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NJ DCF Logo with reverse copy

 

New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date:

Volume:

X

Forms

Chapter:

A

Forms

06-01-2009

Subchapter:

1

Forms

Issuance:

11.69

CP&P Form 11-69, Medicaid Eligibility File Demographic Changes

 

 

Click here to view or print CP&P Form 11-69, Medicaid Eligibility File Demographic Changes.

 

WHEN TO USE IT

 

This form is used any time demographic changes are made on children receiving Medicaid and/or when a new adoption/KLG case is opened, to prevent a potential break in Medicaid and/or HMO coverage.

 

HOW TO USE IT

 

·         The CP&P Form 11-69 is a template located in the on-line Forms Manual, accessed through Folio or the NJ SPIRIT (NJS) desktop, CP&P Online Policy Manual link. 

·         CP&P staff must check the correct box to indicate the purpose of the change.

·         CP&P staff must enter the following information: Child's name as it should appear, Child's name as it previously appeared (when applicable), NJ SPIRIT Case ID Number, NJ SPIRIT Person ID Number, Date of Birth, Social Security Number, Medicaid Number (when applicable), and child's HMO Information (when applicable).

·         CP&P staff completes the template on-line, and sends an e-mail notice to the IT Medicaid Unit <dcfitrmedicaid@dcf.state.nj.us> with the CP&P Form 11-69 as an attachment, each time demographic changes are made on children receiving Medicaid and/or a new adoption/KLG case is opened.

·         The date and time the form is completed will automatically appear when the Worker submits the form to the IT Medicaid Unit.

·         The change request is effective on the first day of the following month the form is submitted. If an earlier effective date is needed, the orker needs to provide documentation requiring the back dated request.

DISTRIBUTION

 

Original

-

CP&P Case Record

Electronic File Copy

-

IT Medicaid Unit