The EBT-4 form is used to make adjustments to providers when incorrect information is transmitted to EPPIC and the provider is paid incorrectly.

The link for the EBT-4 form is EBT

Once you have accessed this, you will find the following screen, click “start now”.

You will then find the screen below. Select ”EBT-4”.

You will then encounter the screen below. Fill in the information accordingly.

Select next and you will find this screen, Input all necessary information. In our example scenario, we are looking to correct April 2024 copay as we charged the customer for a copay when they were supposed to be exempt and it was too late to change in the system.

Select “next” and you will encounter this screen. Fill all information in accordingly.

When finished, select “next” to go to next screen. You will encounter this screen. You can submit any feedback that you feel necessary, but this is not required.

Once you select “submit” you will get

This means your process is done. You will also receive a confirmation email showing that it has been sent successfully.

If the EBT-4 is necessary because of an incorrect unit type or incorrect number of units:

• Click in the box beside incorrect unit type or number of units. This will cause a chart to appear which you will use to enter the correct Unit type / Number of Units for all applicable children. You should notice red boxes to the left and green boxes to the right of the chart. Click on any green + box to add lines for any additional children. Click on any red – box to delete any lines that are not necessary for the EBT-4 form.
• Enter Person Number of child as a two digit number. 03 for example

Unit Type (K55) /  Number of Units (K50)  –  PRIMARY AUTHORIZATIONS ONLY

• Enter ONLY the correct Unit Type (K55) if a correction is needed for the Unit Type (Click the drop down arrow and select the correct Unit Type)
• Enter ONLY the correct Number of Units  (K50) if a correction is needed for the Number of  Units (Click the drop down arrow and select the correct Number of Units)

Unit Type (K68) / Number of Units (K67) – SECONDARY AUTHORIZATIONS ONLY

• • • 1. • Only Use K68/K67 fields if a correction is needed for Secondary Authorizations.
      2. Incorrect star statusIf the EBT-4 is necessary because of an incorrect STAR STATUS:
         • Click in the box beside Incorrect star status
         • Click the drop down arrow and select the correct star status
      3. Incorrect date of birthIf the EBT-4 is necessary because of an incorrect date of birth:
         • Click the box beside Incorrect date of birth
         • Enter Person number of Child.
         • Enter Date of birth in MM/DD/YYYY format
      4. Pending swipes over 90 days old.
         Option 5 is only used for pending swipes that have not been paid and are over 90 days old.
         
         • Remember that all pending swipes that are less than 90 days old will be paid automatically by the EPPIC system once the worker makes the necessary corrections in FACS.
         • For any swipes that have been DENIED and need to be paid, the provider must submit a manual claim. (An EBT-4 form is not used for denied swipes).
           • Click on the Box next to Pending swipes over 90 days old. This will cause a chart to appear which you will use to enter authorization Number and For Date.
           • Enter the Authorization Number. Refer to article Child Care Subsidy: EKL Screen on how to obtain authorization number.
           • Click on the For Date field, Click on the drop down arrow, and click on the calendar date in which payment is needed.

Use the Comments Box to enter any additional information that is pertinent to the case regarding Child Care Payment Adjustments for the Specific Month.

Person Competing Form:

• Enter First Name of Person completing form
• Enter Last Name of Person completing form
• Enter the Supervisor #
• Enter the Worker #
• Enter phone number with area code
• Enter date in MM/DD/YYYY format
• Click drop down arrow and select County
• Click Submit

REMEMBER: One form must be completed for each month payment adjustment is needed.