OHCA will not pay a bill that was sent to them more than 6 months after the service was provided. The bill can still get paid under these circumstances: DHS case had to wait for a disability decision from Social Security, after a hardship approval, or APS is involved with the client retro certification. The worker will need to fill out Form 08MA004E, Notification of Eligibility Status for Medical Assistance, and send it to the client.

The client will give the form to the doctor and/or nursing home facility and the provider sends the form to OHCA along with the claims to be paid for services rendered.

How to complete form 08MA004E.

• Recipient Name, address, city, state, and zip code from case
• Date: date form is completed
• Case Name: payee on the case
• Case Number: Case on which the medical retro cert was completed
• Person Code: person number on case
• Client ID#: Medical ID Number

For instructions on finding the Client ID #, refer to article IMS: CMC Screen.

The Client ID#, Medical ID number can also be found on the EF page 2 as shown here, block CD239.

Patient’s Name: person certified for the medical benefit

Date of Birth

Gender

Race

Admission or service type and date: get the information from client or doctor

Medical Assistance Eligibility Decision: check the statement that applies – whether medical benefit was certified or denied)

(Name of the person applying for medical benefit) was retroactively approved for SoonerCare on (date case was certified) effective (D2/certification date) for the following reason: (check the statement that applies)

Additional comments (if needed to explain why the action was delayed)

(Name of person applying for medical benefit) is not eligible for medical assistance for the following service dates (get the dates from the client or doctor) because: (describe why the medical benefit could not be certified for the dates of service)