Adding New MO Override Eligibility Evidence

Used only when MEDES does not provide proper Eligibility Determination due to technical issues. Should not be used to replace data entry of specific required Evidence

NOTE: A Salesforce Ticket must be submitted anytime MOOE is entered to grant or take away coverage if the worker entering the MOOE feels the system is granting incorrect coverage.

TO ADD NEW MO OVERRIDE ELIGIBILITY EVIDENCE

    1. Navigate to the Integrated Case > Evidence sub-tab > Dashboard folder
    2. Hover cursor over MO Override Eligibility hyperlink > click the Create Evidence icon
    3. Complete data entry of the New MO Override Eligibility
      1. Received Date should be the same as Coverage Start Date

NOTE: If the Coverage Start Date is in the future, then the Received Date cannot be in the future and must be entered as the Current Date.

      1. Select Case Participant from drop down menu
      2. Select Manual as Type from drop down menu
      3. Select the appropriate Reason from drop down menu

NOTE: When selecting the reason of ‘Other’ from the Reason dropdown list, the field Other (Reason) MUST be populated with a description of why ‘Other’ was used for the evidence to Save.

      1. Coverage Start Date should be the desired current coverage begin date
      2. Coverage End Date should be the end of the certification period or the specified eligibility period as defined by the benefit (i.e. MPW 9 months, Post-Partum 12 months)

NOTE: COVERAGE START AND END DATES:

    • Lower LOC Starting in the Past: If Coverage Start Date is prior to the Current Date and the Override Coverage being created is a lower LOC than the MEDES eligibility, seen on the IC Eligibility Timeline, then the Override will not start until the after the Adverse Action period expires. Also, if the Coverage End Date is also in the past for the lower LOC, then eligibility will not be given to the participant. A Bypass SHOULD NOT be used in this circumstance as the higher LOC was already provided to the participant.
    • Certification Period: The Start and End Dates of Override Coverage must be within the certification period or eligibility will not be provided on periods outside of the certification period. If Override is created outside of the certification period, then the user must manually add this certification period.
    1. Select the appropriate Action (one action is to grant coverage the other action is to remove coverage) from the drop down menu
    2. Select the appropriate ME Code from the drop down menu
    3. Enter the Premium amount if applicable
    4. If the override is granting or removing coverage for a SMHB case, click the SMHB Indicator check box
    5. A comment MUST be made with a brief explanation of why the override is necessary
    6. Click Save
    7. Verify all Outstanding Evidence
    8. Apply Changes, Check Proposed Determination, Finalize Proposed Determination

NOTE: MEDES may generate an additional proposed determination, especially in cases with income changes, adding a person, or removing a person. If the system generated an additional proposed determination, you must run the Finalize Proposed Determination again

    1. Make a comment on the HoH Person Page to include:
      1. Why the override was necessary
      2. Incorrect coverage given by MEDES
      3. Correct coverage given by Override
    2. Review Notice Queue to make sure appropriate forms generated
      1. IM-80: Generates in the event of negative coverage changes
      2. IM-33C: Case Action Notice