Denials / Closures

1. Denials: If worker determines that client is not financially, or otherwise, eligible for SPPC, ADvantage, or nursing facility services, worker will deny the authorizations. If the D section is in application status, worker will also deny the D section.
2. Closures: If a worker determines an existing client is no longer eligible for services due to financial reasons, client’s request, death, etc., worker will email the HCMN III (Area Nurse) so they may take the appropriate action in Harmony to close the case. This action also closes the open authorization for the existing service. The email to the HCMN III needs to include the case number, reason for, and effective date, of closure. After the auth is closed, worker may take action to close the D section, if appropriate.

For NF cases, worker will need to take action to close both the D section and the open auth as Harmony does not address NF authorizations. There is no need to notify the HCMN III as there is no action needed in Harmony.

What to do if the client withdraws application?

1. The system would have already placed the authorizations for appropriate services into application status when the application was first submitted.
2. Worker will deny the D section, if not open for another medical program, and deny the authorizations.

What to do when a client’s ADvantage or SPPC benefit has been closed and client files for a hearing, requesting the benefits continue pending the outcome of the hearing:

1. If the D section was also closed when the LTC services were closed, worker should reopen the D section and add the client back to medical benefits (M/A on household tab in FACS).
2. Worker will submit a ticket to the HelpDesk to request services be reopened due to pending hearing. The email should include client name, IMS case number, and service that needs to be reopened. The HelpDesk will take action in Harmony to notify the HCMN of request to re-open and the system will add the appropriate authorization line in “A” status in IMS.
   • There may be a 1-day delay between the entry of the online application and when the authorization line is added to the case in IMS.

Worker should update the status to “F” for financially eligible once the authorization line is available in IMS.

3. The HCMN III will take action in Harmony to reopen the appropriate service, which will in turn trigger the system to certify the authorization in IMS.
4. If the hearing decision is in the agency’s favor and client’s benefits need to close, worker will email the HCMN III to notify of the decision. HCMN III will take closure action in Harmony, which will close the authorization in IMS. Only after the auth is closed should the worker take any further action needed on the D section.
5. If the hearing decision is in the client’s favor and benefits need to continue, worker will only need to notify HCMN III of the decision if the HCMN III was not involved in the hearing process. Otherwise, no action is needed since the service is already open in both IMS and Harmony.