To approve a pending QMB application, complete the Form 552 used to register the application or a blank Form 552 as described in WAG 25-08-02-b with the following exceptions:

  • Item 2 - Line through the previous entry and enter the 4-digit effective month and year of the approval or action to restore assistance. This date may be backdated to 3 months before the month of the SLIB application.
  • Items 19 & 20 - Complete if information is available, otherwise leave blank.
  • Item 39 - Enter code 80 or 92. See WAG 17-02-00 for a complete description of Item 39 coding.
  • Item 60 - Enter the Medicare claim number.
    • Enter the SLIB status indicator code. See WAG 27-60-09. An HIB status indicator code is required in this item. Enter the SMIB status indicator code, if needed. See WAG 27-60-09.
  • Items 64, 65, 67, 68, & 70 - Complete if information is available, otherwise leave blank.
  • Item 77 - Leave blank.

For detailed information on processing a SLIB application, see WAG 06-13-02.