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(Revised 4/1/12 ML #3325)
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Purpose: To notify Medical Services/HCBS an HCBS case has closed or was transferred to another county. This form is to be completed for closures related to SPED, ExSPED, Medicaid Waiver for Aged & Disabled and/or Medicaid Waiver for Traumatic Brain Injured.
If a Medicaid Waiver case closes, in addition to the SFN 474, the SFN 1288, CSSB Request for HCBS NF Determination, must also be completed in order to close the SNF screening.
In the first section, always complete the County name and Case Manager section even if submitting the form to transfer a case.
Closure/Denial Section: Print the client’s last, first, and middle name; record the applicable program identification number, date of closure, and the closure code. The closure codes are identified in the “Closure Codes” section of the form.
Transfer Case to Another County Section: Print the client’s last, first, and middle (initial) name; record the applicable identification number, the date of transfer to another county, the receiving county name, and the client’s new address (if known).
Medical Services/HCBS will process a stop date in the outgoing county’s eligibility line in the payment system. A start date for the incoming county will not be processed until the new case manager indicates when the client can begin services by forwarding a complete SFN 676 or 677. Once Medical Services receives the transfer notice, they will contact the incoming county to alert them the notice has been received.
Transfer/Start Date field is for the State Office to complete.
Provider Termination: If the client's case is closing/transferring and the provider of that client is no longer continuing as a Qualified Service Provider, complete this section and Medical Services/HCBS will process the documentation in order to close the QSP provider file. If, however, the QSP is continuing and providing care to others or moves with the client, do not complete this section.
The new HCBS Case Closure/Transfer Notice is due to Medical Services/HCBS within 3 working days of the date of closure. If the case is to be transferred, the form is due to Medical Services/HCBS within 3 working days from the date the County is made aware that the case is transferring to another County.
This form is not available from the state office. It is electronically available through the state’s e-forms.