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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.