NEWBORN ELIGIBILITY FORM INSTRUCTIONS � pROvIdER INFORMaTION ImmedIately after the bIrth of a chIld to a mother who has valId medIcal assIstance coverage, notIfy the county assIstance offIce (cao) contact person located In the mother's county of resIdence by telephone or fax. follow-up the InItIal contact WIThIN ThREE (3) WORkING daYS of the chIld's bIrth by completIng thIs form and submIttIng It to the approprIate cao/dIstrIct offIce. WhEN COMpLETING ThIS FORM, REMOvE ThIS ShEET aNd FOLLOW ThE INSTRUCTIONS LISTEd. pROvIdER INSTRUCTIONS FOR COMpLETING ThE Ma 112 provIders must complete the unshaded areas of the form to supply requested InformatIon to the approprIate county assIstance offIce (cao). the shaded areas are for use by the cao. after completIng the requIred InformatIon, maIl the form to the approprIate county assIstance offIce. IMpORTaNT before the baby's dIscharge be sure to: 1. complete thIs form wIth the assIstance of the baby's mother or authorIzed representatIve. 2. complete the "temporary newborn elIgIbIlIty card" (ma 467) and present It to the mother In order for her to obtaIn medIcal servIces for her newborn prIor to receIvIng the newborn's medIcal assIstance access card. 3. Instruct the baby's mother or authorIzed representatIve to contact the approprIate managed care organIzatIon for assIstance In choosIng a prImary care case manager who wIll provIde medIcal care for the baby and schedule appoIntments for the baby's epsdt screenIng, ImmunIzatIons and follow-up care. pROvIdER INSTRUCTIONS FOR BILLING bIll medIcal assIstance IMMEdIaTELY after you contact the cao and submIt the ma 112 to the cao. IT IS NO LONGER NECESSaRY TO WaIT FOR ThE Ma 112 TO BE RETURNEd TO YOU BEFORE SUBMITTING YOUR INvOICE. when you submIt your InvoIce to medIcal assIstance prIor to receIvIng the newborn's recIpIent number, you must bIll as follows: � on the UB-04 invoice, Use the mother's recipient nUmBer and condition code "Y0" which indicates that this is a newborn bIllIng. � inthe"remarkssection"oftheinvoice,placethemother's name, date of bIrth and socIal securIty number. � on the cms-1500, Use the mother's recipient nUmBer and attachment type `26' to IndIcate that thIs Is a newborn bIllIng. also, use attachment code `99' and on a separate sheet attach remarks - inclUde the mother's name, date of bIrth and socIal securIty number. ifthisformisretUrnedtoYoUpriortoBilling,checkitem3 for cao elIgIbIlIty determInatIon. If the newborn Is elIgIble, BesUretoUsethe10digitrecipientnUmBershowninitem17 to bIll for the baby's care. theBaBYwillhavemedicalassistancecoverageUnderthe10 dIgIt recIpIent number for one (1) year followIng the baby's bIrth. cash assIstance for the baby wIll begIn wIth the baby's bIrthdate and end on the fIrst day of the second month followIng the bIrth or upon the mother's release from the hospItal, whIchever Is later. cash coverage wIll be desIgnated by the record and category number assIgned by the county assIstance offIce. If the county actIon IndIcates "InelIgIble" In Item 3, the IndIvIdual IdentIfIed by the recIpIent number shown In Item 12 was not elIgIble for medIcal assIstance or cash assIstance on the newborn's date of bIrth. qUESTIONS REGaRdING COUNTY aSSISTaNCE OFFICE aCTION MaY BE dIRECTEd TO ThE CaO CONTaCT pERSON dESIGNaTEd ON ITEM 33 American LegalNet, Inc. www.FormsWorkFlow.com ma 112 12/13 SpECIFIC INSTRUCTIONS FOR COMpLETING EaCh qUESTION aRE aS FOLLOWS: 1. m.a. fee for servIce IdentIfy whether the recIpIent Is covered by regular medIcal assistanceBYcheckingthisBlock. IdentIfy whether the recIpIent Is coveredBYanhmo/hioBYcheckingthe appropriateBlock. cao completIon enter the payment name shown on the mother's access card. entertheareacodeandtelephone number of payment name (home or other). cao completIon cao completIon enter the maIlIng address of payment name obtaIned from mother. cao completIon caocompletion enter the mother's name enterthemother's10digitrecipient number as shown on her access card or through accessIng e.v.s. enter the socIal securIty number of the mother. enter the bIrthdate of mother. enterthetelephonenUmBerofthe mother. cao completIon cao completIon enter the last name, fIrst name and mIddle InItIal of the newborn. (If child is not named, enter last name and either "baby girl" or "baby boy" as appropriate). If more than three babies, complete a second form. enter the bIrthdate of the newborn In sIx (6) dIgIt format (mm/dd/yy). enterthesexofthenewBorn. enter the race of newborn usIng the codes below the Item. checkmarkappropriateBlock(Yesor no) to IndIcate If a socIal securIty applIcatIon (eab) was fIled and complete Item 43. cao completIon American LegalNet, Inc. www.FormsWorkFlow.com 24. 25. assIstance status medicalresoUrcecode(s) cao completIon enterthemother'smedicalresoUrce code(s) obtaIned from the elIgIbIlIty verIfIcatIon system (evs). 27. 29. 31. record number control dIgIt hmo/hioplanname 2. hmo/hIo ThE FOLLOWING aRE CaO COMpLETEd qUESTIONS 26. 28. 33. 34. 30. 32. county category m.a.feeforservice plan code (hmo/hIo) cao completIon only complete thIs sectIon If there are resources avaIlable towards the baby's staYwhicharenotshowninitem25.for example, If the chIld's father has Insurance whIch would cover the baby's medIcal expenses, complete as much of the InformatIon as possIble. havethemotheroraUthorized representatIve for the newborn sIgn here. enter the date the applIcatIon was sIgned. enter the name of hospItal, bIrth center or nurse mIdwIfe submIttIng the applIcatIon. enter your medIcal assIstance provIder I.d. no. enter the area code and phone number of the hospItal or bIrth center contact person, or the nurse mIdwIfe. entertheaddressofthehospital,Birth center, or nurse mIdwIfe submIttIng the applIcatIon. enter the name of the nurse mIdwIfe, or the contact person In the hospItal or bIrth center 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. cao determInatIon payment name telephonenUmBer cIvIl sub dIvIsIon school dIstrIct maIlIng address effectIve date closingdate mother's name mother'srecipientno. county assIstance offIce thIrd party lIabIlIty resources 35. signatUreofmotheror authorIzed representatIve date provIder's name 36. 37. 13. 14. 15. 16. 17. 18. mother's ssn mother's bIrthdate mother'stelephoneno. lIne number newborn's recIpIent no. newborn's name 38. 39. provIder's number telephone number 40. provider'saddress 41. provIder's contact person 19. 20. 21. 22. bIrthdate sex race providerappliedforss# (eab-enumeratIon at bIrth