Free Good Faith Certification Instructions HCF 10111A - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 10111A (Rev. 08/03)

STATE OF WISCONSIN WI Stats. ss. 49.665, 49.468, 49.472, 49.473

GOOD FAITH CERTIFICATION INSTRUCTIONS The shaded areas of the Good Faith Certification form is to be completed by the Medical. Sections 1 and 3 of this form are to be completed by the Economic Support worker. Return the completed original form to: Medicaid P.O. Box 7636 Madison, WI 53707 Fax: (608) 221-8815 Copies should be for the county agency file and one sent to Medicaid to update the case file. SECTION I ­ AGENCY DENIAL Agency Denial If the recipient identified on this Good Faith Certification form was neither eligible nor possessed a valid temporary "Forward" ID card for the dates of service indicated in field six, check the "Yes" box. If you check "Yes" here, you must also check the reasons in the next field. Reason for Denial q Recipient did not have a valid "Forward" ID card after _____________ (date). Check this box if you are certain that the recipient did not possess a valid temporary "Forward" ID card For the date of service. In the blank provided, enter the closing date of eligibility.
q

Recipient not eligible.

Check this box if the recipient was not eligible for the dates of service shown. If the recipient was eligible fo of the dates of service, follow the instructions for completing the Partial Denial box.
q

Record not found. Check this box if the client has never been eligible for Medicaid in your agency.

Partial Deny Use this field if the recipient was eligible for some of the dates of service. Enter the "From" and "To" dates which cover the portion of the dates of service for which the recipient does not have eligibility on MMIS and should have. SECTION II ­ TYPE OF CERTIFICATION ACTION This entire section is completed by Medicaid with all known information. Initial Certification / Amended Certification Medicaid will check the appropriate box. Agency Number Medicaid will enter the three-digit code of the agency they believe may have certified the recipient during the dates in question. W-2 Agency Code Medicaid enters the W-2 agency code. Case Head ID Number Medicaid will enter the known or suspected MMIS case head number of the recipient listed on the provider's claim.

Good Faith Certification Instructions HCF 10111A (Rev. 08/03)

Medical Status Code When Medicaid receives the provider's claim along with a photocopy of a temporary "Forward" ID card the Medicaid compares the dates of service with the dates on the card. If the dates of service fall within the dates of eligibility on the card submitted by the provider, for the recipient's ID number, Medicaid enters a "71" medical status code and pays the claim immediately, if there is no eligibility on file. Medicaid then enters the eligibility dates for the entire month in which services were provided. Period of Certification If Medicaid has entered the suspected period of certification to be added to the recipient master file, check it for accuracy. Complete a Medicaid Certification form (HCF and enter the period of certification if the recipient file does not show eligibility for the time when the recipient was eligible or for the time covered by a temporary "Forward" ID card issued to the recipient. Case Head Name Medicaid enters the case head's last name, first name and middle initial, if known. In Care Of Medicaid enters the name of the person to whom information should be sent in care of, if not sent directly to the recipient. Address Medicaid enters the recipient's address, including street, city, state and zip code, if known. Control Name Year of Birth (YOB) Medicaid will enter the suspected control name and year of birth (YOB) for the recipient. The YOB is the last two digits of the recipient's year of birth. Eligibility Recipient Name Medicaid enters the eligible recipient's last name, first name and middle initial. Birthdate Medicaid completes this field only for initial certifications. Change this birthdate if the date entered is incorrect. Indicate birthdate as mm/dd/ccyy. Gender Medicaid completes. Other Remarks: Medicaid enters other necessary information. SECTION III ­ SIGNATURE Signature Good Faith forms must have an authorized signature for initial certifications. The authorized agency Representative must sign here. Worker ID Number On initial certifications, enter the six-digit worker code of the certifying economic support worker. Date Signed Enter the date (mm/dd/ccyy) of the date the authorized agency representative signed the form.