Medical Eligibility
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Eligibility Determination and Benefit
Calculation (EDBC)
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In this course, you will learn how to run Eligibility Determination and
Benefit Calculation (EDBC) for medical programs.
After completing this course, you will be able to:
•
Explain EDBC
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Understand how a “Rules Engine” relates to EDBC
•
Run EDBC
•
Review and Verify EDBC
•
Override a program configuration
•
Create a manual EDBC
•
Describe batch eligibility processes
2
Introduction
3
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Lesson 2: Run EDBC
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Lesson 3: Review and Verify EDBC
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Lesson 4: Troubleshooting EDBC
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Lesson 5: Overriding EDBC
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Lesson 6: Manual EDBC
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Lesson 7: Batch Eligibility Processes
Agenda
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EDBC = Eligibility Determination and Benefit
Calculation
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EDBC is how KEES executes rules to determine
eligibility and budget for programs based on regulations
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The EDBC rules engine applies policy
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EDBC Summary can be thought of as a snap shot of
eligibility based on what the system knows at a point in
time
Lesson 1: What is EDBC
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What is EDBC?
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Lesson 1: What is EDBC > Online EDBC
There are five (5) Medical programs available in KEES:
1.
Medical
2.
Presumptive Eligibility (PE)
3.
Presumptive Eligibility Pregnant Women (PE PW)
4.
State Supplemental Payment Program (SSPP)
5.
AIDS Drug Assistance Program (ADAP)
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Online EDBC means that the eligibility determination is run in KEES
using the defined rules engine.
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Lesson 1: What is EDBC > Online EDBC
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Lesson 1: What is EDBC > Hierarchy
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Lesson 1: What is EDBC > Hierarchy
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Lesson 1: What is EDBC > Hierarchy
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Lesson 1: What is EDBC > Hierarchy
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Lesson 1: What is EDBC > Requested Medical Types
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EDBC will run apply rules for the requested
medical type (i.e. Working Healthy) versus a
hierarchy of test categories.
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Lesson 1: What is EDBC > Requested Medical Types
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The Requested Medical Type can be added or edited after the case has been
registered on the Program Person Detail page.
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Lesson 1: What is EDBC > Requested Medical Types
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The LTC ‘Requested Medical Type’ must be set for the entire month in which
services are provided.
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Lesson 1: What is EDBC > Customer Options
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This page allows the worker to exclude the consumer from selected programs.
Therefore, once EDBC is run, the results would not return those programs in the
determination.
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Lesson 1: What is EDBC > Missing Information
If information is incomplete KEES gives a hard warning that EDBC cannot be run.
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Based on data collection pages
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Must enter any and all information
When one of the above hard warning appears on your screen, you will not be
able to run EDBC until this information is complete.
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Missing relationships for all or some household members
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Missing birth dates for program persons
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No active or pending program in the case for the selected
benefit month
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No designated primary applicant/recipient
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No worker assigned
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Lesson 1: What is EDBC > Missing Information
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Lesson 1: What is EDBC > Missing or Pending Verifications
Verifications are not required to run EDBC. KEES will display a soft warning
if verifications are missing/pending.
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In Lesson 1: we have learned:
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EDBC stands for Eligibility Determination and Benefit Calculation
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There are five medical programs in KEES
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KEES has a medical hierarchy that determines the best plan
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Adding a RMT will only apply the rules for that RMT
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The difference between a ‘hard’ warning to a ‘soft’ warning
Lesson 1: What is EDBC > Summary
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Lesson 1: What is EDBC
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Lesson 3: Review and Verify EDBC
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Lesson 4: Troubleshooting EDBC
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Lesson 4: Overriding EDBC
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Lesson 5: Manual EDBC
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Lesson 6: Batch eligibility processes
Agenda
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Lesson 2: How to Run EDBC > Running EDBC
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Lesson 2: How to Run EDBC > Running EDBC
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Lesson 2: Run EDBC > Running EDBC
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This run reason is used to allow negative changes to a case and changes the CE
period or review and the type of medical coverage provided.
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If you need to re-determine the Community Spouse Resource Allowance (CSRA)
calculation after you have already run EDBC which was Saved and Accepted. Or
when you want a new “Assessment Only” and a recalculation, the user will need
to change the RMT to “Assessment Only” and run EDBC with this Run Reason.
N
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This run reason is used when a MAGI/ Non-MAGI determination was attempted
through the original EDBC run and wasn’t successful.
Lesson 2: Run EDBC > Run Reasons
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It’s a combined functions of the Review Processing and No Touch service run
reasons. It will create a “Read Only” EDBC, establishes a type of review and only
Passive and Super Passive reviews will be authorized.
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This will update the status of RE documents (if sent through KEES) and establish
a new review period for the medical program on the Case Summary page. This
run reason is used when running EDBC in response to returned review in order to
extend the review period and mark the Review & IR status to ‘Complete’.
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This run reason is used when a consumer already has a spenddown and you
need to establish a new base period prior to the review.
Lesson 2: Run EDBC > Run Reasons
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Let’s take a look at the column headings on this page.
Lesson 2: Run EDBC > EDBC List
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t
i
o
n
w
i
l
l
b
e
p
r
o
v
i
d
e
d
o
n
t
h
e
S
u
m
m
a
r
y
p
a
g
e
)
E
D
B
C
T
y
p
e
:
R
e
a
d
O
n
l
y
o
r
R
e
g
u
l
a
r
Lesson 2: Run EDBC > EDBC List
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
27
T
h
e
R
u
n
S
t
a
t
u
s
c
o
l
u
m
n
p
r
o
v
i
d
e
s
y
o
u
w
i
t
h
t
h
e
s
t
a
t
u
s
o
f
t
h
e
E
D
B
C
.
W
h
e
n
y
o
u
i
n
i
t
i
a
l
l
y
r
u
n
E
D
B
C
a
n
d
t
h
e
E
D
B
C
L
i
s
t
p
a
g
e
i
s
d
i
s
p
l
a
y
e
d
,
t
h
e
r
u
n
s
t
a
t
u
s
w
i
l
l
d
i
s
p
l
a
y
a
s
“
N
o
t
A
c
c
e
p
t
e
d
”
.
Other EDBC statuses include:
•
Accepted - Not Saved
•
Accepted – Saved
Lesson 2: Run EDBC > EDBC List
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
28
A
u
t
h
A
m
o
u
n
t
:
M
e
d
i
c
a
l
w
i
l
l
r
e
a
d
‘
D
e
t
a
i
l
s
’
o
r
‘
F
a
i
l
’
w
h
e
n
a
d
e
t
e
r
m
i
n
a
t
i
o
n
h
a
s
b
e
e
n
c
o
m
p
l
e
t
e
d
.
D
a
t
e
R
u
n
:
D
a
t
e
E
D
B
C
i
s
r
u
n
E
D
B
C
S
o
u
r
c
e
:
C
o
n
v
e
r
s
i
o
n
,
B
a
t
c
h
E
D
B
C
R
u
l
e
s
,
M
a
n
u
a
l
,
O
n
l
i
n
e
E
D
B
C
R
u
l
e
s
,
O
v
e
r
r
i
d
d
e
n
,
o
r
S
p
e
c
i
a
l
P
r
o
g
r
a
m
P
a
g
e
s
Lesson 2: Run EDBC > EDBC List
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
29
There will be times when a worker will need to use the Timely Notice Exception.
This will most often occur when the user will need to re-run EDBC for a paid
month where Long Term Care either starts or stops.
Lesson 2: Run EDBC > Timely Notice Exception
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
30
Lesson 2: Run EDBC > Summary
In Lesson 2: we have learned:
•
Steps in running EDBC
•
How to read the EDBC List page
•
Run Reasons available to use on the Run EDBC page
•
Timely Notice Exception Reasons
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
31
•
Lesson 1: What is EDBC
•
Lesson 2: Run EDBC
•
L
e
s
s
o
n
3
:
R
e
v
i
e
w
a
n
d
V
e
r
i
f
y
E
D
B
C
•
Lesson 4: Troubleshooting EDBC
•
Lesson 4: Overriding EDBC
•
Lesson 5: Manual EDBC
•
Lesson 6: Batch eligibility processes
Agenda
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
•
Program Configuration
•
Reporting Configuration
•
Resource Determination
•
Income
•
Household Size
•
Deductions
•
Aid Codes
32
Lesson 3: Review and Verify EDBC Results
I
n
t
h
i
s
l
e
s
s
o
n
,
w
e
w
i
l
l
a
c
c
e
s
s
,
r
e
v
i
e
w
a
n
d
v
e
r
i
f
y
t
h
e
E
D
B
C
r
e
s
u
l
t
s
f
o
r
o
u
r
c
o
n
s
u
m
e
r
.
T
h
e
f
o
l
l
o
w
i
n
g
c
o
m
p
o
n
e
n
t
s
o
f
o
u
r
M
e
d
i
c
a
l
E
D
B
C
S
u
m
m
a
r
y
w
i
l
l
b
e
r
e
v
i
e
w
e
d
:
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
33
Lesson 3: Review and Verify EDBC Results
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
34
Lesson 3: Review and Verify EDBC Results
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
35
Lesson 3: Review and Verify EDBC Results
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
36
T
h
e
t
o
p
s
e
c
t
i
o
n
o
f
t
h
e
M
e
d
i
c
a
i
d
E
D
B
C
S
u
m
m
a
r
y
d
i
s
p
l
a
y
s
:
•
The range of benefit months that the EDBC encompasses
•
The date EDBC was run
•
The run status
•
The Worker who ran and accepted the EDBC
•
T
h
e
E
D
B
C
t
y
p
e
w
i
l
l
b
e
e
i
t
h
e
r
‘
R
e
a
d
O
n
l
y
’
o
r
‘
R
e
g
u
l
a
r
’
Lesson 3: Review and Verify EDBC Results
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
37
Lesson 3: Review and Verify EDBC Results
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
38
I
n
t
h
e
P
r
o
g
r
a
m
C
o
n
f
i
g
u
r
a
t
i
o
n
s
e
c
t
i
o
n
,
y
o
u
c
a
n
v
i
e
w
t
h
e
E
D
B
C
S
o
u
r
c
e
,
P
r
o
g
r
a
m
S
t
a
t
u
s
,
a
n
d
,
i
f
a
p
p
l
i
c
a
b
l
e
,
t
h
e
P
r
o
g
r
a
m
S
t
a
t
u
s
R
e
a
s
o
n
.
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
Lesson 3: Review and Verify EDBC Results
39
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
E
D
B
C
S
o
u
r
c
e
:
T
h
i
s
i
s
t
h
e
s
o
u
r
c
e
f
r
o
m
w
h
i
c
h
e
l
i
g
i
b
i
l
i
t
y
w
a
s
d
e
t
e
r
m
i
n
e
d
.
Lesson 3: Review and Verify EDBC Results
EDBC Sources include:
•
Online EDBC Rules
•
Batch EDBC Rules
•
Manual
40
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
P
r
o
g
r
a
m
S
t
a
t
u
s
:
T
h
e
o
v
e
r
a
l
l
s
t
a
t
u
s
o
f
t
h
e
p
r
o
g
r
a
m
c
a
n
i
n
c
l
u
d
e
:
Lesson 3: Review and Verify EDBC Results
•
Active
•
Denied
•
Discontinued
P
r
o
g
r
a
m
P
e
r
s
o
n
This section will also list the program members.
41
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
P
r
o
g
r
a
m
S
t
a
t
u
s
:
T
h
e
o
v
e
r
a
l
l
s
t
a
t
u
s
o
f
t
h
e
p
r
o
g
r
a
m
c
a
n
i
n
c
l
u
d
e
:
Lesson 3: Review and Verify EDBC Results
•
Active
•
Denied
•
Discontinued
P
r
o
g
r
a
m
S
t
a
t
u
s
R
e
a
s
o
n
w
i
l
l
d
i
s
p
l
a
y
i
f
t
h
e
r
e
i
s
a
d
e
t
e
r
m
i
n
a
t
i
o
n
o
f
‘
D
e
n
i
e
d
’
o
r
‘
D
i
s
c
o
n
t
i
n
u
e
d
’
E
D
B
C
.
S
o
m
e
e
x
a
m
p
l
e
s
i
n
c
l
u
d
e
:
•
No Eligible Member
•
Over Resources
•
Whereabouts Unknown
•
No Linkage to MC
42
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
P
r
o
g
r
a
m
P
e
r
s
o
n
This section will list the program members and their vital information.
Lesson 3: Review and Verify EDBC Results
•
Date of birth
•
Role
•
Role Reason
•
Status
•
Status Reason
43
T
h
e
u
s
e
r
c
a
n
s
e
l
e
c
t
t
h
e
m
e
m
b
e
r
’
s
n
a
m
e
h
y
p
e
r
l
i
n
k
i
n
t
h
e
p
r
o
g
r
a
m
c
o
n
f
i
g
u
r
a
t
i
o
n
b
l
o
c
k
t
o
a
c
c
e
s
s
t
h
e
I
n
d
i
v
i
d
u
a
l
E
l
i
g
i
b
i
l
i
t
y
C
r
i
t
e
r
i
a
p
a
g
e
.
T
h
i
s
p
a
g
e
d
i
s
p
l
a
y
s
e
v
e
r
y
i
n
c
o
m
e
,
e
x
p
e
n
s
e
,
a
n
d
r
e
s
o
u
r
c
e
,
r
e
g
a
r
d
l
e
s
s
o
f
t
y
p
e
a
n
d
p
o
s
s
i
b
l
e
e
x
e
m
p
t
i
o
n
s
.
S
e
l
e
c
t
i
n
g
t
h
e
C
l
o
s
e
b
u
t
t
o
n
w
i
l
l
r
e
t
u
r
n
t
h
e
u
s
e
r
t
o
t
h
e
M
e
d
i
c
a
i
d
E
D
B
C
S
u
m
m
a
r
y
p
a
g
e
.
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
Lesson 3: Review and Verify EDBC Results
44
Lesson 3: Review and Verify EDBC Results
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
45
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
Lesson 3: Review and Verify EDBC Results
R
e
p
o
r
t
i
n
g
C
o
n
f
i
g
u
r
a
t
i
o
n
T
h
e
p
r
o
g
r
a
m
p
e
r
s
o
n
s
a
n
d
t
h
e
i
r
A
d
u
l
t
/
C
h
i
l
d
c
o
d
e
w
i
l
l
b
e
l
i
s
t
e
d
i
n
t
h
i
s
s
e
c
t
i
o
n
.
46
Lesson 3: Review and Verify EDBC Results
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
47
Lesson 3: Review and Verify EDBC Results
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
A
f
t
e
r
s
e
l
e
c
t
i
n
g
t
h
e
R
e
s
o
u
r
c
e
T
o
t
a
l
h
y
p
e
r
l
i
n
k
o
n
t
h
e
M
e
d
i
c
a
i
d
E
D
B
C
S
u
m
m
a
r
y
p
a
g
e
,
t
h
e
u
s
e
r
w
i
l
l
a
c
c
e
s
s
t
h
e
P
r
o
p
e
r
t
y
D
e
t
a
i
l
p
a
g
e
.
S
e
l
e
c
t
i
n
g
C
l
o
s
e
w
i
l
l
r
e
t
u
r
n
t
h
e
u
s
e
r
t
o
t
h
e
M
e
d
i
c
a
i
d
E
D
B
C
S
u
m
m
a
r
y
p
a
g
e
.
48
Lesson 3: Review and Verify EDBC Results
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
49
Lesson 3: Review and Verify EDBC Results
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
50
Lesson 3: Review and Verify EDBC Results
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
51
Lesson 3: Review and Verify EDBC Results
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
52
Lesson 3: Review and Verify EDBC Results
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
53
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
C
l
i
c
k
t
h
e
T
e
s
t
c
a
t
e
g
o
r
y
h
y
p
e
r
l
i
n
k
t
o
a
c
c
e
s
s
t
h
e
I
n
c
o
m
e
D
e
t
e
r
m
i
n
a
t
i
o
n
p
a
g
e
.
T
h
i
s
p
a
g
e
s
h
o
w
s
h
o
w
m
u
c
h
i
n
c
o
m
e
w
a
s
c
o
u
n
t
e
d
f
o
r
t
h
a
t
p
e
r
s
o
n
.
Lesson 3: Review and Verify EDBC Results
T
h
e
I
n
c
o
m
e
D
e
t
e
r
m
i
n
a
t
i
o
n
p
a
g
e
s
h
o
w
s
:
•
Income used
•
Deductions allowed
•
Income Allocations
•
Protected Income Limit
54
M
e
d
i
c
a
l
E
l
i
g
i
b
i
l
i
t
y
:
E
D
B
C
Lesson 3: Review and Verify EDBC Results
S
e
l
e
c
t
i
n
g
t
h
e
h
y
p
e
r
l
i
n
k
s
i
n
t
h
e
I
n
c
o
m
e
D
e
t
e
r
m
i
n
a
t
i
o
n
p
a
g
e
w
i
l
l
n
a
v
i
g
a
t
e
t
h
e
u
s
e
r
t
o
t
h
e
d
e
t
a
i
l
p
a
g
e
f
o
r
t
h
a
t
l
i
n
e
i
t
e
m
.
55
Lesson 3: Review and Verify EDBC Results
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i
b
i
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i
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y
:
E
D
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Lesson 3: Review and Verify EDBC Results
57
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Lesson 3: Review and Verify EDBC Results
C
l
i
c
k
t
h
e
T
e
s
t
c
a
t
e
g
o
r
y
h
y
p
e
r
l
i
n
k
t
o
a
c
c
e
s
s
t
h
e
I
n
c
o
m
e
D
e
t
e
r
m
i
n
a
t
i
o
n
p
a
g
e
.
T
h
i
s
p
a
g
e
s
h
o
w
s
h
o
w
m
u
c
h
i
n
c
o
m
e
w
a
s
c
o
u
n
t
e
d
f
o
r
t
h
a
t
p
e
r
s
o
n
.
58
Lesson 3: Review and Verify EDBC Results
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59
Lesson 3: Review and Verify EDBC Results
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a
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E
l
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g
i
b
i
l
i
t
y
:
E
D
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A
t
t
h
e
b
o
t
t
o
m
o
f
t
h
e
M
e
d
i
c
a
l
E
D
B
C
S
u
m
m
a
r
y
p
a
g
e
i
s
t
h
e
O
v
e
r
p
a
y
m
e
n
t
s
/
U
n
d
e
r
p
a
y
m
e
n
t
s
s
e
c
t
i
o
n
.
This section will not display results at initial application.
An overpayment is a result of a shift in eligibility or a change in spenddown
amount when EDBC is recalculated for a paid month.
R
e
v
i
e
w
i
n
g
E
D
B
C
i
s
a
s
i
m
p
l
e
b
u
t
a
v
e
r
y
i
m
p
o
r
t
a
n
t
f
u
n
c
t
i
o
n
i
n
K
E
E
S
.
E
D
B
C
c
a
n
b
e
:
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Lesson 3: Review and Verify EDBC Results
61
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Once you have reviewed EDBC, you can either:
•
A
c
c
e
p
t
t
h
e
E
D
B
C
b
y
c
l
i
c
k
i
n
g
t
h
e
A
c
c
e
p
t
b
u
t
t
o
n
Lesson 3: Review and Verify EDBC Results
O
R
•
B
y
c
l
i
c
k
i
n
g
t
h
e
C
a
n
c
e
l
b
u
t
t
o
n
t
h
e
u
s
e
r
r
e
t
u
r
n
s
t
o
t
h
e
E
D
B
C
L
i
s
t
p
a
g
e
.
T
h
e
s
e
b
u
t
t
o
n
s
a
r
e
m
a
d
e
a
v
a
i
l
a
b
l
e
t
o
y
o
u
a
t
t
h
e
t
o
p
a
n
d
b
o
t
t
o
m
o
f
e
v
e
r
y
M
e
d
i
c
a
i
d
E
D
B
C
S
u
m
m
a
r
y
p
a
g
e
.
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Lesson 3: Review and Verify EDBC Results
O
n
c
e
E
D
B
C
r
e
s
u
l
t
s
a
r
e
a
c
c
e
p
t
e
d
,
t
h
e
s
t
a
t
u
s
i
s
u
p
d
a
t
e
d
t
o
A
c
c
e
p
t
e
d
–
N
o
t
S
a
v
e
d
a
n
d
a
S
a
v
e
a
n
d
C
o
n
t
i
n
u
e
b
u
t
t
o
n
a
p
p
e
a
r
s
.
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Lesson 3: Review and Verify EDBC Results
C
l
i
c
k
i
n
g
t
h
e
S
a
v
e
a
n
d
C
o
n
t
i
n
u
e
b
u
t
t
o
n
g
e
n
e
r
a
t
e
s
a
N
o
t
i
c
e
o
f
A
c
t
i
o
n
(
N
O
A
)
.
Y
o
u
c
a
n
l
o
c
a
t
e
t
h
i
s
N
O
A
o
n
t
h
e
D
i
s
t
r
i
b
u
t
e
d
D
o
c
u
m
e
n
t
s
S
e
a
r
c
h
p
a
g
e
.
I
f
a
n
o
t
i
c
e
i
s
n
o
t
g
e
n
e
r
a
t
e
d
a
u
s
e
r
w
i
l
l
n
e
e
d
t
o
c
r
e
a
t
e
a
f
o
r
m
.
A NOA will generate after saving an EDBC at initial application
or when there is change in benefits.
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In this lesson, we learned:
•
EDBC List page
•
Medical EDBC Summary
Program Configuration
Passed Budgets
Failed and Overridden Budgets
Accept or Cancel Results
Notifications
Lesson 3: Review and Verify EDBC Results > Summary
65
•
Lesson 1: What is EDBC
•
Lesson 2: Run EDBC
•
Lesson 3: Review and Verify EDBC
•
L
e
s
s
o
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4
:
T
r
o
u
b
l
e
s
h
o
o
t
i
n
g
E
D
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•
Lesson 5: Overriding EDBC
•
Lesson 6: Manual EDBC
•
Lesson 7: Batch eligibility processes
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Agenda
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Lesson 4: Troubleshooting EDBC
67
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Lesson 4: Troubleshooting EDBC
68
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Lesson 4: Troubleshooting EDBC
69
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Lesson 4: Troubleshooting EDBC
70
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Lesson 4: Troubleshooting EDBC
71
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Lesson 4: Troubleshooting EDBC
Important items to look for when Income or Resources affect benefit
determinations.
•
A budget wasn’t created at the time EDBC was run.
•
Begin dates must be entered as the 1
st
day of the Month regardless of
when the application was received.
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Lesson 4: Troubleshooting EDBC > Summary
•
It is important to verify all information on the
data collection pages is accurate.
•
Ensure the begin dates are correct.
•
If KEES has not been updated with new
regulations, override the EDBC results.
73
•
Lesson 1: What is EDBC
•
Lesson 2: Run EDBC
•
Lesson 3: Review and Verify EDBC
•
Lesson 4: Troubleshooting EDBC
•
L
e
s
s
o
n
5
:
O
v
e
r
r
i
d
i
n
g
E
D
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C
•
Lesson 6: Manual EDBC
•
Lesson 7: Batch eligibility processes
Agenda
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Lesson 5: Overriding EDBC > Program Configuration
75
Lesson 5: Overriding EDBC > Program Configuration
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EDBC Override Reasons includes:
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Lesson 5: Overriding EDBC > Program Configuration
77
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:
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Lesson 5: Overriding EDBC > Medical Summary Page
78
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Lesson 5: Overriding EDBC > Summary
•
Overriding is used to change the eligibility determination made by KEES.
•
You would override program configuration if KEES determination
was not correct for a reason other than incorrect data entry.
79
•
Lesson 1: What is EDBC
•
Lesson 2: Run EDBC
•
Lesson 3: Review and Verify EDBC
•
Lesson 4: Troubleshooting EDBC
•
Lesson 5: Overriding EDBC
•
L
e
s
s
o
n
6
:
M
a
n
u
a
l
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C
•
Lesson 7: Batch Eligibility Processes
Agenda
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80
Lesson 6: Manual EDBC > Manual EDBC
A manual EDBC is used for a few programs that do not have rules built into
EDBC such as:
•
Presumptive Eligibility (PE)
•
Presumptive Eligibility Pregnant Women (PE PW)
M
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81
S
e
l
e
c
t
t
h
e
c
o
r
r
e
c
t
b
e
n
e
f
i
t
m
o
n
t
h
f
r
o
m
t
h
e
B
e
n
e
f
i
t
M
o
n
t
h
d
r
o
p
-
d
o
w
n
b
o
x
a
n
d
c
l
i
c
k
t
h
e
G
o
b
u
t
t
o
n
.
A
r
e
a
s
o
n
f
o
r
t
h
e
m
a
n
u
a
l
E
D
B
C
i
s
s
e
l
e
c
t
e
d
f
r
o
m
t
h
e
M
a
n
u
a
l
E
D
B
C
R
e
a
s
o
n
d
r
o
p
-
d
o
w
n
b
o
x
.
M
e
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c
a
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y
:
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Lesson 6: Manual EDBC
Click the Run EDBC Program:
82
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L
i
s
t
p
a
g
e
a
f
t
e
r
t
h
e
m
a
n
u
a
l
E
D
B
C
h
a
s
b
e
e
n
c
r
e
a
t
e
d
t
h
e
E
D
B
C
S
o
u
r
c
e
w
i
l
l
s
h
o
w
M
a
n
u
a
l
.
M
e
d
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a
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E
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i
b
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y
:
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Lesson 6: Manual EDBC
83
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Lesson 6: Manual EDBC
1
.
C
l
i
c
k
S
e
t
P
r
o
g
r
a
m
C
o
n
f
i
g
u
r
a
t
i
o
n
.
2.
Update the status to ‘Active’.
3.
Edit the Program Configuration for the applicant.
4.
Save and Return.
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Lesson 6: Manual EDBC
N
e
x
t
t
h
e
u
s
e
r
w
i
l
l
n
e
e
d
t
o
s
e
t
t
h
e
m
e
d
i
c
a
l
s
u
m
m
a
r
y
b
y
c
l
i
c
k
i
n
g
S
e
t
M
e
d
i
c
a
l
S
u
m
m
a
r
y
.
85
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Lesson 6: Manual EDBC > Summary
A manual EDBC is a determination of eligibility
made outside of KEES.
A Notice of Action is not created when a Manual
EDBC is run.
86
•
Lesson 1: What is EDBC
•
Lesson 2: Run EDBC
•
Lesson 3: Review and Verify EDBC
•
Lesson 4: Troubleshooting EDBC
•
Lesson 5: Overriding EDBC
•
Lesson 6: Manual EDBC
•
L
e
s
s
o
n
7
:
B
a
t
c
h
E
l
i
g
i
b
i
l
i
t
y
P
r
o
c
e
s
s
e
s
Agenda
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:
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Lesson 7: Batch Eligibility Processes
W
h
a
t
i
s
B
a
t
c
h
E
l
i
g
i
b
i
l
i
t
y
?
•
The process of running EDBC systematically on a scheduled basis.
•
This is done for changes that affect many cases at once as well as for individual
case changes (i.e. age changes).
88
O
t
h
e
r
T
h
i
n
g
s
t
o
K
n
o
w
:
•
KEES automatically approves and generates a Notice of
Action (NOA), if appropriate, for each Batch EDBC result.
•
A task will be created for program that do not process
automatically. Worker action will be necessary.
•
The system produces tasks for action when validations,
such as identification of overpayments, require worker
action.
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Lesson 7: Batch Eligibility Processes
89
EDBC results will appear on the EDBC List and EDBC Results List page for
EDBCs completed through Batch Eligibility similar to EDBCs that you run, accept
and save yourself.
The EDBC Source for EDBCs processed through Batch Eligibility will display as
”Batch EDBC Rules”.
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Lesson 7: Batch Eligibility Processes
An automated task will tell you which programs were not
processed through batch eligibility and for which benefit
month EDBC needs to be run.
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Lesson 7: Batch Eligibility Processes
91
In Lesson 7: we have learned:
The Batch Eligibility process runs at night and will run with
the rules
Users will be notified which cases did not run during the
Batch Eligibility
EDBC results will appear on the EDBC List and EDBC
Results List page for EDBCs completed through Batch
Eligibility similar to EDBCs that you run, accept and save
yourself.
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Lesson 7: Batch Eligibility Processes > Summary
92
In this course, you learned how to:
•
Explain EDBC
•
Understand how a “Rules Engine” relates to EDBC
•
Run EDBC
•
Review and Verify EDBC
•
Override a program configuration
•
Create a manual EDBC
•
Describe batch eligibility processes
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Welcome to Medical Eligibility - Eligibility Determination and Benefit Calculation or EDBC
Cover any housekeeping items such as:
The location of restrooms and break rooms.
Ground rules for the training.
Instructor introductions.
Participant introductions.
Transition: Let’s talk about why we’re all here.
version 2.5
Unit 19: Medical Eligibility Determination
Learning about EDBC involves understanding how rules are executed to determine eligibility and budget for medical programs based on regulations. The EDBC rules engine applies policy to provide a snapshot of eligibility at a specific point in time. This course covers topics like running EDBC, reviewing and verifying results, troubleshooting issues, and more.
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Presentation Transcript
Medical Eligibility Eligibility Determination and Benefit Calculation (EDBC) 1
Medical Eligibility: EDBC Introduction In this course, you will learn how to run Eligibility Determination and Benefit Calculation (EDBC) for medical programs. After completing this course, you will be able to: Explain EDBC Understand how a Rules Engine relates to EDBC Run EDBC Review and Verify EDBC Override a program configuration Create a manual EDBC Describe batch eligibility processes 2
Medical Eligibility: EDBC Agenda Lesson 1: What is EDBC Lesson 2: Run EDBC Lesson 3: Review and Verify EDBC Lesson 4: Troubleshooting EDBC Lesson 5: Overriding EDBC Lesson 6: Manual EDBC Lesson 7: Batch Eligibility Processes 3
Medical Eligibility: EDBC Lesson 1: What is EDBC What is EDBC? EDBC = Eligibility Determination and Benefit Calculation EDBC is how KEES executes rules to determine eligibility and budget for programs based on regulations The EDBC rules engine applies policy EDBC Summary can be thought of as a snap shot of eligibility based on what the system knows at a point in time 4
Medical Eligibility: EDBC Lesson 1: What is EDBC > Online EDBC There are five (5) Medical programs available in KEES: 1. Medical 2. Presumptive Eligibility (PE) 3. Presumptive Eligibility Pregnant Women (PE PW) 4. State Supplemental Payment Program (SSPP) 5. AIDS Drug Assistance Program (ADAP) Only Medical utilizes online rules. Online EDBC means that the eligibility determination is run in KEES using the defined rules engine. 5
Medical Eligibility: EDBC Lesson 1: What is EDBC > Online EDBC 6
Medical Eligibility: EDBC Lesson 1: What is EDBC > Hierarchy Refugee Medical Transitional Medical Extended Medical Aged Out Foster Care Caretaker Medical Title 19 Working Healthy ADAP Foster Care CHIP Adoption Support Medical Protected Medical Groups Medically Needy MSP Breast Cancer Cervical SSI MediKan Tuberculosis Recipients 7
Medical Eligibility: EDBC Lesson 1: What is EDBC > Hierarchy 8
Medical Eligibility: EDBC Lesson 1: What is EDBC > Hierarchy 9
Medical Eligibility: EDBC Lesson 1: What is EDBC > Hierarchy In situations where the consumer could be eligible for more than one program and has the option to choose which program they agree to the terms and conditions of (e.g. premium vs. spenddown), there are two solutions for handling this: Requested Medical Type (RMT) Customer Options 10
Medical Eligibility: EDBC Lesson 1: What is EDBC > Requested Medical Types You can add the Requested Medical Type to be more specific to the type of medical coverage on the Requested Medicaid Type Detail page. Requested Medical Types Inmate LTC (Long Term Care) MAGI MSP Medical PPS Qualified Disabled Working Individual Resource Assessment Only Working Healthy EDBC will run apply rules for the requested medical type (i.e. Working Healthy) versus a hierarchy of test categories. 11
Medical Eligibility: EDBC Lesson 1: What is EDBC > Requested Medical Types Requested Medical Type On the person s Program Detail page a user will select the consumer s Requested Medical Type. The Requested Medical Type can be added or edited after the case has been registered on the Program Person Detail page. 12
Medical Eligibility: EDBC Lesson 1: What is EDBC > Requested Medical Types In the event a child enters a Psychiatric Residential Treatment Facility (PRTF) or requires HCBS services, the Requested Medical Type will need to add a LTC RMT. The LTC Requested Medical Type must be set for the entire month in which services are provided. 13
Medical Eligibility: EDBC Lesson 1: What is EDBC > Customer Options Customer Options This page allows the worker to exclude the consumer from selected programs. Therefore, once EDBC is run, the results would not return those programs in the determination. 14
Medical Eligibility: EDBC Lesson 1: What is EDBC > Missing Information If information is incomplete KEES gives a hard warning that EDBC cannot be run. Based on data collection pages Must enter any and all information When one of the above hard warning appears on your screen, you will not be able to run EDBC until this information is complete. 15
Medical Eligibility: EDBC Lesson 1: What is EDBC > Missing Information Some examples of hard warnings if one or more of the following is missing: Missing relationships for all or some household members Missing birth dates for program persons No active or pending program in the case for the selected benefit month No designated primary applicant/recipient No worker assigned 16
Medical Eligibility: EDBC Lesson 1: What is EDBC > Missing or Pending Verifications Verifications are not required to run EDBC. KEES will display a soft warning if verifications are missing/pending. 17
Medical Eligibility: EDBC Lesson 1: What is EDBC > Summary In Lesson 1: we have learned: EDBC stands for Eligibility Determination and Benefit Calculation There are five medical programs in KEES KEES has a medical hierarchy that determines the best plan Adding a RMT will only apply the rules for that RMT The difference between a hard warning to a soft warning 18
Medical Eligibility: EDBC Agenda Lesson 1: What is EDBC Lesson 2: Run EDBC Lesson 3: Review and Verify EDBC Lesson 4: Troubleshooting EDBC Lesson 4: Overriding EDBC Lesson 5: Manual EDBC Lesson 6: Batch eligibility processes 19
Medical Eligibility: EDBC Lesson 2: How to Run EDBC > Running EDBC The Run EDBC page allows you to run eligibility determination and benefit calculation for programs in which a consumer is applying or participating. 20
Medical Eligibility: EDBC Lesson 2: How to Run EDBC > Running EDBC The Benefit Month drop-down box will default to the application month. However, you can change the benefit month by selecting the month from the Benefit Month drop-down box. If you change the benefit month, the Run EDBC page will then be refreshed with programs pending or active for that month. Select the Program(s) by clicking the check box next to the program. You can select ALL programs to run at the same time by clicking the check box next to the program title, if applicable. 21
Medical Eligibility: EDBC Lesson 2: Run EDBC > Running EDBC By selecting a run reason from the Run Reason drop-down box, a user may indicate why EDBC is being run. It is not necessary to indicate a run reason at initial application. Run Reasons are available CE Reset CSRA Reassessment No Touch Review No Touch Review Processing Spenddown 22
Medical Eligibility: EDBC Lesson 2: Run EDBC > Run Reasons What do these Run Reasons mean/do? CE (Continuous Eligibility) Reset This run reason is used to allow negative changes to a case and changes the CE period or review and the type of medical coverage provided. CSRA Reassessment If you need to re-determine the Community Spouse Resource Allowance (CSRA) calculation after you have already run EDBC which was Saved and Accepted. Or when you want a new Assessment Only and a recalculation, the user will need to change the RMT to Assessment Only and run EDBC with this Run Reason. No Touch This run reason is used when a MAGI/ Non-MAGI determination was attempted through the original EDBC run and wasn t successful. 23
Medical Eligibility: EDBC Lesson 2: Run EDBC > Run Reasons Review No Touch It s a combined functions of the Review Processing and No Touch service run reasons. It will create a Read Only EDBC, establishes a type of review and only Passive and Super Passive reviews will be authorized. Review Processing This will update the status of RE documents (if sent through KEES) and establish a new review period for the medical program on the Case Summary page. This run reason is used when running EDBC in response to returned review in order to extend the review period and mark the Review & IR status to Complete . Spenddown This run reason is used when a consumer already has a spenddown and you need to establish a new base period prior to the review. 24
Medical Eligibility: EDBC Lesson 2: Run EDBC > EDBC List Once EDBC is run, the page refreshes with the EDBC List page. Let s take a look at the column headings on this page. 25
Medical Eligibility: EDBC Lesson 2: Run EDBC > EDBC List Begin Month: Benefit month End Month: Will display if budgeted for one month Program Name: Medical (specific program information will be provided on the Summary page) EDBC Type: Read Only or Regular 26
Medical Eligibility: EDBC Lesson 2: Run EDBC > EDBC List The Run Status column provides you with the status of the EDBC. When you initially run EDBC and the EDBC List page is displayed, the run status will display as Not Accepted . Other EDBC statuses include: Accepted - Not Saved Accepted Saved 27
Medical Eligibility: EDBC Lesson 2: Run EDBC > EDBC List Auth Amount: Medical will read Details or Fail when a determination has been completed. Date Run: Date EDBC is run EDBC Source: Conversion, Batch EDBC Rules, Manual, Online EDBC Rules, Overridden, or Special Program Pages 28
Medical Eligibility: EDBC Lesson 2: Run EDBC > Timely Notice Exception There will be times when a worker will need to use the Timely Notice Exception. This will most often occur when the user will need to re-run EDBC for a paid month where Long Term Care either starts or stops. 29
Medical Eligibility: EDBC Lesson 2: Run EDBC > Summary In Lesson 2: we have learned: Steps in running EDBC How to read the EDBC List page Run Reasons available to use on the Run EDBC page Timely Notice Exception Reasons 30
Medical Eligibility: EDBC Agenda Lesson 1: What is EDBC Lesson 2: Run EDBC Lesson 3: Review and Verify EDBC Lesson 4: Troubleshooting EDBC Lesson 4: Overriding EDBC Lesson 5: Manual EDBC Lesson 6: Batch eligibility processes 31
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results In this lesson, we will access, review and verify the EDBC results for our consumer. The following components of our Medical EDBC Summary will be reviewed: Program Configuration Reporting Configuration Resource Determination Income Household Size Deductions Aid Codes 32
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results 33
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results 34
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results 35
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results The top section of the Medicaid EDBC Summary displays: The range of benefit months that the EDBC encompasses The date EDBC was run The run status The Worker who ran and accepted the EDBC The EDBC type will be either Read Only or Regular 36
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results Program configuration Reporting configuration Resource Test CSRA Determination Medical Summary Overpayments / Underpayments 37
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results In the Program Configuration section, you can view the EDBC Source, Program Status, and, if applicable, the Program Status Reason. 38
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results EDBC Source: This is the source from which eligibility was determined. EDBC Sources include: Online EDBC Rules Batch EDBC Rules Manual 39
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results Program Status: The overall status of the program can include: Active Denied Discontinued Program Person This section will also list the program members. 40
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results Program Status: The overall status of the program can include: Active Denied Discontinued Program Status Reason will display if there is a determination of Denied or Discontinued EDBC. Some examples include: No Eligible Member Over Resources Whereabouts Unknown No Linkage to MC 41
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results Program Person This section will list the program members and their vital information. Date of birth Role Role Reason Status Status Reason 42
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results The user can select the member s name hyperlink in the program configuration block to access the Individual Eligibility Criteria page. This page displays every income, expense, and resource, regardless of type and possible exemptions. Selecting the Close button will return the user to the Medicaid EDBC Summary page. 43
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results Program configuration Reporting configuration Resource Test CSRA Determination Medical Summary Overpayments / Underpayments 44
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results Reporting Configuration The program persons and their Adult/Child code will be listed in this section. 45
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results Program configuration Reporting configuration Resource Test CSRA Determination Medical Summary Overpayments / Underpayments 46
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results After selecting the Resource Total hyperlink on the Medicaid EDBC Summary page, the user will access the Property Detail page. Selecting Close will return the user to the Medicaid EDBC Summary page. 47
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results Program configuration Reporting configuration Resource Test CSRA Determination Medical Summary Overpayments / Underpayments 48
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results 49
Medical Eligibility: EDBC Lesson 3: Review and Verify EDBC Results Program configuration Reporting configuration Resource Test CSRA Determination Medical Summary Overpayments / Underpayments 50
