Form H1217, Quality Assurance Monitoring System

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Documents

Effective Date: 6/2002

Instructions

Updated: 5/2001

PURPOSE

  • To serve as a guide in case reading.
  • To provide a means of collecting data for the Quality Assurance Monitoring System (QAMS).
  • To provide a means for documenting worker performance and corrective action on a specific case.
  • To provide a means of collecting data for the Quality Control Waiver pilot project.

PROCEDURE

When to Prepare

Regional staff appointed to read cases must prepare Form H1217 on each case read.

For QAMS purposes, the case reader must complete Form H1217 for each case designated by state office as part of the QAMS sample.

Regions may complete Form H1217 for all cases being read and report the findings on the region/worker specific automated QAMS report. However, only the designated sample results must be entered into the automated system.

Number of Copies

Form H1217 is a three-part carbonless form.

Transmittal

The case reader distributes Form H1217 based on regional needs.

For QAMS purposes, the case reader sends the original Form H1217 to the designated regional data entry site, where it will be entered on the region's QAMS monthly case reading report. (This report is on MAPPER.) Regions must ensure that this data is entered by the ninth of the month after the cases are read. The case reader distributes the remaining copies at regional discretion.

Form

A copy of Form H1217 must accompany the case record for validation case reading. Form H1217 is to be kept in the Unit or Worker Assessment file. Do not file Form H1217 in the case record.

DETAILED INSTRUCTIONS

1. Case Name— Self-explanatory. Required computer entry.

2. Worker Name— Self-explanatory. Computer-entered only on Region/Worker Report. Optional if employee number is used.

3. Empl. No.— Employee number. Self-explanatory.

4. Case No.— Self-explanatory. Required computer entry.

5. Trans.— Transaction and Denial Codes. For QAMS, the transaction code should correspond to the code on the sample list. For QAMS, read only the transaction on the QAMS list. Do not score this form for other case transactions not found on the QAMS list when reading a QAMS list transaction. (For example, QAMS list reflects TP 14-10 SLMB. Read only the ongoing transaction. If prior SLMB is incorrect, record in Item 24 and assign a due date. If QAMS list reflects TP 14-10 SLMB and 090-SLMB, you must read each on a separate Form H1217.) For other case reading purposes, the transaction code should correspond with the transaction being read. Required computer entry. Codes and their meanings are:

1 = Granted Application
2 = Sustained Review
3 = Denied Application
4=Denied Review

6. Case Read By — Self-explanatory.

7. Date Read — Self-explanatory.

8. Trans. Date — Transaction Date. Enter the date Form H1000 A/B was processed. For QAMS, this date should correspond with the date on the sample list.

9. Reg. — Region/Unit. Enter the region and the unit to which the case is assigned. For QAMS, if the case has been transferred since being worked, the region and unit that worked the requested transaction should be listed. Required computer entry.

10. TP — Type Program. Self-explanatory. Required computer entry.

10a. BP — Base Plan. Self-explanatory. Required computer entry.

11. Client Type — Code as follows:

1 = Individual
2 = Couple
3 = Companion
4 = Spousal

12. Case Reader Emp. No. — Self-explanatory. Four-digit computer entry required.

13. Was MAO eligibility decision correct? — Pertains to eligibility decision on applications and reviews. Enter "N/A" when reading Medicare Programs Only. Medicare Program eligibility decisions are scored in Item 14. Computer entry required.

1 "Yes" For correct eligibility MAO decision
2 "No" For incorrect eligibility MAO decision
3 "N/A" If you are reading only a Medicare Program

If "No" is scored for this item, score Items 15 - 21 "N/A" pertaining to MAO elements.

Example: Reading a single program, MAO is N/A and MP is correct.

Item Number MAO - N/A Medicare Program (MP) - correct
13 Code "N/A" Does not apply
14 Does not apply Code "Yes"
15 Code "N/A" Does not apply
16 Code "N/A" Does not apply
17 Does not apply Score for MP, Code "N/A" for reviews
18 Does not apply Score for MP
19 Does not apply Score for MP
20 Code "N/A" Does not apply
21 Code "N/A" Does not apply
22 Does not apply Score for MP
23 Does not apply Score for MP

Example: Reading a single program, MAO is "N/A" and MP is incorrect.

Item Number MAO - N/A Medicare Program (MP) - incorrect
13 Code "N/A" Does not apply
14 Does not apply Code "No"
15 Code "N/A" Does not apply
16 Code "N/A" Does not apply
17 Does not apply Code "N/A"
18 Does not apply Code "N/A"
19 Does not apply Code "N/A"
20 Code "N/A" Does not apply
21 Code "N/A" Does not apply
22 Does not apply Score for MP
23 Does not apply Score for MP

Example: Reading dual programs, MAO is correct and MP is correct.

Item Number MAO - correct Medicare Program (MP) - correct
13 Code "Yes" Does not apply
14 Does not apply Code "Yes"
15 Score for MAO Does not apply
16 Score for MAO Does not apply
17 Does not apply Score for MP
18 Does not apply Score for MP
19 Score for MAO Score for MP
20 Score for MAO Does not apply
21 Score for MAO Does not apply
22 Score for MAO Score for MP
23 Score for MAO Score for MP

Example: Reading dual programs, MAO is incorrect and MP is incorrect.

Item Number MAO - incorrect Medicare Program (MP) - incorrect
13 Code "No" Does not apply
14 Does not apply Code "No" *
15 Code "N/A" Does not apply
16 Code "N/A" Does not apply
17 Does not apply Code "N/A"
18 Does not apply Code "N/A"
19 Code "N/A" Code "N/A"
20 Code "N/A" Does not apply
21 Code "N/A" Does not apply
22 Score for MAO Score for MP
23 Score for MAO Score for MP

* If "No" for the same reason, score "N/A" for Item 14 and "No" for Item 13. If "No" for different reasons, score "No" for both Items 13 and 14.

Example: Reading dual programs, MAO is correct and MP is incorrect.

Item Number MAO - correct Medicare Program (MP) - incorrect
13 Code "Yes" Does not apply
14 Does not apply Code "No"
15 Score for MAO Does not apply
16 Score for MAO Does not apply
17 Does not apply Code "N/A"
18 Does not apply Code "N/A"
19 Score for MAO Code "N/A"
20 Score for MAO Code "N/A"
21 Score for MAO Code "N/A"
22 Score for MAO Score to indicate eligible error, if appropriate
23 Score for MAO Score to indicate eligible error, if appropriate

Example: Reading dual programs, MAO is incorrect and MP is correct.

Item Number MAO - incorrect Medicare Program (MP) - correct
13 Code "No" Does not apply
14 Does not apply Code "Yes"
15 Code "N/A" Does not apply
16 Code "N/A" Does not apply
17 Does not apply Score for MP
18 Does not apply Score for MP
19 Code "N/A" Score for MP
20 Code "N/A" Does not apply
21 Code "N/A" Does not apply
22 Score to indicate eligible error, if appropriate Score for MP
23 Score to indicate eligible error, if appropriate Score for MP

13a. Cause of eligibility finding:— Answered if Item 13 was coded "No." Score the standard that caused the finding:

1 — Income
2 Resources
3 "Other" If budget problem, use "other" as cause. Note: This is when the income or resource elements were developed and the correct values were assigned, but the value did not transfer correctly into the budget areas (eligibility and AI/Co-Pay).

14. Was Medicare Program eligibility decision correct?— All cases are scored for this eligibility decision. Computer entry is required in all cases.

1 "Yes" If the eligibility decision was correct.
2 "No" If the eligibility decision was incorrect.
3 "N/A"

14a. Cause of eligibility finding:— Answered if Item 14 was coded "No." Score the standard that caused the finding:

1 — Income
2 Resources
3 Other - If budget problem, use "other" as cause. Note: This is when the income or resource elements were developed and the correct values were assigned, but the value did not transfer correctly into the budget areas (eligibility and AI/Co-Pay).

15. Were prior MAO effective dates correct? — (Prior eligibility effective dates are those prior to the month of application. Ongoing eligibility effective dates are those beginning with the month of application and any thereafter.) Pertains to medical effective dates or start of care dates determined for prior coverage. If more than one prior eligibility date, consider all either correct or incorrect. Computer entry required in all cases. Score "N/A" on denials and reviews. If Item 13 is scored "No," score this element as "N/A."

1 — Yes
2 — No
3 — N/A

15a. Cause of effective date finding:— Answered if Item 15 was coded "No." Score the standard that caused the finding:

1 — Income
2 — Resources
3 — SNF/NF Admit Date
4 — CBA Start Date
5 — Medical Bills
6 — Other

16. Were ongoing MAO effective dates correct?— Pertains to medical effective dates or start of care dates for ongoing coverage. Ongoing effective dates are those beginning with the month of application and any thereafter. Computer entry required in all cases. Score "N/A" on denials and reviews. If Item 13 is scored "No," score this element as "N/A."

1 — Yes
2 — No
3 — N/A

16a. Cause of effective date finding:— Answered if Item 16 was coded "No." Score the standard that caused the finding:

1 — Income
2 — Resources
3 — SNF/NF Admit Date
4 — CBA Start Date
5 — Medical Bills
6 — Other

17. Were prior Medicare Program effective dates correct? — Prior effective dates are those prior to the month of application. Computer entry required in all cases. Score "N/A" on denials and reviews. If Item 14 is scored "No," then score this element as "N/A."

1 — Yes
2 — No
3 — N/A

17a. Cause of effective date finding:— Answered if Item 17 was coded "No." Score the standard that caused the finding:

1 — Income
2 — Resources
3 — Continuous QMB
4 — QI Calendar Year
5 — No Medicare
6 — Other

18. Were ongoing Medicare Program effective dates correct? — Ongoing effective dates are those from the month of application and any thereafter. Computer entry required in all cases. Score "N/A" on denials and reviews. If Item 14 is scored "No," then score this element "N/A."

1 — Yes
2 — No
3 — N/A

18a. Cause of effective date finding:— Answered if Item 18 was coded "No." Score the standard that caused the finding:

1 — Income
2 — Resources
3 — Continuous QMB
4 — QI Calendar Year
5 — No Medicare
6 — Other

19. Were client's rights procedures followed?— Answer and computer entry required on all cases. Score "N/A" if no notifications were required, such as reviews or denial due to death. Score each notice (next to form number listed) associated with the correctly determined QAMS transaction that is being read. If Form H1230 was also used to notify the client of QMB eligibility, score "Yes" for Form H1230 and "Yes" for Form H1207. (If an MAO and MP eligibility information was sent to the client via Form H1230 and the MAO is ineligible and MP eligible, do not score Form H1230. In this case, score Form H1207 only as correct.) If you are reading an incorrect eligibility decision on a single type program, score "N/A."

1 — Correct = If the notice was correct.
2 — Inaccurate Notice = If the notice was the wrong notice, or contained inaccurate or incomplete information. (For example, MED decision = 11/1/00 and the notice says 12/1/00.)
3 — No Notice = If no notice was sent but was required.
4 — Wrong Notice = If the notice was an inaccurate form number and contained inaccurate information. (For example, denial notice used to grant eligibility or certification notice used when actually denying an applicant/client.)
5 — 12 Day Hold = If the 12-Day Hold was not allowed.
6 — Invalid Admin. Denial = If it was an administrative denial.

20. Were prior AI/Co-Pay amounts correct? — Prior AI/Co-Pay amounts are those prior to the month of application. If more than one prior AI/Co-Pay amount, consider all either correct or incorrect. If Item 13 is scored "No," then score this element as "N/A."

1 — Yes, when all prior applied income/co-pay budgets were correctly determined or incorrectly determined by $4.99 or less.
2 — No, when any prior applied income/co-pay budgets were incorrectly determined by $5 or more.
3 — N/A, when there are no prior applied income/co-pay budgets.

20a. Error caused by: —

1 — Variable Income - When VI was miscalculated.
2 — Incurred Medical - When either an incorrect Incurred Medical Expense (IME) was allowed or an IME was not allowed and should have been.
3 — Income - When income other than variable income, IME caused an AI error.
4 — Spousal - When diversion was incorrectly determined, resulting in an incorrect applied income. Does not apply when spousal diversion was incorrectly determined but did not impact applied income.
5 — Other - Use when AI/Co-Pay was incorrect for reasons other than those listed Items 1 through 4.

21. Were ongoing AI/Co-Pay amounts correct? — Ongoing AI/Co-Pay amounts are those from the month of application and any thereafter. If Item 13 is scored "No," then score this element as "N/A."

1 — Yes, when all ongoing applied income/co-pay budgets were correctly determined or incorrectly determined by $4.99 or less.
2 — No, when any ongoing applied income/co-pay budgets were incorrectly determined by $5 or more.
3 — N/A, when there are no ongoing applied income/co-pay budgets.

21a. Error caused by —

1 — Variable Income - When VI was miscalculated.
2 — Incurred Medical - When either an incorrect IME was allowed or an IME was not allowed and should have been.
3 — Income - When income other than variable income, IME caused an AI error.
4 — Spousal - When diversion was incorrectly determined, resulting in an incorrect applied income. Does not apply when spousal diversion was incorrectly determined but did not affect applied income.
5 — Other - Use when AI/Co-Pay was incorrect for reasons other than those listed Items 1 through 4.

22. Was income correct?— Score each element in income involved in the case transaction being read. If an element does not exist, leave it blank.

This area is scored regardless of how Item 13 and 14 are scored.

1 — Correct - If the element was determined accurately when establishing the eligibility decision.
2 — Error - This is an error that requires correction within 30 days. This can be misapplied policy error which appears not to affect eligibility, MED or applied income. A verification/documentation error — When a particular element was not verified and/or documented according to the Verification Documentation Guide or per a regional improvement plan, but does not appear to have an adverse affect on the outcome of the case, applied income, or MED. This also includes elements that need additional work where the reader is unable to determine the outcome. This code automatically triggers correction required and mandatory entry in Item 25.
3 — Requires Development - This is an element that needs additional work, where there is enough information to make a decision of no impact but does not meet the Verification/Documentation standards of Appendix XVI. Correction within 30 days is optional but probably should be requested. It will be recorded in Item 24 and a date is entered in Item 26.
4 — Eligibility Cause - This is an element that has been identified as causing the case to be ineligible or cause the worker to determine the case incorrectly ineligible. Correction is required based on the eligibility call. Check box in Item 25 for "correction required."
5 — MED Cause - This is an element that was identified as causing an MED error. Correction is required based on the MED error call. Check box in Item 25 for "correction required."
6 — Applied Income/Co-Pay Cause (is not an option in resources) - Element that was identified as causing an applied income or co-pay error. Correction is required based on the AI/CP call. Check box in Item 25 for "correction required."

23. Were resources correct?— Score each element in resources involved in the case transaction being read. If an element does not exist, leave it blank.

This area is scored regardless of how Items 13 and 14 are scored.

1 — Correct - If the element was determined accurately when establishing the eligibility decision.
2 — Error - This is an error that requires correction within 30 days. This can be misapplied policy error that does not appear to affect eligibility, MED, or applied income. A verification/documentation error — This is when a particular element was not verified and/or documented according to the Verification Documentation Guide or per a regional improvement plan, but does not appear to have an adverse affect on the outcome of the case, applied income, or MED. This also includes elements that need additional work where the reader is unable to determine the outcome. This code automatically triggers correction required and mandatory entry in Item 25.
3 — Requires Development - This is an element that needs additional work, where enough information to make a decision of no impact but does not meet the Verification/Documentation standards of Appendix XVI. Correction within 30 days is optional but probably should be requested. It will be recorded in Item 24 and a date is entered in Item 26.
4 — Eligibility Cause - This is an element that has been identified as causing the case to be ineligible or cause the worker to determine the case incorrectly ineligible. Correction is required based on the eligibility call. Check box Item 25 for "correction required."
5 — MED Cause - This is an element that was identified as causing an MED error. Correction is required based on the MED error call. Check box in Item 25 for "correction required."

24. Other Correction— For use when an item in Income or Resources has been scored by the reader/region as: 3 - Requires Development - unable to determine the outcome. It can also be used for recording any non-QAMS errors. Correction within 30 days is optional and will be recorded in this item.

25. Correction Required— Check box when an error is identified and the case requires correction.

26. Due Date— Enter due date (not to exceed 30 days) of correction.

27. Error Correction Date— Enter the date when the error was actually corrected.