrepancy


Transaction Types: 06 - Case or individual Level

All Covered Care and Services to Community Coverage with No LTC Due to Failure to

Provide Documentation of Income and/or Resources, No Spenddown


February 2011

43


Transaction Types: 05, 06 - Case or individual Level

Continue MA unchanged (limited benefit package due to resource

documentation)





or ESHI- Non Cost Effective, S/CC


February 2011

44




FHP Ineligible Due to Excess Income Non-ESHI, Federal Employee,

or ESHI- Non Cost Effective, FNP Parent



Accept limited coverage due to transfer, individual in community,

excess income spenddown not met


February 2011

45



Accept limited coverage due to transfer, individual in community, no excess


February 2011

46



Accept institutionalized individual, limited coverage due to prohibited

transfer, no excess




transfer, 1-month excess income spenddown met


February 2011

47




transfer, 6-month excess income & resources spenddown met


February 2011

48




1-month excess income spenddown met


February 2011

49




6-month excess income spenddown met


February 2011

50




transfer excess resources, spenddown met


February 2011

51




excess resource spenddown met


February 2011

52



Accept non-immigrant/undocumented immigrant emergency excess income


February 2011

53



Accept non-immigrant/undocumented immigrant emergency excess resource



Accept non-immigrant/undocumented immigrant emergency excess

income and resource


February 2011

54



Approve Retro, Deny Ongoing MA Due to Excess Income and/or

Resources, FHP Ineligible Due to Excess Income, Equivalent Health

Insurance, Federal Employee or Over 65, FP


February 2011

55



Approve ongoing – Deny retro period, FP



Accept Community Coverage without Long-Term Care


screen:


February 2011

56



Accept institutionalized individual, ancillary only, fail to provide

document of resources, 1-month excess income spenddown not met


February 2011

57



Accept institutionalized individual, ancillary only due to failure to

provide documentation of resources (no excess income)



Community Coverage With CBLTC to Community Coverage With No LTC, Fail to Prov

Doc of Income and/or Resource at Renewal No SD


February 2011

58



Continue MA unchanged (attestor or current documenter failed to verify)


February 2011

59


Transaction Types: 02, 10 - Case or individual level

Accept Community Coverage Without LTC, Home Equity Interest Exceeds Limit, No Undue

Hardship, Exc Inc SD Met


February 2011

60


Transaction Types: 05,06

RMA with Spenddown toFHP, Chose a Plan, S/CC#


Transaction Types: 02,10 - Case or individual level

Accept FHP/FHP-PAP, FP


February 2011

61



Accept FHP/FHP-PAP, FNP Parent



Accept FHP/FHP-PAP, S/CC


February 2011

62



Accept FHP/PAP Employer Buy-In (EBI)

T01/S0001 Case Type: 20


Informational letter, monthly/6-month spenddown met, bills & receipts


February 2011

63


February 2011

64

T02/S0002 Case Type: 20


Informational letter, monthly/6-month spenddown met, pay-in only,

no bills receipts


February 2011

65

Informational Letters Only (Transaction type 00)

T06/S0007 – SNN Failed Verification/Validation (active case)

Case Type: 20

Transaction Types: 00 - Case or individual level

T07/S0009 – SSN Failed Verification/Validation

Case Type: 20


T11/S0011 – MBI-WPD to MA, turning 65

Case Type: 20


T12/S0012 – MBI-WPD to MA, no longer working

Case Type: 20



February 2011

66

reason codes for Informational Letters only - Once you transmit on Reason Code Screen (see

above) after entering transaction type “00” and reason code “T11”, or “T12” at the case

and/or individual level it will bring you back to the WNS / Client Notice Subsystem Menu

(see below).

In order for the notice to be released for mailing you must enter selection number “07”

from the WNS / Client Notice Subsystem Menu (F11) and complete the Notice

Authorization/Release screen (see below)


February 2011

67

U03/C0133 Case Type: 20

Transaction Types: 05, 06 – Individual level only


Discontinue MBI-WPD, no longer meets medically improved group requirements, S/CC


February 2011

68

U05/U0124 Case Type: 20


Medically improved with a severe impairment, continue MBI-WPD


screen:


February 2011

69




Discontinue MBI-WPD, Medically Improved Group, not working 40 hours

or not working at federal minimum wage, FP




Discontinue MBI-WPD, Medically Improved Group, not working 40 hours

or not working at federal minimum wage, FNP


February 2011

70




Discontinue MBI-WPD, no longer meets Medically Improved

Group requirements, FNP




Discontinue MBI-WPD, no longer meets Medically Improved

Group requirements, FP


February 2011

71



MBI-WPD to MA, excess income, spenddown not met, turning 65


screen:


February 2011

72

U12/X0026 Case Type: 20


MBI-WPD to MA, excess income, spenddown not met


screen:


February 2011

73




Discontinue MBI-WPD Medically Improved Group, not working 40 hours or

not working federal minimum wage, S/CC



MBI-WPD to MA


February 2011

74


screen:




Discontinue MBI-WPD, excess income and/or resources


February 2011

75

U19/D0152 Case Type: 20

Transaction Types: 03 – Case or individual level


Deny MBI-WPD, excess income and/or resources, MA ineligible

U20/C0063/ C0064– Discontinue MA/RMA/FHP/FHP-PAP/FPBP Due to Verification of

factors Which Affected Eligibility, Did not State Unable to Get

Information Case Types: 21

Transaction Types: 09 (Presumptive for Children) Case or individual level

U20/C0065 – Discontinue, unable to get information, not a good reason – intro

Case Types: 20, 24


Transaction Types: 07, 08 – Case or individual level

U20/C0064 - Discontinue, fail to provide information, did not state unable – summary

Case Types: 20, 24



U20/D0039 – Deny – Verifications of factors which effect eligibility, did not state

unable to get info - Intro

Case Types: 20, 24



U20/D0040 – Deny – Verifications of factors which effect eligibility, did not state

unable to get info – summary


February 2011

76

Case Types: 20, 24



U21/C0065/ C0066 – Discontinue MA/RMA/FHP/FHP-PAPFPBP Due to Verification of

factors Which Affected Eligibility, Unable to Get Information,

But Not a Good Reason Case Types: 21

Transaction Types: 09 (Presumptive for Children) Case or individual level

U21/C0063 – Discontinue MA/FHP/FPBP, fail to verify, did not state unable – intro

Case Types: 20, 24



U21/C0066 – Discontinue MA/FHP/FPBP, fail to verify, not good reason – summary

Case Types: 20, 24



U21/D0041 – Deny – Verifications of factors which effect eligibility, unable to get info

Reason not good – intro

Case Types: 20, 24



U21/D0042 – Deny – Verifications of factors which effect eligibility, unable to get info

Reason not good - summary

Case Types: 20, 24



For the examples on the following pages (pgs. 86-114) the selection has been made on the

“failed to verify” screen to show you the screen that will follow for that selection;

Note: the screen displays are for U20, but U21 screens are exactly the same except on failed

to verify screen the case reason would say: CASE REASON U21 : NO VERF : NG-I


February 2011

77


February 2011

78


February 2011

79


February 2011

80


February 2011

81


February 2011

82


February 2011

83


February 2011

84


February 2011

85


February 2011

86


February 2011

87


February 2011

88


February 2011

89


February 2011

90


February 2011

91


February 2011

92


February 2011

93


February 2011

94


February 2011

95


February 2011

96


February 2011

97


February 2011

98

U25/P0011 Case Types: 20, 24


MA to FHP Due to excess income, 60 day post-partum,

no infant, chose plan or staying in same plan or will be auto assigned, S/CC


February 2011

99

U26/P0007 Case Types: 20, 24


MA to FHP due to excess income, 60 days postpartum,

No infant, Chose a plan or staying in same plan or will be auto assigned, FP




Discontinue MBI-WPD, turning 65, excess income and/or resources


February 2011

100




Discontinue MBI-WPD, no longer working, excess income



MBI-WPD to MA, excess income, spenddown not met, no longer working


February 2011

101


screen:



MBI-WPD to MA, excess income, non-financial reason, spenddown not met


February 2011

102


screen:




Deny MA, excess income


February 2011

103




Discontinue MA due to excess income

U33/X0170 Case Types: 20 Transaction Types: 05, 06 – Individual level only


Case Types: 24



Discontinue MA, excess income/resources, turning 19, FPBP excess

income/decline


February 2011

104

U34/D0116 Case Types: 20, 24



Deny MA Due to Excess Income and/or Resources, FHP Ineligible Due to Excess Income,

Non-ESHI, Federal Employee, or EHSI- Not Cost Effective, FPBP Ineligible Due to Excess

Income or Eligible but Declines, FP


February 2011

105

U35/D0115 Case Types: 20, 24



Deny MA Due to Excess Income, FHP Ineligible Due

to Excess Income, Non-ESHI, Federal Employee,

or ESHI- Not Cost Effective, FPBP Ineligible Due to

Excess Income or Eligible but Declines, S/CC

U37/U0113 Case Types: 20, 24


Pregnant, chose to go from FHP to MA


February 2011

106




Deny MA, excess resources, Chronic Care




Discontinue MA due to excess resources


February 2011

107

U49/D0134 Case Types: 20, 24



Deny MA Due to Excess Income, FHP Ineligible Due

to Excess Income, Non-ESHI, Federal Employee,

or ESHI- Not Cost Effective, FPBP Ineligible Due to

Excess Income or Eligible but Declines, FNP Parent



MA to MBI-WPD, client request


February 2011

108


screen:



MA excess income/resource to MBI-WPD


February 2011

109


screen:

U57/C0183 Case Types: 20



Discontinue MA, excess income, ineligible for FHP excess income, FPBP excess income

/declined, Equiv Health Insurance or Federal Employee, S/CC


February 2011

110




Discontinue MA, excess income, ineligible for FHP, Federal Employee

FPBP excess income /declined, FP




Deny MA, excess income/resources, Chronic Care


February 2011

111




Discontinue MA, due to excess income/resources




MBI-WPD Ineligible, Not Currently Working, MA Ineligible Due to Excess Income and/or

Resources, FHP Ineligible Due to Excess Income Equivalent Health Insurance or Federal

Employee


February 2011

112




Deny MBI-WPD, not certified disabled, MA/FHP ineligible, FP




Deny medical emergency and MA excess income/resources,

Non-immigrant/undocumented immigrant, FP


February 2011

113




Deny MBI-WPD, not certified disabled, MA/FHP ineligible, Equivalent Health Ins or

Federal Employee, S/CC


February 2011

114

U65/C0006 Case Types: 20, 24



Discontinue, not a resident of district (MA ext)

U66/C0070 Case Types: 20, 22, 24



Case Types: 21

Transaction Types: 09- Case or individual level

Discontinue MA/FHP/FPBP, currently in receipt of assistance


February 2011

115

U66/D0003 Case Types: 20, 24



Deny, currently in receipt of assistance




Deny MBI-WPD, failure to submit proof of work, MA/FHP ineligible


February 2011

116




Discontinue MA due to excess income, COLA, S/CC


February 2011

117




Deny medical emergency and MA excess income,

Non-immigrant/undocumented immigrant, S/CC


February 2011

118




Deny MBI-WPD, not certified disabled, MA/FHP ineligible, FNP



No change in excess income amount


February 2011

119


screen:

U77/C0140 Case Types: 20, 24




Discontinue, concurrent benefits intra-state, no aid continuing


February 2011

120

U78/C0141 Case Types: 20, 24



Case Types: 21


Discontinue, concurrent benefits inter-state, aid continuing

U79/D0070 Case Types: 20, 24



Deny, concurrent benefits intra or inter state


February 2011

121




Deny, Qualified individual (QI-1)




Deny, concurrent benefits intra-state, AFIS match


February 2011

122

U85/U0081 Case Types: 20, 24

Transaction Types: 05, 06

Case or individual level

MA to FHP Due to Excess Income, Chose a plan or staying in same plan or will be auto

assigned, FP

U86/U0082 Case Types: 20, 24


MA to FHP Due to Excess Income, Chose a plan or staying in same plan or auto assigned ,

S/CC


February 2011

123

U87/U0098 Case Types: 20, 24


MA spenddown to FHP, chose plan or auto assigned

U89/U0106 Case Types: 20, 24


MA to FHP Due to Excess Income, Chose a plan or staying in same plan or auto assigned,

FNP Parent


February 2011

124

U90/U0112 Case Types: 20, 24


Turning 19, MA to FHP Due to Excess Income, Chose a plan or staying in same plan

U95/X0202 Case Types: 20, 24


FHP to MA, excess income, spenddown not met, turning 65


February 2011

125


screen:

V13/C0015 Case Types: 20, 24



Case Types: 21


Discontinue, failure to utilize benefits


February 2011

126

V13/D0014 Case Types: 20, 24



V13/D0015 Case Types: 20, 24


Deny, failure to utilize benefits and resources

V14/D0026 Case Types: 20, 24



Deny MA/FHP, fail to complete declaration of citizenship/immigration


February 2011

127

V17/C0050 Case Types: 20, 24



Case Types: 21


Discontinue, incorrect/fraudulent Social Security Number

V17/D0137 Case Types: 20, 24



Deny, incorrect/fraudulent Social Security Number


February 2011

128

V30/C0008 – Discontinue MA/FHP, failure to comply with IV-D requirements Case Types: 20, 24



V30/D0007 – Deny MA/FHP, failure to comply with IV-D requirements Case Types: 20, 24



For the examples on the following pages (pgs. 152-157) the selection has been made on the

“Failure to comply with IV-D requirements” screen to show you the screen that will follow

for that selection.

Note: the screen displays are for V30/C0008, but V30/D0007 screens are exactly the same.


February 2011

129


February 2011

130


February 2011

131


February 2011

132

V31/C0014 Case Types: 20, 24



Case Types: 21


Discontinue, failure to provide a Social Security Number


February 2011

133

V31/D0013 Case Types: 20, 24



Deny, Failure to provide a Social Security Number

V38/C0072 Case Type: 20



Discontinue, failed to contact agency


February 2011

134

V39/C0206 Case Types: 20


Case Types: 24



Discontinue FHP, equivalent insurance or Federal employee

V76/U0139 Case Type: 20


Over 19, MA to FPBP due to excess income, FHP ineligible due to

Equivalent insurance or Federal employee


February 2011

135



MA to FPBP, S/CC


Transaction Types: 05, 06 - Individual level only

MA, 60 days post-partum, MA to FPBP, over 19


February 2011

136

V79/U0137 Case Types: 20, 24


FHP/FHP-PAP to FPBP

V80/U0099 Case Types: 20, 24


FHP to MA, excess income, spenddown not met, under 65

If message 3 is selected (No Longer Elig for LTC) you will also need to complete this

screen:


February 2011

137

V85/D0138 Case Type: 20



Deny FPBP due to excess income, no application for MA and FHP


February 2011

138


Transaction Types: 05, 06 - Individual level

Case Type: 24


FPBP to FHP due to excess income, selected a plan, FP


Transaction Types: 05, 06 - Individual level

Case Type: 24


FPBP to FHP due to excess income, chose a plan, S/CC


February 2011

139



MA to FPBP, FNP parent



MA to FPBP, FP


February 2011

140

X10/X0086 Case Type: 20



Deny, inpatient hospital does not meet 6 month excess income amount

X13/C0054 Case Type: 20



Discontinue MA, excess resources for institutionalized spouse,

spousal impoverishment


February 2011

141

X13/D0036 Case Type: 20



Deny MA, excess resources for institutionalized spouse, spousal impoverishment




Discontinue, no longer eligible for MA payment of AHIP premiums


February 2011

142




Discontinue Medicare Buy-In Program, QI-1




Discontinue MA, fail to provide income and/or resource documentation


February 2011

143

X23/D0160 Case Types: 20, 24



Deny MA/FHP, attestor failed to provide amount of resource(s) at application




Discontinue MA payment of health insurance premiums


February 2011

144




Deny MA payment of health insurance premiums

X26/Y0061 Case Type: 20


Accept MA payment of insurance premiums


February 2011

145


Transaction Types: 07, 08- Case or Individual level

05, 06

Discontinue RMA, Medicaid Ineligible due to Excess Income, FHP Ineligible due to Excess

Income, Equivalent Health Insurance, or Federal Employee, FPBP Ineligible or Eligible but

declines, S/CC

X31/U0186 Case Type: 24


FHP to FHP-PAP


February 2011

146



FHP-PAP to FHP



FHP-PAP to MA, FP, FNP Parent


screen:


February 2011

147



FHP-PAP to MA, S/CC


screen:


February 2011

148



FHP to FHP-PAP, Employer Buy-In (EBI)


February 2011

149

X45/D0123 Case Types: 20, 24



Deny MA, excess income and/or resources, FHP failed to choose a plan, FP

X46/D0124 Case Types: 20, 24



Deny MA, excess income and/or resources, FHP failed to choose a plan, S/CC


February 2011

150

X47/D0125 Case Types: 20, 24



Deny MA, excess income and/or resources, FHP failed to choose a plan,

FNP parent




Discontinue MA, excess income, ineligible for FHP, FPBP excess income/declined, FNP

parent


February 2011

151




Discontinue MA payment for COBRA continuation coverage for group

health insurance premiums




Deny COBRA continuation coverage of group health insurance premium


February 2011

152




Discontinue COBRA continuation coverage of group health

insurance premium, prior conditions acc




Discontinue Medicare Buy-In Program (QMB’s)


February 2011

153




Deny Medicare Buy-In Program (QMB’s)




Discontinue Medicare Buy-In Program (SLIMB’s) due to excess income, not

enrolled/eligible for Part A, other


February 2011

154




Deny Medicare Buy-In Program (SLIMB’s) due to excess income,

not enrolled/eligible for Part A, other



Accept Medicare Buy-In Program, QMB


February 2011

155




Discontinue qualified individual (QI-1), over income




screen:


February 2011

156




screen:


February 2011

157



Decrease in excess income amount


screen:


February 2011

158



Decrease in excess income amount due to COLA increase, MA deductible


screen:


February 2011

159



MA to excess income


screen:


February 2011

160

X81/X0220 Case Types: 20, 24


MA to FHP due to COLA, Chose a Plan


February 2011

161

X86/U0080 Case Types: 20, 24


FHP to MA, S/CC


screen:


February 2011

162

X88/U0120 Case Types: 20, 24


FHP to MA, income eligible, FNP parent, FP


screen:


February 2011

163



Accept Community Coverage without LTC, home equity interest exceeds limit, no

undue hardship, 6-month excess income and/or resources, spenddown met

Chronic Care



Recalculation of contributions toward Chronic Care, single, COLA (upstate)


February 2011

164



Recalculation of contributions toward Chronic Care, spouse, COLA (upstate)



Recalculation of contributions toward Chronic Care, (spouse), income only


February 2011

165



Recalculation of contributions toward Chronic Care, (individual), income only



Recalculation of contributions toward Chronic Care, (individual),

Excess resources only


February 2011

166



Recalculation of contributions toward Chronic Care, (spouse),

Excess resources only




Same income contribution


February 2011

167




Same income contribution




Income/resources


February 2011

168




Income/resources




no liability


February 2011

169




no liability




income/resource contribution same


February 2011

170




resources only, no income change


Transaction Types: 02, 10, 05, 06 - Case or individual level

Intent to establish liability toward Chronic Care, (individual), income only


February 2011

171



Intent to establish liability toward Chronic Care, (spouse), excess income only



Intent to establish liability toward Chronic Care, (spouse), income/

excess resources only


February 2011

172



Intent to establish liability toward Chronic Care, (individual), excess

income/resources



Intent to establish liability toward Chronic Care, (waiver recipient), income/resources


February 2011

173



Intent to establish liability toward Chronic Care, (waiver recipient),

income contributions



Intent to establish liability toward Chronic Care, (waiver recipient),

resource contribution


February 2011

174



Intent to establish liability toward Chronic Care, (waiver recipient), no liability



Intent to establish liability toward Chronic Care, (individual), no liability


February 2011

175



Intent to establish liability toward Chronic Care, (spouse), no liability



Intent to establish liability toward Chronic Care, (spouse), resource contribution


February 2011

176



Intent to establish liability toward Chronic Care, (individual), resource contribution



Intent to establish liability toward Chronic Care, (individual), income

contribution, not month 1 of institutionalization


February 2011

177



Intent to establish liability toward Chronic Care, (spouse), income contribution,

not month 1 of institutionalization



Intent to establish liability toward Chronic Care, (spouse), income/resources



February 2011

178



Intent to establish liability toward Chronic Care, (individual), income/resources




Intent to establish liability toward Chronic Care, (waiver recipient), income/resources



February 2011

179



Intent to establish liability toward Chronic Care, (waiver recipient), income contribution,




Intent to establish liability toward Chronic Care, (waiver recipient), resource contribution,



February 2011

180



Intent to establish liability toward Chronic Care, (waiver recipient), no liability,




Intent to establish liability toward Chronic Care, (individual), no liability,



February 2011

181



Intent to establish liability toward Chronic Care, (spouse), no liability,




Intent to establish liability toward Chronic Care, (spouse), resource contribution,



February 2011

182



Intent to establish liability toward Chronic Care, (individual), resource


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