2752 DCH Presumptive Reports | Medicaid

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

DCH Presumptive Reports

Effective Date:

June 2020

Chapter:

2700

Policy Number:

2752

Previous Policy Number(s):

MT 48

Updated or Reviewed in MT:

MT-60

Requirements

DCH notifies DFCS of Presumptive Eligibility determinations and Newborn enrollments through the issuance of four periodic reports. DFCS is required to act on these reports.

Basic Considerations

Certain “qualified providers” are authorized to perform eligibility determinations for pregnant women and most participating providers can enroll Deemed Newborns into Medicaid. DCH notifies DFCS of Presumptive Eligibility Determinations and Deemed Newborn enrollments through the issuance of four periodic Presumptive Eligibility reports. All four reports are available to local DFCS and Right from the Start Project offices on-line at www.mmis.georgia.gov.

The reports are an effective management tool. Proper handling and updating of the information contained on the reports ensure correct closure of Presumptive Eligibility and deemed newborn records when pregnant women and infants are approved under regular categories of medical assistance. Linkage of provider generated member ID numbers to GA Gateway generated client and assistance unit identification numbers eliminates duplication of records and facilitates the Medicaid claims payment process.

Pregnant Women

In order to eliminate barriers to health care and to expedite enrollment into the Medicaid program, qualified hospitals participating in the Hospital Presumptive Eligibility (HPE) program and the following “qualified providers” are authorized to perform temporary or presumptive eligibility determinations for pregnant women:

Public Health (PH) Departments
federally qualified health centers
rural health centers
Grady Hospital

These providers have the capacity to enter, or have entered for them by DCH’s fiscal agent, eligibility information directly into the GAMMIS system. The report produced as a result of these eligibility determinations:

Presumptive Pregnant Add Report

This report is generated monthly and shows the names of pregnant women determined presumptively eligible for Medicaid by “qualified providers”. Information on this report includes the date the pregnant woman’s eligibility was added to GAMMIS, her member identification number, her beginning date of eligibility, her date of birth and her address.

Newborns

An infant, born to a woman receiving Medicaid on the day the infant is born, qualifies for Deemed Newborn Medicaid until it reaches its first birthday. There is no separate eligibility determination and most Medicaid participating providers can enroll a deemed newborn into the program. These provider enrollments generate the following two reports:

Presumptive Newborn Add Report

This report is generated monthly and shows the names of deemed newborns added to GAMMIS as a result of enrollment by a Medicaid participating provider. Information on this report include the deemed newborn’s name, member identification number, the date the newborn was added, the beginning date of eligibility, the deemed newborn’s date of birth, and the mother’s name and address.

Presumptive Newborn Non-Confirmation Report

This report is generated monthly and shows all entries from the Presumptive Newborn Add Report that are over 30 days old and no action has been taken.

Although the Newborn reports are labeled as Presumptive, there is no presumptive eligibility program or process for newborns. These children are deemed newborns and are not limited to Family Medicaid or ABD Medicaid. They also include deemed newborns born to a mother receiving SSI Medicaid, Women’s Health Medicaid, and PeachCare for Kids®.

Procedures

When DFCS receives the Presumptive Eligibility and Newborn reports, they should act on the cases and notify DCH of the correct client ID and case number. Notification is accomplished by accessing and updating information through the GAMMIS system.

Pregnant Women

Either report can be used to update the GAMMIS system. Information pertaining to the pregnant woman is on the web portal. Entry of the member identification number, as shown on either report, in the Member Identification field of the View/Update Presumptive Eligibility screen of the web portal, allows access to her data record.

Step 1

“Qualified providers and qualified hospitals” send a Presumptive Eligibility (P.E.) packet to the RSM Project or local county DFCS office. This packet contains the DFCS copy of the PE application, an application for Healthcare coverage, and supporting documents.

Step 2

Register the application in GA Gateway, using the application date contained on the documents in the P.E. packet. This is the date the woman applied for Medicaid with the “qualified provider”. This date will be the same as the ADDED DT on the report. If there is a discrepancy in the date on the application and the ADDED DT, register the application using the ADDED DT. This is the date eligibility information was added to GAMMIS. Do NOT require an additional signed Healthcare coverage application.

Step 3

Access View/Update of Presumptive Eligibility* screen on the GAMMIS web portal to update and link the member ID and GA Gateway identification numbers.

It is not mandatory for the update to occur at application registration. However, it must occur before or on the same day the case is approved or denied in GA Gateway.

Step 4

Using SDX/BENDEX, DOL, related cases, and information in the PE packet, determine eligibility for Pregnant Woman Medicaid or other appropriate COA. Contact the client when information needs to be clarified or to obtain missing information.

If the applicant has children, screen for potential Parent/Caretaker with Child(ren), Children Under 19 Years of Age, or PeachCare for Kids® eligibility.

Step 5

Approve or deny the case and document the case record within 10 days of receipt of the report. If linkage of member ID and GA Gateway identification numbers did not occur after application registration, it must occur the same day the case is either approved or denied on GA Gateway.

Step 6

Notify the A/R of the eligibility decision.

Newborns

Either report can be used to update the GAMMIS system. Information pertaining to the newborn is on the web portal. Entry of the infant’s member identification number in the View/Update Presumptive Eligibility screen on the portal allows access to the data record.

Step 1

The infant is enrolled by the provider. The county office will not receive an application or packet. For most providers, enrollment is an on-line, paperless process.

Step 2

Register an application on GA Gateway for the deemed newborn using the date of birth from either Newborn list. Do NOT require a signed Healthcare coverage application.

Step 3

Access View/Update of Presumptive Eligibility screen on the GAMMIS web portal to update and link the member ID and GA Gateway identification numbers.

This is not mandatory for newborns added to GA Gateway through the automation process. However, if a newborn is being added manually by the eligibility specialist the linking must occur before or on the same day the case is approved or denied in GA Gateway.

Step 4

Confirm that the deemed newborn’s mother correctly received Medicaid on the deemed newborn’s date of birth. If the mother correctly received Medicaid, proceed to Step 5. If Medicaid was not received, or was incorrectly received, deny Deemed Newborn Medicaid and complete a CMD.

The ‘correctly receiving' criterion is met if the mother is approved for Medicaid after delivery and the approval includes the delivery date.

Step 5

Confirm that the deemed newborn continues to reside in the state of Georgia. There is no reason to contact the parent or caretaker for that information if the child is on the newborn list, unless DFCS has information to the contrary.

In situations where the deemed newborn does not reside with the birth mother, process eligibility following the steps for when a child lives with a female or male caretaker/relative.

Step 6

Step 7

Notify the A/R of the eligibility decision.

Currently there is an automated process that adds newborns' Medicaid eligibility to GA Gateway via a daily interface file from GAMMIS. For newborns that could not be added through this automation due to exceptions or were not received in the file, they will be added using the steps 1-7 described above.

Non-Confirmation reports

Non-confirmation reports are generated as a result of member identification numbers not being linked to GA Gateway (client and assistance unit) identification numbers. To eliminate cases from this report, update the View/Update Presumptive screen on the GAMMIS web portal, after GA Gateway registration or on the same day the case is approved or denied in GA Gateway.

If problems are encountered during the update or linking process the worker should send an email to membernotification@dch.ga.gov to report the problem. The worker should include as much client demographic information as possible, including name, date of birth, SSN, member ID number and client ID number.

Other Considerations

GAMMIS/GA Gateway Linkage

The GA Gateway action of approving a case will generate a closure of the Presumptive Eligibility record in GAMMIS if the records are linked. If linkage does not occur at or before this point, the member could have two active records in the GAMMIS system.

GAMMIS will not allow for duplication of action. When successful linkage of a PE record to a GA Gateway record occurs, the system will not allow successive attempts to link the same records.

Incorrect County

If a county receives a list and determines that an individual(s) on the list resides in another county, the receiving county shall correct the address if necessary, and continue processing procedures.

Filing

All counties must keep a central file of all presumptive reports generated by DCH. The county shall annotate for each name any action taken. These reports should be kept by the county office for a period of one year, after which time they can be destroyed.

Case Records

Upload the following in each case record in DIS.

a copy of the Presumptive Eligibility (PE) packet and any verification sent from the hospitals and health departments. Refer to 2067 Presumptive Eligibility Medical Assistance for full list of items included in PE Packet.
any additional verification, if any, used to determine eligibility

The CMD process must be fully documented detailing application and information received in the PE packet in case notes.