Free 43714.pdf - Indiana

WORKSHEET FOR DATA ENTRY - TERMINATION OR DENIAL
State Form 43714 (R4 / 9-01) / DE T/D

PLEASE FILL OUT FORM COMPLETELY.
Check appropriate status

Termination
Check appropriate waiver

Denial

Aged and Disabled
Last name

Autism

ICF / MR
First name

Medically Fragile Children

TBI
Middle initial

AL

AFC

Medicaid number

Date of birth (month, day, year)

Social Security number

Area Agency on Aging number

BDDS district number (Autism and ICF / MR waiver only)

Please refer to the Termination, Denial, Level of Care, and Marital Status codes on the reverse side of this form.
A. TERMINATION - (complete this section if services are terminated) Stop date
Date waiver case closed (month, day, year) Termination reason code Level of care S.B. provision (please check)

Yes OR
B. DENIAL - (complete this section if denied services)
Date denied - applicants only (month, day, year) Denial reason code Marital status

No

N/A

A
Date of application (month, day, year) Sex Diagnosis

B

C

D

E

F

Male

Female
Case manager authorization number

Case manager 4 digit I.D. number

Name of case manager

Case manager telephone number

(
Address of case manager (number and street, city, state and ZIP code)

)

Name of agency

Date data sheet completed (month, day, year)

STATE AGENCY USE ONLY Date

Initial

Received in Medicaid Waiver Unit Received in Level of Care Unit Returned to Case Manager

Medicaid Waiver Program P.O. Box 7083, MS 21 Indianapolis, IN 46207-7083 TERMINATION / DENIAL REASON CODES Code Description A Voluntary withdrawal B Chose institutional placement / entered institutional long-term care C Death of consumer D Total costs to Medicaid for home-base services exceed the standard costs for institutional care E Consumer no longer meets requirement for institutional Level of Care F Client is not eligible for Medicaid services G Home and Community-Based Waiver services no longer required H Aged and Disabled Waiver . . . . . . . . . . Client not disabled Assisted Living Waiver . . . . . . . . . . . Client not disabled Autism Waiver . . . . . . . . . . . . . . . . . . . . Client not autistic ICF / MR Waiver . . . . . . . . . . . . . . . . . . Client not developmentally disabled Medically Fragile Children Waiver . . . . Client does not meet Medically Fragile diagnosis TBI Waiver . . . . . . . . . . . . . . . . . . Client does not meet Traumatic Brain Injury diagnosis I Aged and Disabled Waiver . . . . . . . . . . . Client not aged or disabled Assisted Living Waiver . . . . . . . . . . . . . . Client is not age 18 or older, or disabled Medically Fragile Children Waiver . . . . . . Client over age 18 J Initial denial - applicant does not meet Level of Care criteria K Waiting List L Other ________________________________________________________________________ AGED AND DISABLED WAIVER LEVEL OF CARE CODES Code Description (Intermediate / Skilled) NF Level of Care; Diverted, Aged / Disabled; Waiver effective 7/1/90 A00 (Intermediate / Skilled) NF Level of Care; Deinstitutionalized, Aged / Disabled; Waiver effective 7/1/90 A50 ASSISTED LIVING WAIVER LEVEL OF CARE CODES Code Description Intermediate Nursing Facility Level of Care; Diverted; HCBS Waiver effective 7/1/2001 B00 Intermediate Nursing Facility Level of Care; Deinstitutionalized; HCBS Waiver effective 7/1/2001 B50 AUTISM WAIVER LEVEL OF CARE CODES Code Description P Intermediate Care Facility for the Mentally Retarded Level of Care (ICF/MR) Diverted; Waiver effective 1/1/90 Q Intermediate Care Facility for the Mentally Retarded Level of Care (ICF/MR) Deinstitutionalized; Waiver effective 1/1/90 DD HCBS WAIVER (Intermediate Care Facility for the Mentally Retarded (ICF/MR) Level of Care Codes Code Description Diverted; Waiver effective 7/1/92 T Diverted; 317 Funding Priority Waiver slot; Effective 7/1/99 T01 Diverted; 317 General Funding (non-priority slot); Effective 7/1/99 T02 Deinstitutionalized from non-State Facility; Effective 7/1/92 U00 Deinstitutionalized from non-State Facility; 317 Funding Priority Waiver slot; Effective 7/1/99 U01 Deinstitutionalized from non-State Facility; 317 General Funding (non-priority slot); Effective 7/1/99 U02 Conversion Group Home (Small Private) U10 Conversion Res-Care (Large Private) U20 Conversion SVNH (Large Private) U21 Conversion Arcadia (Large Private) U22 Conversion Holy Cross Living Center (Large Private) U23 Conversion Knox Co. ARC (Large Private) U24 Conversion Millers Merry Manor (Large Private) U25 Conversion New Horizon Developmental Center (Large Private) U26 Conversion Normal Life of Indiana (Large Private) U27 Conversion North Willow Center (Large Private) U28 Cascade due to non-State Facility conversion U29 U30 Conversion Oak Meadows Learning Center (Large Private) U31 Conversion Procare Developmental Center (Large Private) U32 Conversion Riverbend Learning Center (Large Private) V00 Deinstitutionalized from State Operated Facility; Effective 7/1/92 V01 Deinstitutionalized from State Facility; 317 Funding Priority Waiver slot; Effective 7/1/99 Conversion Central State Hospital V20 Conversion NCSDC, Effective 7/1/96 V21 Conversion NISDC, Effective 7/1/96 V22

Upon completion, mail this form to:

V23 V24 V25 V26 V27 V29 W W01

Conversion FWSDC, Effective 7/1/96 Conversion MSDC, Effective 7/1/96 Conversion Evansville SH/DTU, Effective 7/1/96 Conversion Madison/Gold, Effective 7/1/96 Conversion Logansport JEU, Effective 7/1/96 Cascade due to State Facility Conversion Deinstitutionalized from Nursing Facility; (NF/OBRA); Effective 7/1/92 Deinstitutionalized from Nursing Facility; 317 Funding Priority Waiver slot; Effective 7/1/99

MEDICALLY FRAGILE CHILDREN'S WAIVER LEVEL OF CARE CODES Code Description J Hospital Level of Care; Diverted; Waiver effective 7-1-92 X Hospital Level of Care; Deinstitutionalized; Waiver effective 7-1-92 Y Skilled Nursing Facility Level of Care; Diverted; Waiver effective 7-1-92 Z Skilled Nursing Facility Level of Care; Deinstitutionalized; Waiver effective 7-1-92 TBI WAIVER LEVEL OF CARE CODES Code Description K10 Nursing Facility Level of Care; Diverted; In-State, Effective 1/1/2000 K11 ICF/MR Level of Care; Diverted; In-State K12 Hospital Level of Care; Diverted; In-State L10 Nursing Facility Level of Care; Deinstitutionalized; In-State; Effective 1/1/2000 L11 ICF/MR Level of Care; Deinstitutionalized; In-State L12 Hospital Level of Care; Deinstitutionalized; In-State L20 Nursing Facility Level of Care; Deinstitutionalized; Out of State; Effective 1/1/2000 L21 ICF/MR Level of Care; Deinstitutionalized; Out of State L22 Hospital Level of Care; Deinstitutionalized; Out of State MARITAL STATUS CODES Code Description Married A Widowed B Divorced C Code D E F Description Separated Single / Never Married Unknown