Individual Not Enrolled In Medicaid

This reject code applies only to bills for covered Medicaid Waiver services. Fee-for-service bills are rejected with this reason code if:

  • The individual is not enrolled in the Medicaid program on one or more of the dates of service on the bill.
  • The individual's spenddown obligation is marked as "unmet" in the Medicaid Management Information System (MMIS).
  • The SSN on ROCS does not exactly match the SSN used by the DHS local office MMIS.
  • The Medicaid Recipient Identification Number (RIN) on ROCS does not exactly match the RIN used by the DHS local office MMIS.
  1. Call the Department of Healthcare and Family Services (HFS) Provider Hot Line during state working hours at the Toll-Free Number or use MEDI Web Site the at any time to verify Medicaid status. This is a good preventive practice also. 
  2. Verify as described above that the SSN and RIN in ROCS match the SSN and RIN in the local office Medicaid database.

Note: Occasionally an individual's RIN is changed and ROCS will need to be updated with the new RIN.

  1. Contact the local office caseworker to find out why the individual is no longer active in Medicaid, including spenddown unmet status if applicable.
    • If necessary, help the individual reapply for Medicaid and ask for the available three months retroactive eligibility to cover any gaps in Medicaid benefits.
    • If necessary, submit a paper Notice of DHS Community Services (DPA-2653) to the DHS local office to document that the individual's spenddown obligation is met by the costs of DD program services (excluding room and board). The form is in the Provider Waiver Manual Appendices.
  2. Work with the guardian/family (if the individual lives in a family home) and the local office to get the Medicaid issues resolved.

Important note: Always request retroactive Medicaid coverage when applying or reapplying for Medicaid benefits. Up to three months of retroactive coverage can be approved. This is critical to avoid any gaps in Medicaid coverage.

  1. Resubmit the rejected bills when Medicaid issues are resolved.

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