Form H1120, Medical Bills Transmittal

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Documents

Effective Date: 3/2021

Instructions

Updated: 3/2021

Purpose

To provide

  • MN Clearinghouse with information needed to determine spend down for clients.
  • client with information needed to submit medical bills to the Clearinghouse.

Procedure

When to Prepare

The advisor prepares two copies of the transmittal side of the card when an applicant must meet spend down to become Medicaid-eligible.

The client completes the insurance information side of the card when they submits medical bills to the Clearinghouse.

Number of Copies

Complete two originals in ink.

Transmittal

The advisor:

  • mails one card to the Texas Medicaid and Healthcare Partnership (TMHP) address: Spend Down Unit, PO Box 202947, Austin, TX 78720-2947; and
  • gives the client one card and a stamped envelope addressed to the Clearinghouse when the applicant must meet spend down to become Medicaid-eligible.

The client mails the card the first time he sends medical bills to the Clearinghouse.

Detailed Instructions

Complete only the transmittal side of the card.

Application No., Case Name, Date of Birth, Sex, and Address: Enter applicant identifying information.

TPR (private insurance): Check the appropriate box indicating whether the client or other household member(s) has health insurance.

Three Months Prior: Check the appropriate box indicating whether the client is applying for three months prior assistance. If yes, indicate which prior month the client is applying for and the spend down amount for that month in the Month, SD Amount section.

The client completes the insurance information side of the card.

Month, SD Amount: Indicate the month(s) and spend down amount(s) for which the client is applying. Do not enter month(s) without spend down or month(s) for which the client has insufficient bills to meet spend down.

*Other Case No. (s): Use this section to cross reference other cases to which the Clearinghouse should refer when working this case. Situations for cross referencing include the following:

  • a month previously included in another case is again included in this case.
  • two application months are processed with the same Form H1010-B, Application for Assistance - Part B, at the same interview, and both months have spend down.

Include a brief explanation for the cross reference.