Body
C—621 Minimum Entries for Certification
Revision 02-3; Effective April 1, 2002
C—621.1 TANF Minimum Entries
Revision 02-3; Effective April 1, 2002
TANF
Section I
| Item | Detail |
|---|---|
| 02 | Category |
| 07 | Mail Code |
| 08 | Date Filed |
| 09 | Case Name |
| 13 | Mailing Address |
| 15 | City |
| 16 | State |
| 17 | ZIP Code |
| 25 | County |
Section II
| Item | Detail |
|---|---|
| 32 | Client Number |
| 33 | Client Name |
| 34 | Birth Date |
| 35 | Sex |
| 37 | Social Security Number (if known) |
| 38 | Social Security Claim Number (if enrolled in Medicare or receiving benefits) |
Section III
| Item | Detail |
|---|---|
| 40 | Status in Group |
| 41 | ESP Code (unless Category 5) |
| 42-44 | Individual Income, if applicable |
| 46 | Medical Effective Date |
Section IV
| Item | Detail |
|---|---|
| 55 | Total Railroad Retirement (if appropriate) |
| 56 | Total Other (Income) (if appropriate) |
| 58 | Dependent Care Deductions (if appropriate) |
| 59 | Adjusted Gross Income |
| Note: Total income minus deductions must equal adjusted gross income. | |
Section V
| Item | Detail |
|---|---|
| 66 | Total Needs |
Section VIII
| Item | Detail |
|---|---|
| 127 | Type Program |
| 129 | Grant Effective Date |
| 132 | Action Code |
| 133 | Three Months Prior Indicator (only if eligible for three months prior medical assistance) |
| 134 | Three Months Prior Application Date (if entry made in Item 133) |
| 138 | Child Support Cooperation |
| 149, 151 and 152 | For cases with earned income, enter dependent care and 90% earned income deduction information if these deductions are used in determining the adjusted gross |
Section XIV
| Item | Detail |
|---|---|
| 188 | Signature |
| 189 | Date Signed |
| 190 | Employee Number |
C—621.2 SNAP Minimum Entries
Revision 02-3; Effective April 1, 2002
SNAP
Section I
| Item | Detail |
|---|---|
| 02 | Category |
| 04 | Page number and the number of pages if there are more than 11 individuals |
| 06 | Budgeted Job Number |
| 07 | Mail Code |
| 08 | Date Filed |
| 09 | Case Name |
| 13 | Mailing Address – first line |
| 15 | City |
| 16 | State |
| 17 | ZIP Code |
| 25 | County |
Section II
| Item | Detail |
|---|---|
| 32 | Client Number |
| 33 | Client Name |
| 34 | Birth Date |
| 35 | Sex (if known) |
| 36 | Race (if known) |
| 37 | Social Security Number |
| 38 | Social Security Claim Number (if visually verified) |
| 39 | Education Level (if Item 41 is 1, 2, 3, or 4) |
Section III
| Item | Detail |
|---|---|
| 40 | Status in Group |
| 41 | Work Registration |
| 42-45 | Individual Income, if applicable |
| 48 | Medical Cost of eligible members as appropriate |
| 49 | Disqualification Code and Date, if applicable |
Section IV
| Item | Detail |
|---|---|
| 55 | Total Railroad Retirement (if appropriate) |
| 56 | Total Other (Income) (if appropriate) |
| 58 | Dependent Care Deduction (if any) |
| 59 | Adjusted Gross Income |
Section V
| Item | Detail |
|---|---|
| 60 | Shelter |
| 63 | Net Income |
Section VI
| Item | Detail |
|---|---|
| 78 | Type Review |
| 79 | Application Codes |
| 80 | Certification Date |
| 81 | Months Certified |
| 82 | Last Benefit Month |
| 83 | Household Number |
| 84 | Aid Type |
| 85 | Test (Gross/net income eligibility test identifier codes) |
| 89 | SSI Code (if applicable) |
| 90 | Utility Code |
| 91 | Action Code (if case is opened and closed on same document) |
| 92 | Action date (if entry made in Item 91) |
| 96 | Late Determination/Rescheduled Appointment Date, if applicable |
| 103 and 104 | (if appropriate) |
Section VII
| Item | Detail |
|---|---|
| 112 and 113 | Associated TANF case numbers, if appropriate |
| 118-122 | (if appropriate) |
Section VIII
| Item | Detail |
|---|---|
| 152 | Child Support Disregard, if applicable |
Section XI
| Item | Detail |
|---|---|
| 179-187 | As appropriate to request or report benefits |
Section XIV
| Item | Detail |
|---|---|
| 188 | Signature |
| 189 | Date Signed |
| 190 | Employee Number |
C—621.3 Minimum Entries for Medical Programs
Revision 02-3; Effective April 1, 2002
Medical Programs except TP 45
NOA Entries
Section I
| Item | Detail |
|---|---|
| 01 | Case Number |
| 02 | Category |
| 03 | Prior Recipient |
| 06 | Budgeted Job Number |
| 07 | Mail Code |
| 09 | Case Name |
| 12 | Employee Number |
| 13 | Mailing Address |
| 15 | City |
| 16 | State |
| 17 | ZIP Code |
| 25 | County |
| 31 | Medical Programs Application Number |
Section II
| Item | Detail |
|---|---|
| 33-38 | Client Names and Biographical Data |
Certification Entries
Section I
| Item | Detail |
|---|---|
| 02 | Category |
| 07 | Mail Code |
| 08 | Date Filed |
| 09 | Case Name |
| 13 | Mailing Address |
| 15 | City |
| 16 | State |
| 17 | ZIP Code |
| 25 | County |
| 29 | Notice Date |
| 30 | Medical Delay (if appropriate) |
Section II
| Item | Detail |
|---|---|
| 32 | Client Number |
| 33 | Client Name |
| 34 | Birth Date |
| 35 | Sex |
| 37 | Social Security Account Number (if known) |
| 38 | Social Security Claim Number (if enrolled in Medicare or receiving benefits) |
Section III
| Item | Detail |
|---|---|
| 40 | Status in Group |
| 42-44 | Individual Income, if applicable |
| 46 | Medical Effective Date |
Section IV
| Item | Detail |
|---|---|
| 55, 56 and 58 | Case Income, if applicable |
| 59 | Adjusted Gross Income |
| Note: Total income minus deductions must equal adjusted gross income. | |
Section V
| Item | Detail |
|---|---|
| 66 | Total Needs |
Section VIII
| Item | Detail |
|---|---|
| 125 | Number of Adults |
| 126 | Number of Children |
Section VIII
| Item | Detail |
|---|---|
| 127 | Type Program |
| 132 | Action Code |
| 133 | Three Months Prior Indicator only if eligible for three months prior medical assistance |
| 134 | Three Months Prior Application Date (if entry is made in Item 133) |
| 136 | Medicaid Termination Date |
Section XIV
| Item | Detail |
|---|---|
| 188 | Signature |
| 189 | Date Signed |
| 190 | Employee Number |
C—621.3.1 TP 45 Minimum Entries
Revision 02-3; Effective April 1, 2002
TP 45
Section I
| Item | Detail |
|---|---|
| 02 | Category |
| 07 | Mail Code |
| 08 | Date Filed |
| 09 | Case Name |
| 13 | Mailing Address |
| 15 | City |
| 16 | State |
| 17 | ZIP Code |
| 25 | County |
| 29 | Notice Date |
Section II
| Item | Detail |
|---|---|
| 32 | Client Number |
| 33 | Client Name |
| 34 | Birth Date |
| 35 | Sex |
| 37 | Social Security Account Number (if known) |
Section III
| Item | Detail |
|---|---|
| 40 | Status in Group |
| 46 | Medical Effective Date |
Section VIII
| Item | Detail |
|---|---|
| 127 | Type Program |
| 132 | Action Code |
Section XIV
| Item | Detail |
|---|---|
| 188 | Signature |
| 189 | Date Signed |
| 190 | Employee Number |
C—622 Entries for Three Months Prior
Revision 02-3; Effective April 1, 2002
C—622.1 Three Months Prior Medicaid – Currently Eligible – No Gap in Coverage
Revision 02-3; Effective April 1, 2002
TANF
Complete Form H1000-A, Notice of Application, using TANF entry requirements.
Item 46 – Enter prior medical effective dates for applicants eligible for three months prior medical coverage.
Item 133 – Enter the number of months of prior eligibility.
Item 134 – Enter three months of prior application date.
Note: For three months prior with a gap in coverage, see C-623.2.
C—622.2 Three Months Prior Entries for a Medically Needy Case
Revision 02-3; Effective April 1, 2002
TP 55 and 30
Make minimum certification entries for a case with or without spend down. For a TP 30 case, do not make entries in Items 179-187 if Item 137 has an entry of 40, 43, 44, or 48. Refer to Form H1000-A and Form H1000-B instructions for Items 133 and 137.
Make the following entries in Section XI when there is no gap in eligibility during the prior period:
Item 179 – Enter N if the prior month has spend down or E if the prior month does not have spend down. This code corresponds with the month entered in Item 183.
Item 183 – Enter the month to correspond with the code in Item 179.
Item 184 – Enter the net income to correspond with the month in Item 183. Round down to the whole dollar amount.
Item 185 – Enter the spend down amount to correspond with the month entered in Item 183. Enter 0 if there is no spend down.
Item 187 – Enter the household size to correspond with the month entered in Item 183. Enter the number of adults in the budget group in the first digit and the number of children in the budget group in the second digit.
If there is a gap in eligibility during the three-month prior period, process a separate Form H1000-A for the eligible months.
C—623 Entries for Open and Close Certifications
Revision 02-3; Effective April 1, 2002
C—623.1 TP 04, Medical Assistance Only – Deceased
Revision 02-3; Effective April 1, 2002
TANF
Make TANF minimum entries except for Items 41 and 129
Item 40 – Enter X with status in group code for deceased individual.
Item 46 – Enter the medical effective date for each eligible person.
tem 47 – Enter the appropriate dates.
Item 132 – Enter action code 090.
Item 133 – Enter three months prior indicator, if eligible.
C—623.2 TP 11, Three Months Prior Medical Assistance – Not Currently Eligible; Gap in Coverage; or Reopened Applications
Revision 02-3; Effective April 1, 2002
TANF
Make all TANF minimum entries except Items 41 and 129.
For reopened applications,
Item 08 – Enter the date the applicant requests the application be reopened.
Item 134 – Enter the month and year the original application was filed.
Item 140 – Enter M with primary Codes 5, 6, 7, or 8 for applicants eligible for retroactive coverage. Enter N with primary Codes 5, 7, or 8 for applicants who are not eligible for retroactive coverage but are included to show need.
Item 47 – Enter last day of medical coverage for all applicants with Code M in Item 40.
Item 132 – Enter Code 090.
Notes:
- Enter MX with primary codes for an applicant who dies during the three month prior period or if the person died before the application was made on his behalf.
- For Three Months Prior Currently Active – In addition to the above entries, enter the existing case number in Item 01 and the existing client number in Item 32.
C—623.3 Simultaneous Open and Close for TANF
Revision 02-3; Effective April 1, 2002
TANF
Use this procedure to process applications for
- denied households eligible for restored benefits (See B-800, Restored Benefits),
- applicants eligible for TANF for the current month but ineligible for future months,
- applicants eligible for OTTANF, or
- applicants eligible for TANF Medicaid for the application month but ineligible for the months following the application month. Note: Form H1000-A, Notice of Application, can be processed only if the month after the application month is entered in Item 129.
Make all minimum entries for the appropriate type program.
Note: Do not reassign an old case number.
Item 40 – Enter secondary status in group Code N for OTTANF applicants.
Item 47 – Enter last month of eligibility for each certified person. If an applicant is deceased, enter date of death.
Item 127 – enter Type Program 71 or 72 for OTTANF cases.
Item 132 – Enter Code 090.
Items 179, 180, 183, 184, 185 and 187 (Section XI) – Enter information to authorize benefits for Type Program 01 and 61 certifications. Exceptions: Do not make entries in Section XI for OTTANF cases. When the form processes, benefits are automatically issued.
C—623.4 Simultaneous Open and Close for Medical Programs
Revision 02-3; Effective April 1, 2002
Medical Programs
Use this procedure to process applications for
- TP 55 and 30 with spend down in the application month;
- TP 30 when the applicant is a caretaker or a second parent with an emergency condition; or
- three months prior only including
- TPs 30 and 55 with or without spend down, and
- applications for TPs 30, 40, 43, 47, 48, and 55 reopened within two years after the original application was filed.
Make minimum certification entries for a case (with or without spend down) including the file date of the application. Note: Do not reassign an old case number.
Item 40 – Enter the appropriate SIG codes. For three months prior, only include in the certified group members who have Title XIX-reimbursable bills for the prior period. For TP 30, include only one member in the certified group.
Item 46 – Enter the Medical Effective Date (MED) or earliest possible MED. For TP 30 cases, enter the start date of the emergency condition taken from Form H3038, Emergency Medical Services Certification.
Item 47 – Enter the last day of medical coverage. For TP 30 cases enter the earliest of either
- the end date of the emergency condition, or
the last day of the application month.
Note: For TP 55 cases with spend down, computer edits will not allow a date later than the last day of the application month.
Item 66 – Enter the correct needs allowance for the month(s) entered in Items 46 and 47.
Item 127 – Enter the correct type program (30, 40, 43, 44, 47, 48, or 55).
Item 132 – Enter code 090.
Item 133 – For three months prior only, enter the total number of unduplicated calendar months of three months prior.
Item 137 – For TP 30 cases, enter the appropriate TP. Refer to Form H1000-A and Form H1000-B instructions for this entry.
Section XI – For three months prior only, make appropriate entries for each of the prior months. For TP 30 cases, do not make these entries if Item 137 has an entry of 40, 43, 44, or 48.
For reopened three months prior applications,
Item 08 – Enter the date the applicant requests the application be reopened.
Item 134 – Enter the month and year the original application was filed.
C—624 Entries for Reinstatements
Revision 02-6; Effective July 1, 2002
C—624.1 TANF
Revision 10-1; Effective January 1, 2010
Make all Form H1000-A minimum entries.
Item 01 – Enter the previous case number.
Item 08 – Enter first day of the month of reinstatement.
Item 46 – Enter each individual's medical effective date.
Item 131 – Enter type review Code C.
Item 132 – Enter Code 054 or 055.
Item 164 – Enter the three-digit code for the individual's county of residence. See C-350.
Note: SAVERR edits prevent household additions when Code 054 is used in Item 132. Use Form H1000-B turnaround to make this change.
C—624.2 SNAP
Revision 10-1; Effective January 1, 2010
SNAP
Item 08 – Enter the original file date.
Item 79 – Enter 3X0.
Item 80-82 – Reenter the information from the certification period when the case was denied.
Section XI – Make entries as appropriate to order benefits.
C—624.3 TP 07/20 (Four, 12, or 18 Months Medicaid) for a Case Previously Denied in Error
Revision 10-1; Effective January 1, 2010
TANF
Make all TANF minimum entries except Items 41 and 129.
Item 01 – Enter case number of the case denied in error.
Item 32 – Enter each individual's previous client number.
Item 46 – Enter each individual's medical effective date as the day after the date the erroneous denial became effective.
Item 132 – Enter
- Code 090 if the Medicaid end date is before the current process month, or
- Code 055 if the Medicaid end date is during or after the current process month.
Item 136 – Enter the Medicaid end date.
Item 138 – Enter the reason for transfer to TP 07 or TP 20.
Item 164 – Enter the three-digit code for the individual's county of residence. See C-350.
C—624.4 TP 37 (12 or 18 Months Medicaid) for a Case Previously Denied in Error
Revision 10-1; Effective January 1, 2010
TANF
Make all TANF minimum entries except Items 41 and 129.
Item 01 – Enter case number of the case denied in error.
Item 32 – Enter each individual's previous client number.
Item 46 – Enter each individual's medical effective date as the day after the date the erroneous denial became effective.
Item 132 – Enter
- Code 090 if the Medicaid end date is before the current process month, or
- Code 050 if the Medicaid end date is during or after the current process month, or
- Code 054 to reinstate a denied household that meets the requirements in A-800.
Item 149 – Enter Code 9 for the 90% Earned Income Deduction (EID).
Item 151 – Enter the original date of the 90% EID. Do not enter a dollar amount in Item 152.
Item 164 – Enter the three-digit code for the individual's county of residence. See C-350.
C—624.5 Reinstatement for Post Medicaid (TP 20), Transitional Medicaid (TP 07 or 37), or TP 29
Revision 10-1; Effective January 1, 2010
TANF
Make all TANF minimum entries.
Item 01 – Enter the previous case number.
Item 08 – Enter the first day of the month of reinstatement.
Item 46 – Enter each individual's medical effective date.
Item 131 – Enter Type Review Code C.
Item 132 – Enter Code 054 or Code 090.
Item 136 – TP 07, TP 20, or TP 29: Enter
- the original end date as shown on SAVERR, or
- an earlier end date, when applicable, when using Code 090.
Item 138 – Enter
- S for TP 20, or
- E or B for TP 07.
Item 151 – Enter the original date of the 90% EID. Do not enter a dollar amount in Item 152.
Item 164 – Enter the three-digit code for the individual's county of residence. See C-350.
Note: SAVERR edits prevent the actions listed below when Code 054 is used in Item 132. Therefore, use Form H1000-B turnaround to
- add a person.
- correct the end date of the original TP 07, TP 29, or TP 37 period. Change the end date only if it was incorrect when the case originally transferred to transitional Medicaid.
C—625 Miscellaneous Certification Entries
Revision 02-3; Effective April 1, 2002
C—625.1 Certifying Benefits for the Month After Certification
Revision 02-3; Effective April 1, 2002
TANF
Make all minimum TANF entries.
Item 46 – Enter first calendar day of the month after the application month.
Item 129 – Enter first calendar day of the month after the application month.
Note: Do not make future grant or medical effective dates for TANF more than one month past the future cutoff month.
C—625.2 Certifying a TP 29 Case
Revision 02-3; Effective April 1, 2002
TANF
Certify only one individual on each TP 29 case.
Item 40
- For the individual being certified on TP 29 enter
- SIG 8G if the individual was SIG 8 on the TANF case, or
- SIG 7G if the individual was SIG 7 on the TANF case.
- For other household members listed on the case enter
- SIG 0 or 2Y for an adult, or
- SIG 2, 2I, 2IT, 2IU, 2W, or 3 for a child.
Note: The case must be include a SIG 2, 2W, or 3 for the caretaker or second parent to be certified.
Item 127 – Enter Type Program 29.
Item 132 – Enter opening Code 057 on Form H1000-A, Notice of Application, or code 121 on Form H1000-B, Record of Case Action.
Item 136 – Enter the Medicaid end date.
C—625.3 Independent Child as the Case Name When a Representative from a Child Care Facility Applies for the Child
Revision 02-3; Effective April 1, 2002
Medical Programs
Make all minimum entries for the appropriate type program.
Item 13 – Enter the child's residence or, upon request, the address of the child care facility located near the child.
Item 25 – Enter the BJN's county code.
Item 26 – Enter the name of the child care representative as representative payee.
Item 271 – Enter Code R.
Item 40 – Enter SIG Code 8 to designate the child as case name.
Item 164 – Enter the child's residence county code.