WAG 17-01-04-c: Form 360L

(System) Centrally generates a Notice of Decision on Application for Cash and/or Medical-Third Party (Form 360L) for regular roll approvals and denials processed through AIS. The form is generated when a final disposition is made and parties other than the applicant (such as vendors, institutions, agencies, etc.) must be notified.

Form 360L is also generated for Healthy Start/MPE and MCH dispositions except for the following denial reasons (TARs):

TAR 92-MPE coverage is provided in another case, or

TAR 93-MPE pregnant woman did not come to the Family Community Resource Center to apply for regular benefits by the 45th day following the start date of MPE coverage.

(FCRC) Make sure the Form 360C is centrally sent to the client. Do not send a Form 360L to a client.

(FCRC) To generate a Form 360L, enter the name and address of the 3rd party to be sent the form on the correct AIS screen. The name and address of the 3rd party appear on the revised textthe Request for Cash, Medical and/or SNAP (Form 2378C).

(System) Automatically enters the names and addresses of Healthy Start/MPE and MCH providers. Form 360L is generated at final disposition for each case initially registered as a Healthy Start/MPE or MCH application.

Information Contained on Form 360L

The following information is included on Form 360L for all dispositions:

  • date of notice;
  • Family Community Resource Center name and address;
  • name and address of the 3rd party;
  • caseload number, case number, and application date; and
  • name of the person affected by the disposition.

The following information is generated for all eligible persons:

  • Recipient Identification Numbers (RINs);
  • first and last names; and
  • the beginning medical eligibility date (persons eligible for QMB benefits will not have a beginning medical eligibility date, but the month and year that Medicaid will begin paying the Medicare premiums will be printed).

Other Form 360L Information

  • For Cash and/or Medical, Form 360L contains the denial message for an ineligible person(s).
  • For QMB denials, the 3rd party is required to contact the Family Community Resource Center or the client for specific details regarding the denial.
  • The notice informs a 3rd party if a person(s) approved for medical has a spenddown. The notice does not give specific information about the spenddown amount. The notice tells the 3rd party to contact the client or the Family Community Resource Center for more details.

NOTE: Form 360L does not contain information about the amount of any cash benefits to be received (IPE or first regular check).