Add New Record to MMIS Eligibility File (ExSPED), SFN 677 525-05-60-40

Add New Record to MMIS Eligibility File for Expanded SPED, SFN 677 525-05-60-40

(Revised 7/1/11 ML #3273)

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Purpose: In order for an individual to receive a ExSPED client identification number, to update client statistical information, or to begin applicant client eligibility for payment purposes.

For new applicants:

An Add New Record to MMIS Eligibility File form (SFN 677) must be submitted to the Medical Services Division along with the ExSPED Program Pool Data, SFN 56. This form is used to identify active ExSPED program recipients in the payment system. When billings are received from providers, the claim is checked against the ExSPED eligibility MMIS file.

For changes to statistical information or re-entry into the ExSPED Pool:

An Add New Record to MMIS Eligibility File form (SFN 677) must be completed if there is a change in the statistical information such as address or corrections to the Social Security Number or birthdate.


ITEM
ORIG.	In the first two boxes enter the initials of the person completing the form; in the last two boxes enter the county number. (This information will be used in contacting the county should there be questions about the information on the form.)
BASE ID:	This number is assigned and completed by the Medical Services/HCBS. The number will begin with 550; IT WILL BE UNIQUE TO THE EXPANDED SPED PROGRAM RECIPIENTS. ALL BILLING UNDER THE EXPANDED SPED PROGRAM WILL REQUIRE THE USE OF THIS NUMBER. NO MEDICAID NOR SOCIAL SECURITY NUMBERS WILL BE USED. If the person was previously assigned an Expanded SPED Program number, the county should enter that number OR advise the Medical Services/HCBS that a number was previously issued. Only one MMIS record is to be established per person under the Expanded SPED Program.
NAME:	Print the client's last name, first name and middle initial in spaces provided.
ADDRESS:	Mailing address of the client.
ZIP CODE:	Enter the remainder of the zip code. The "58" is preprinted because all zip codes in North Dakota begin with those numbers.
RACE:	Enter the most appropriate code: 1 = White 2 = Native American 3 = Black 4 = Asian 5 = Hispanic 6 = Southeast Asian
SEX:	Enter the code: 1 for Male; 2 for Female
BIRTH DATE:	The first two boxes (mm) are for the month, the second two boxes are for the day (dd), the next two for the century (cc), and the last two boxes are for the year (yy). July 20, 2005 is entered as 07202005.
APPL. DATE:	Enter the date the most recent assessment was completed. The date is two digits for the month, two for day, two for century, and two for year. July 4, 2005 is entered as 07042005.
CASE NO:	Same as BASE ID. (Medical Services/HCBS will complete.)
SSN (Numeric Only):	Enter the client's social security number. DO NOT USE DUMMY NUMBERS. The client must provide their Social Security numbers as a condition of Medicaid eligibility.
AID CATEG:	Enter applicable code: 01 = Aged (65 years of age or older) 04 = Disabled (under age 65)
PHY. CNTY:	Enter the two digit code for county of client’s physical residence.
MEDICAL (EXPANDED SPED) APPR. DATE:	Expanded SPED Program effective date will be completed by the Medical Services/HCBS. (Unless, the individual is an exception to the ExSPED Pool pull. If an exception date is granted, the date ExSPED services are to begin should be recorded and a note stating the exception should be written at the bottom of the form.)
DIAG:	Enter the two digit code if applicable. If the client has more than the maximum of three conditions, enter those that most affect the need for services. 10 = AIDS/HIV Positive 11 = Alzheimer’s/Dementia 12 = Arthritis/Rheumatism/ Degenerative Joint Disease 13 = Cancer, NOT TERMINAL 14 = Closed Head Injured 15 = Diabetes, INSULIN DEPENDENT ONLY 16 = Discharged from Hospital (Receiving HCBS for first time) 17 = Discharged from Nursing Home (Receiving HCBS for first time) 18 = Heart (Receiving treatment/ medications for) 19 = Incontinence 20 = Lung or respiratory disease 21 = Paralysis: Paraplegic, Quadriplegic, Hemiplegia 22 = Stroke/CVA (may or not have paralysis) 23 = Terminally Ill (NOT expected to live more than 6 months) 24 = Multiple Sclerosis 25 = Congenitally Disabled 26 = Diabetes, NON-INSULIN DEPENDENT (TYPE II) 27 = Parkinson's Disease 28 = Legally Blind 29 = Deaf 30 = Osteoporosis 31 = Neuro-muscular Disease OTHER THAN MULTIPLE SCLEROSIS 32 = Intellectual disability 33 = Mental Illness (SMI/CMI) 34 = Chronic Alcoholism 35 = Kidney Dialysis

ITEM

ORIG.

In the first two boxes enter the initials of the person completing the form; in the last two boxes enter the county number. (This information will be used in contacting the county should there be questions about the information on the form.)

BASE ID:

This number is assigned and completed by the Medical Services/HCBS. The number will begin with 550; IT WILL BE UNIQUE TO THE EXPANDED SPED PROGRAM RECIPIENTS. ALL BILLING UNDER THE EXPANDED SPED PROGRAM WILL REQUIRE THE USE OF THIS NUMBER. NO MEDICAID NOR SOCIAL SECURITY NUMBERS WILL BE USED.

If the person was previously assigned an Expanded SPED Program number, the county should enter that number OR advise the Medical Services/HCBS that a number was previously issued. Only one MMIS record is to be established per person under the Expanded SPED Program.

NAME:

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

ADDRESS:

Mailing address of the client.

ZIP CODE:

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

RACE:

Enter the most appropriate code:

1 = White

2 = Native American

3 = Black

4 = Asian

5 = Hispanic

6 = Southeast Asian

SEX:

Enter the code: 1 for Male; 2 for Female

BIRTH DATE:

The first two boxes (mm) are for the month, the second two boxes are for the day (dd), the next two for the century (cc), and the last two boxes are for the year (yy). July 20, 2005 is entered as 07202005.

APPL. DATE:

Enter the date the most recent assessment was completed. The date is two digits for the month, two for day, two for century, and two for year. July 4, 2005 is entered as 07042005.

CASE NO:

Same as BASE ID. (Medical Services/HCBS will complete.)

SSN (Numeric Only):

Enter the client's social security number. DO NOT USE DUMMY NUMBERS. The client must provide their Social Security numbers as a condition of Medicaid eligibility.

AID CATEG:

Enter applicable code:

01 = Aged (65 years of age or older)

04 = Disabled (under age 65)

PHY. CNTY:

Enter the two digit code for county of client’s physical residence.

MEDICAL (EXPANDED SPED) APPR. DATE:

Expanded SPED Program effective date will be completed by the Medical Services/HCBS. (Unless, the individual is an exception to the ExSPED Pool pull. If an exception date is granted, the date ExSPED services are to begin should be recorded and a note stating the exception should be written at the bottom of the form.)

DIAG:

Enter the two digit code if applicable. If the client has more than the maximum of three conditions, enter those that most affect the need for services.

10 = AIDS/HIV Positive

11 = Alzheimer’s/Dementia

12 = Arthritis/Rheumatism/
Degenerative Joint Disease

13 = Cancer, NOT TERMINAL

14 = Closed Head Injured

15 = Diabetes, INSULIN DEPENDENT
ONLY

16 = Discharged from Hospital
(Receiving HCBS for first time)

17 = Discharged from Nursing Home
(Receiving HCBS for first time)

18 = Heart (Receiving treatment/
medications for)

19 = Incontinence

20 = Lung or respiratory disease

21 = Paralysis: Paraplegic,
Quadriplegic, Hemiplegia

22 = Stroke/CVA (may or not have
paralysis)

23 = Terminally Ill (NOT expected to
live more than 6 months)

24 = Multiple Sclerosis

25 = Congenitally Disabled

26 = Diabetes, NON-INSULIN
DEPENDENT (TYPE II)

27 = Parkinson's Disease

28 = Legally Blind

29 = Deaf

30 = Osteoporosis

31 = Neuro-muscular Disease OTHER
THAN MULTIPLE SCLEROSIS

32 = Intellectual disability

33 = Mental Illness (SMI/CMI)

34 = Chronic Alcoholism

35 = Kidney Dialysis

This completed form is to be mailed to the Medical Services/HCBS at the same time the Expanded SPED Program Data form is submitted.

The form, SFN 677, is not available from the state office. An electronic copy is available through the state e-forms.

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