DHS Patient Financial Services Staff Application Processing

MEDI-CAL

DHS Patient Financial Services Staff Application Processing

Release Date

02/11/2020

Section Heading

Purpose

To convert existing policy to new webpage- No concept changes.

Policy

Patient Financial Services (PFS) staff employed by the Los Angeles (L.A.) County Department of Health Services (DHS) conduct initial Medi-Cal (MC) application processing activities for individuals seeking medical treatment at the various DHS facilities throughout L.A. County.

“Initial processing” includes taking MC applications, assisting applicants in completing the application, providing information and referrals, obtaining required documentation to complete processing of the application, assuring that the information contained on the application form is complete, and conducting any necessary interviews. It does not include certifying the determination of eligibility or ineligibility.

MC applications processed by PFS staff must be reviewed and approved by Eligibility Supervisors (ES) employed by the Department of Public Social Services (DPSS) known as Hospital Certifiers (HCs), before the eligibility determination is considered complete.

Background

DPSS has assigned ESs to perform the duties of HCs at county hospitals for the purpose of reviewing the initial processing of MC applications by PFS staff. The HCs review applications and authorize the approval or denial of MC benefits in compliance with current eligibility requirements.

PFS staff and HCs are assigned to the following county hospital facilities:

Hospitals and Address

Los Angeles County USC Medical Center
1200 N. State Street (T1- 26) Los Angeles, CA 90033

Harbor - UCLA Medical Center
1000 W. Carson Street Torrance, CA 90509

Martin Luther King Jr. Outpatient Care Center
1670 E. 120th Street Los Angeles, CA 90059

Olive View – UCLA Medical Center
14445 Olive View Drive Sylmar, CA 91342

Rancho Los Amigos National Rehabilitation Center
7601 E. Imperial Highway Downey, CA 90242

High Desert Regional Health Center
335 E. Ave I Lancaster, CA 93535

Definitions

Terms and Descriptions

PFS Staff

Include:

Medi-Cal Clerical Support staff (i.e., Application Registration, Case Opening Clerk, Transfer Desk); Patient Financial Services Workers (PFSWs); Patient Financial Services Control Workers (PFSCWs); Patient Financial Services Supervisors (PFSSs); and Patient Financial Services Managers (PFSMs).

Hospital Certifier

DPSS ESs assigned to review the initial processing of MC applications taken by PFS staff. The HCs review and authorize the approval or denial of MC benefits in compliance with current eligibility requirements.

Single Streamlined Application (SSApp) (CCFRM604)

The SSApp is used to apply for a range of affordable health care coverage options, including free or low-cost MC. This form collects individual demographics, income, tax household information, and other information needed to determine eligibility to health care programs.

Self-Attestation

A formal declaration by an applicant/beneficiary that information is true and correct.

Federal Data Service Hub (FDSH)

The electronic verification system that is used to compare and verify information with other State and federal systems during the eligibility determination process.

Electronic Verification (E-Verification)

Process of sending self-attested information to the FDSH for verification. If the attested information is electronically verified (e-verified) by the FDSH, then there is no need to request physical verification (e.g., check stubs) from the applicant/beneficiary.

Electronic Data Management System (EDMS)

EDMS stores electronic copies of documents submitted to the county as verification of the information needed for eligibility purposes. Documents placed in EDMS are stored in a secure repository and can be easily accessed and retrieved by authorized staff.

Determination Change Referral

Electronic referral received in LEADER Replacement System (LRS) when changes are reported by the applicant/beneficiary directly to Covered California (CoCA). Also known as Unsolicited Determination of Eligibility Response (U-DER).

Additional Income and Property Information Needed for Medi-Cal (MC 604 IPS)

This form captures the required property/assets, income, and expense information to evaluate the beneficiary for Non-Modified Adjusted Gross Income (Non-MAGI) MC.

Note: The signed MC 604 IPS must be returned along with the requested verification(s) within 30 days.

Requirements

Medi-Cal Evaluation

Individuals applying for MC at DHS facilities must be evaluated for all MC programs the individual is potentially eligible for. When an applicant is eligible for more than one program, and one is more beneficial than the other, the individual must be placed in the MC program that is most beneficial to him/her, unless the individual requests otherwise.

Note: DHS does not evaluate for all programs in the MC hierarchy (e.g., Pickle, Long-Term Care (LTC), Waivers, etc.). DHS is to expedite the transfer of these applications to the appropriate district office within DPSS.

Eligibility Certification

The State of California has mandated that only DPSS ESs assigned to its Hospital Certification Section can certify cases processed by DHS PFS staff.

Processing Timeframes

As mandated by federal and state processing standards, MC eligibility determinations must be completed within the following timeframes:

Application Type and Processing Timeframes

Non-Disability
Within 45 days following the date the application was filed unless there is good cause.

Disability
Processing Timeframes: Within 90 days following the date the application was filed, unless there is good cause.

Note: MC application processing begins the date the application is taken and ends the date the Notice of Action (NOA) is issued.

Disability Evaluations

Individuals claiming a disability must be evaluated for all MC programs following the established MC hierarchy including MAGI and Non-MAGI MC while a disability packet is submitted to the Disability Determination Service Division – State Programs (DDSD-SP).

Exceptions for Good Cause

The 45 and 90 day periods may be extended for any of the following reasons:

The applicant, the applicant’s guardian, or other person acting on the applicant’s behalf has been unable to return, due to a good cause, the completed SSApp, Supplemental to Statement of Facts for Retroactive Coverage/Restoration (MC 210A); MC 604 IPS if applicable; or necessary verifications in time for the county department to meet the promptness requirement; or
There has been a delay in the receipt of verification necessary to determine eligibility, and the delay is beyond the control of either the applicant or the county department (e.g., natural disaster, national/local emergency, mail service interruption, etc.).

Transfer of Approved Cases

Approved MC cases must be transferred to the DPSS district office of residence (nearest office to the applicant’s home) no more than 30 days after approval. The date or approval must be within the processing timeframe established by the Department of Health Care Services (DHCS) for Disability and Non-Disability cases.

Verification Docs

Information provided by the applicant on the SSApp that cannot be e-verified with the FDSH, or by ex-parte process, must be verified with actual documentation from the applicant (e.g., verification of income, expenses, property for Non-MAGI, etc.).

Attachments

N/A

DPSS ePolicy

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