Form H3081, QI Transaction Report

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Effective Date: 7/2009


Updated: 3/2011


To report the decision to certify or deny an application filed for the Qualified Individuals (QI) program and to identify benefit periods for eligible individuals.

The QI program is 100% federally funded, with specific amounts allocated to each state. This program is not yet automated and must be manually tracked and monitored to:

  • identify the number of applicants for the QI program;
  • identify the number of clients certified or denied;
  • ensure that Medicare Part B Buy-In processes accurately for eligible QI-1 clients (using only federal dollars); and
  • ensure that the agency does not exceed the spending limit for client enrollment in the QI program.


Number of Copies

Complete an original and one copy of the QI Transaction Report.


Send the original to Data Integrity, Mail Code Y-922, and keep a copy in the case record.

Form Retention

The QI Transaction Report is kept in the case record for three years after the recipient's eligibility is denied.

Detailed Instructions

From — Enter the name and city/mail code of the worker completing the form.

Application/Case No. — Enter the nine-digit application number or case number.

Client No. — Enter the nine-digit client number.

Worker's BJN — Self-explanatory.

Worker's Mail Code — Self-explanatory.

New — Indicates that the client is being certified for QI-1 benefits, or an application is being denied due to ineligibility (and the client is not being certified for any other Medical Assistance Only (MAO) program benefits).

Update — Indicates that new information is being reported on an existing QI client. Note: When the update reports an adverse action, do not submit Form H3081 until the hold period has expired and Form H1000-B, Record of Case Action, is entered into the System for Applications Verification, Eligibility Reports and Referral (SAVERR).

Correction — Indicates that previously reported QI information is being corrected/amended.


Name — Enter the applicant/client's name, as it appears on Form H1000-A, Notice of Application, or H1000-B (last name, first name, middle initial).

Social Security No. — Enter the individual's Social Security number.

Medicare Claim No. — Enter the individual's Medicare claim number.

Address — Enter the individual's street address, city, ZIP code, county name and county number.

Telephone No. — Enter the individual's telephone number (including area code).

Check the appropriate box for the QI action being reported.


Medical Effective Date — The medical effective date for QI-1 coverage to begin. Enter the medical effective date even when certifying a client for prior only QI-1 coverage or when it is an update to end QI-1 coverage.

End Date — If the applicant is being certified for prior only QI-1 coverage, or an active client is no longer eligible for QI-1 coverage, enter the date QI-1 coverage is to end.

End Reason — Indicate the reason QI-1 coverage is ending.

If the client is being transferred to another MAO program, enter the new Type Program and Base Plan (TP/BP). If the new program will be specified low income Medicare beneficiary (SLMB), enter the program name.

If the client is no longer eligible for QI-1 (and is not being transferred to another MAO program), enter the denial reason code.


Denial Reason Code — If the client is not eligible for QI-1, enter the denial reason code.

Other Information — Enter any additional or new information on a QI-1 client (i.e. reporting transfer to new program, spousal information).

Worker Information — Enter the reporting worker's signature, telephone number (including area code and office extension) and the date the form was completed.