5075            MEDICAID RECIPIENT IDENTIFICATION CARD

 

5075 A.       ISSUING MEDICAID TO ELIGIBLE RECIPIENTS

 

There are four ways that the Department issues written documentation that a recipient is eligible for Medicaid coverage in a given month. These documents inform the recipient and their health care provider of the recipient’s Medicaid identification number (e.g., 060000000 / 060100000), which the provider needs to submit a claim to Medicaid. Many medical providers require written proof of Medicaid eligibility before they will provide service to an individual.  Any of the following documents will serve as proof of Medicaid eligibility:

 

1. STANDARD SYSTEM ISSUED RECIPIENT IDENTIFICATION CARD (COUPON)

 

Most Medicaid recipients will receive the green Medicaid Recipient Identification Card, which is used for a recipient who is eligible to receive the full array of Medicaid services.  This ID card contains the name, recipient ID number, date of birth, eligibility month and year, eligibility code, and up to three medical resource coverage codes.  See Sample D below.

 

One standard card can be issued for up to four household members per case with five peel-off coupons (stickers) for each person.  A medical provider may adhere one of these coupons to their Medicaid claim.

 

Recipient ID Cards are issued by DPA to each recipient on a monthly basis.  For new applicants or when a recipient requests additional coupons, cards are issued throughout the month usually three times a week according to the EIS production schedule.  If more than five coupons are needed for a recipient in a given month, a manual coupon (see #3 below) may be issued by a Public Assistance office.

 

2. NON-STANDARD SYSTEM ISSUED RECIPIENT IDENTIFICATION CARD (COUPON)

 

A non-standard Recipient Identification Card has the same recipient and medical resource information as the standard card, but is used for a recipient whose Medicaid coverage is restricted to certain services, such as an exam for disability, or emergency treatment for an alien.  Instead of the multiple coupons (stickers), this ID card contains a statement of the service limitation.  A provider may photocopy this coupon and submit it with their claim for reimbursement.  See Sample E below.

 

3. SYSTEM ISSUED DENALI KIDCARE CARD

 

Each child enrolled in Denali KidCare will receive a Denali KidCare Card.  This card can be used for health care and certain medical related services only for the person named on the card. The coverage period is generally six months and is valid for the period shown on the front of the card.  See Sample F below.

 

4. MANUAL COUPON

 

Once Medicaid coverage has been authorized on EIS, a manual coupon can be printed at any DPA office.  A manual coupon contains the same recipient and medical resource information as a system issued ID card, but it does not have stickers.  A manual coupon is provided when

 

 

A manual coupon may be printed, but each printed coupon must be signed (no initials).   After the coupon is signed, it may be copied as many times as necessary before it is given to the recipient.  See Sample G below.

 

Note:  

Do not F9 out of the MEMC screen unless you want to cancel the issuance.  You must always type in the “F” issuance indicator and press “Enter” to record the issuance so the recipient’s medical claims will be paid.

 

5075 B.       AUTHORIZED REPRESENTATIVE

 

If an authorized representative (e.g., a public guardian) requests the Recipient Identification Card to be sent to him or her, the caseworker must enter the authorized representative's address in the mailing address field on the EIS Address (ADDR) screen.  To have the Medicaid ID cards mailed to the recipient and the notices mailed to the representative, the authorized representative's address must be entered in the mailing address field on the ADDR and the recipient's address in the Medicaid benefit address field on the ADD2 screen.

 

5075 C.       USING THE IDENTIFICATION CARD OR MANUAL COUPON

 

The caseworker must advise the recipient that it is the recipient’s responsibility to:

 

  1. present a current ID card or manual coupon when each medical service is received;
     

  2. ensure that the medical provider they choose is an enrolled provider in the Alaska Medicaid program;
     

  3. ensure that the service they are receiving is covered by Medicaid;
     

  4. be prepared to present proof of their identity;
     

  5. guard their coupons to prevent use by unauthorized persons; and
     

  6. pay for any medical services for which an ID card or manual coupon was not properly presented.

 

5075 D.       SAMPLE - STANDARD SYSTEM ISSUED RECIPIENT IDENTIFICATION CARD (WITH PEEL-OFF COUPONS)

 

RECIPIENT IDENTIFICATION CARD

STATE OF ALASKA

MEDICAL ASSISTANCE PROGRAM

NAME OF ELIGIBLE PERSON(S)

CLIENT I.D. NO.

ELIG. MONTH

DOB Date of Birth

E.C.

RESOURCES

MEDICARE

DOE    JOHN
****************
****************
****************

060000586
*********
*********
*********

0303
****
****
****

0461
****
****
****

00
**
**
**

x  ** **
** ** **
** ** **
** ** **

********
********
********
********

OOOOOOOOOO XOOOO
DOE    JOHN
****************

OOOOOOOOOO XOOOO
****************
****************

OOOOOOOOOO XOOOO
****************
****************

OOOOOOOOOO XOOOO
****************
****************

OOOOOOOOOO XOOOO
DOE    JOHN
****************

OOOOOOOOOO XOOOO
****************
****************

OOOOOOOOOO XOOOO
****************
****************

OOOOOOOOOO XOOOO
****************
****************

OOOOOOOOOO XOOOO
DOE    JOHN
****************

OOOOOOOOOO XOOOO
****************
****************

OOOOOOOOOO XOOOO
****************
****************

OOOOOOOOOO XOOOO
****************
****************

OOOOOOOOOO XOOOO
DOE    JOHN
****************

OOOOOOOOOO XOOOO
****************
****************

OOOOOOOOOO XOOOO
****************
****************

OOOOOOOOOO XOOOO
****************
****************

HEALTH CARE PROVIDER INSTRUCTIONS:  THIS CARD IDENTIFIES THE PERSON(S) LISTED ABOVE AS Alaska Statute A MEDICAID RECIPIENT WHO IS ELIGIBLE TO RECEIVE MEDICAL ASSISTANCE FROM HEALTH CARE PROVIDERS ENROLLED TO USE THE ALASKA MEDICAID PROGRAM.  

PROVIDERS MUST VERIFY THAT THE BEARER(S) OF THIS CARD IS THE NAMED PERSON(S) AND

WRITE THE CLIENT I.D. NUMBER ON OR AFFIX A LABEL TO EACH CLAIM THE IDENTIFICATION CARD TO EACH CLAIM.

 

  00  00000000  X0000001

  DOE    JOHN

  111 LONG AND WINDING ROAD

  ANCHORAGE, AK 99501

NOTE:  Cooperation with third party resources includes supplying your provider with medical insurance coverage information such as TRICARE, BLUE CROSS, etc. Providers must accept payment from all resources prior to billing Medicaid.

 

5075 E.       SAMPLE - NON-STANDARD SYSTEM ISSUED RECIPIENT IDENTIFICATION CARD

 

RECIPIENT IDENTIFICATION CARD

STATE OF ALASKA

MEDICAL ASSISTANCE PROGRAM

NAME OF ELIGIBLE PERSON(S)
DOE    JOHN
****************
****************
****************

CLIENT I.D. NO.
0600000586
**********
**********
**********

ELIG. MONTH
0303
****
****
****

DOB Date of Birth
0461
****
****
****

E.C.
00
**
**
**

RESOURCES
X  ** **
** ** **
** ** **
** ** **

MEDICARE
********
********
********
********

** AUTHORIZATION STATEMENT **

AUTH. IS LIMITED TO DISABILITY EXAM BY A LICENSED

PHYSICIAN OR PSYCHIATRIST, WAIVER DETERMINATION

BY CARE COORDINATION AGENCY AND

RELATED TRANS. APPROVED BY FIRST HEALTH.

HEALTH CARE PROVIDER

HEALTH CARE PROVIDER INSTRUCTIONS:  THIS CARD IDENTIFIES THE PERSON(S) LISTED ABOVE AS Alaska Statute A MEDICAID RECIPIENT WHO IS ELIGIBLE TO RECEIVE MEDICAL ASSISTANCE FROM HEALTH CARE PROVIDERS ENROLLED TO USE THE ALASKA MEDICAID PROGRAM.  

PROVIDERS MUST VERIFY THAT THE BEARER(S) OF THIS CARD IS THE NAMED PERSON(S) AND

WRITE THE CLIENT I.D. NUMBER ON OR AFFIX A LABEL TO EACH CLAIM THE IDENTIFICATION CARD TO EACH CLAIM.

 

 

  00  00000000  X0000001

  DOE    JOHN

  111 LONG AND WINDING ROAD

  ANCHORAGE, AK 99501

 

NOTE:  Cooperation with third party resources includes supplying your provider with medical insurance coverage information such as TRICARE, BLUE CROSS, etc. Providers must accept payment from all resources prior to billing Medicaid.

 

5075 F.       SAMPLE - DENALI KIDCARE CARD

 

 

5075 G.       SAMPLE - MANUAL COUPON

 

MEMC

    MEDICAL MANUAL COUPON ISSUANCE

120403 09:10
KATHY E

RECIPIENT
I.D.

  

RECIPIENT NAME

D.O.B.
MM DD YY

  

SEX

ELIG
CODE

PGM/
MEDSB

RE-
SOURCE(S)

60000000

DOE       JOHN

02 03 38

M

2

ME AF

Y

 
 
 

JOHN    DOE
PO BOX 20
KOTZEBUE AK 99752

  
 
 

******************************
*THIS AUTHORIZATION GOOD FOR *
*BENEFIT MONTH 0904 ONLY !   *
******************************

  
 
 
 

VILL: X01
DIST : 047

 

SPECIAL INFORMATION (OPTIONAL)

AUTHORIZATION SIGNATURE:

DOCUMENT # Z00000293

 

*** STATE OF ALASKA ***

ISSUANCE INDICATOR: F

 

 

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MC #28 (9/04)