Learn about the Medicaid 1115 Transformation Waiver Renewal.
For information about COVID-19, call 2-1-1 and select Option 6.
Find a COVID-19 testing site | COVID-19 vaccine | More COVID-19 information
Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
To notify Operations Coordination of:
- a gap in enrollment for STAR+PLUS managed care members;
- claims filed with the managed care organization (MCO) during an enrollment gap; and
- claims denied by the MCO.
To notify the MCO of:
- a gap in enrollment for managed care members;
- authorization to pay claims during a gap period; and
- a provider filing claims.
When to Prepare
The long-term services and supports provider completes the Provider Section when a member has a gap in managed care enrollment during a time frame when they are Medicaid eligible.
MCOs must keep records, documents and forms for a minimum of three years and 90 days after the end of the contract or case closure.
Name of Provider – Enter the name of the provider.
Contact Name – Enter the name of the contact.
Phone Number – Enter the contact's phone number.
Name of Member — Enter the name of the member.
Medicaid No. — Enter the member's nine-digit Medicaid number.
Dates of Service — Enter the begin and end dates of service.
Claim Filed with MCO? — Check "Yes" if the claim has been filed with the MCO; check "No" if the claim has not been filed with the MCO.
Name of MCO — Enter the name of the MCO.
Claim Denied?— Check "Yes" if the filed claim was denied; check "No" if the filed claim was not denied.
Reason for Denial — If the claim was denied, enter the reason for denial.
Operations Coordination Section
Date Received — Operations Coordination staff enter date the form was received from the provider.
Gap Confirmed — Operations Coordination staff check "Yes" if the gap is confirmed and "No" if it is not confirmed.
Gap Resolved — Operations Coordination staff check "Yes" if the gap is resolved and "No" if it is not resolved.
If not resolved, provide reason — If the gap is not resolved, document the reason it is not resolved.
This authorizes the MCO . . . — Operations Coordination staff add the dates of service and the name of the provider submitting the claim.
Date emailed to MCO — Enter the date the form was emailed to the MCO.
Estimated Risk Group — Enter the estimated risk group.
Note: Provider's claims must meet MCO claims requirements.
Date Received — Enter the date the form was received from the MCO.
Claim Adjudicated On — Enter the date the claim was adjudicated.