(Revised 6/1/17 ML #3515)
View Archives
Purpose: To notify Aging Services/HCBS an HCBS case has closed or was transferred to another county OR To take action on a level of care screening for a Medicaid Wavier case that would temporarily or permanently end a screening or to reopen a current screen.
When Prepared:
This form is to be completed for closures related to SPED, ExSPED, Medicaid Waiver for Aged & Disabled.
Steps of Completion:
In the first section, always complete the County name and Case Manager section even if submitting the form to transfer a case. Also complete the Client Name: Record the first and last name.
ID Number: Record the Medicaid recipient identification number.
Waiver reopen-close section:
Reopen Current Screening effective date: Record the date the Waiver services are to begin. This line is used when a previous Waiver client was screened skilled nursing facility level of care, the individual was admitted to a facility or received services from a non-Waiver services, and now the individual will be transitioning back to the Waiver services. If the initial screening had expired during the individual's stay in the facility or while seeking other services, a new HCBS screening would be required and this form would not be completed/submitted;
Termination/Closure effective date: Use this line for closures/terminations that may occur due to ineligibility, death, or other that is not related to entering a nursing home or swingbed or Basic Care facility. This will designate when the waiver services are to end.
Mark the correct funding source being closed, SPED/EXSPED or Waiver.
Closure/Denial Section: Enter date of closure, and the closure code. The closure codes are identified in the “Closure Codes” section of the form.
If Waiver Client is Closed Due to Death Section: Enter the location of waiver client’s death (home, hospital, etc.), cause of death, age of client at death or date of birth, and any additional information.
Transfer Case to Another County Section: Print the client’s last, first, and middle (initial) name; record the applicable ND identification number, the receiving county name, and the client’s new address (if known). Enter the date client is leaving current county and date client is entering new county.
Aging 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 Aging Services receives the transfer notice, they will contact the incoming county to alert them the notice has been received.
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 Aging 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 Aging Services/HCBS within 3 working days of the date of closure. If the case is to be transferred, the form is due to Aging 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.