27-33-02-o: Medical Denials (AABD and Breast and Cervical Cancer) (TA 05 and TA 62)

Use the TARs in this sub-section for AABD Medical, QMB Only, SLIB Only, and QI-1 Only to:

deny an application (TA 05); or
progress a denied application to another category (TA 62).

For denials (TA 05) and case progression (TA 62) processed through AIS or IPACS, the following TARs generate a central denial notice (Form 360C) with the related reason, unless Item 39 is coded to suppress the notice. If the central notice is suppressed, the FCRC must complete and send the Notice of Decision on Application for Medical Assistance - MANG - Non-spenddown (Form 458).

Send the Notice of Decision on Applications for Payment of Medicare Premiums, Deductibles and Coinsurance (Form 458M) to approve or deny QMB/SLIB/QI-1 benefits when a unit member claims to be a Medicare Part A beneficiary and Form 458 is sent.

NOTE: If a TAR applies only to case denial, the Reason for Denial box shows TA 05 Only. If a TAR applies only to case progression, the Reason for Denial box shows TA 62 Only.

Denial and Case Progression - AABD Medical (Category 91, 92, and 93), QMB Only, SLIB Only, and QI-1 Only
TAR	REASON FOR DENIAL	MESSAGE
01	Funeral or burial application not received on time. TA 05 Only	We did not receive the application for funeral/burial payments by the last day of the 3rd month after the month of death. PM 15-07
02	Applicant could not be located. TA 05 Only	The Department has been unable to locate you. Your eligibility for assistance cannot be established. PM 02-06
03	Applicant failed to appear for eligibility interview. TA 05 Only	Due to your failure to keep appointments your eligibility cannot be established. PM 02-06
05	Applicant does not meet citizen/BCIS requirements. TA 05 Only	You do not meet Department citizenship/ alienage requirements. PM 03-01
07	Applicant not an Illinois resident, or Illinois residency not verified. TA 05 Only	You do not meet the Department residence requirement. PM 03-02
12	Not eligible for any Department cash or medical program. (Category 93 Only) TA 05 Only	Based on the information provided you are not eligible for any program the Department offers. PM 17-01
14	SSN requirement not met. TA 05 Only	Due to your failure/refusal to provide a Social Security number for a persons(s) for whom you requested assistance. PM 03-11
15	Applicant determined not blind. (Category 92 Only)	You do not meet Department definition of blindness. PM 03-07
17	Applicant determined not disabled by SSA. (Category 93 Only)	You do not meet Department definition of permanent and total disability. PM 03-08
18	Applicant determined not disabled by Client Assessment Unit (CAU). (Category 93 Only)	You do not meet Department definition of disabled. If you wish to get more information about the reason for this decision, contact the local Healthcare and Family Services office. PM 03-08 PM 03-18
23	Applicant failed to give financial information needed to decide eligibility. TA 05 Only	Your eligibility cannot be determined due to your failure to provide necessary information. PM 02-07
26	Applicant institutionalized. TA 05 Only	Your needs are currently being met by the institution. PM 03-10
39	Refused to cooperate with CSE without good cause. TA 05 Only	You refused to cooperate, without good cause, with the Child Support Enforcement Program. PM 24-01
40	Did not give nonfinancial information. Use SSN reason (TAR 14) if SSN requirement not met. TA 05 Only	Your eligibility cannot be determined due to your failure to provide necessary information. PM 02-07
42	Unmet spenddown case and income/assets over QMB limits. TA 05 Only	Your countable income and/or assets exceed the QMB standard/disregard after considering your medical expenses. PM 06-12
43	Definition of emergency medical condition not met. TA 05 Only	You do not meet Department definition of emergency medical condition. PM 06-05
44	Assets exceed the QMB/SLIB/QI-1 asset limit. TA 05 Only	Your assets exceed Department standards for Medicare cost sharing. PM 06-12 PM 06-13
55	Applicant did not comply with policy on potential income sources. TA 05 Only	You did not comply with Department policy regarding potential sources of income. PM 09-03 PM 01-02
60	Application withdrawn. TA 05 Only	Your application has been withdrawn at your request. PM 17-04
64	Applicant insured, ineligible for BCC. TA 05 Only	Applicant does not meet the Department's definition of uninsured for healthcare benefits. PM 06-20 El solicitante no satisface la definición del Departamento de no tener seguro para beneficios de cuidado de salud. PM 06-20
69	Applicant does not meet age requirements for BCC. TA 05 Only	You cannot get Breast or Cervical Cancer health benefits because of your age. To find out if you can get other health benefits, contact your local DHS office. PM 06-20 Usted no puede recibir Beneficios de Salud Para Personas con Cáncer del Seno o Cáncer del Cerviz debido a su edad. Para saber si usted es elegible para otros beneficios de salud, comuníquese con su oficina local del DHS. PM 06-20
74	Application withdrawn due to objection to policy on estate claims and liens. TA 05 Only	Your application has been withdrawn at your request due to Department policy regarding Estate Claims/Liens. PM 23-09 PM 17-04
76	Not enrolled in Medicare Part A. (QMB Only, SLIB Only, QI-1 Only) TA 05 Only	You are not a Medicare Part A beneficiary. PM 06-12 PM 06-13
77	Income exceeds QMB/SLIB/QI-1 income standard. TA 05 Only	Your income exceeds Department standards for Medicare cost sharing. PM 06-12 PM 06-13
79	Refused to cooperate with medical support policy. TA 05 Only	You did not cooperate regarding medical support rights. PM 03-19
87	Assets, as verified by Unearned Income Data Match. (QMB Only, SLIB Only, QI-1) TA 05 Only	The value of your assets from Interest, Dividends, etc. exceeds the maximum allowed by agency standards. PM 07-02
90	Change or correct ID number or category. TA 62 Only	No notice is sent.
C2	Income over 350% of the FPL.	Your income exceeds the allowable income level. Sus ingresos exceden el nivel de ingreso permitido.
C3	Assets over $25,000.	Your assets exceed the allowable asset limit. Sus bienes exceden el límite de bienes permitido.
C4	Applicant failed to provide proof of FICA/IMRF payment or its equivalent.	You did not provide proof of your employment. You failed to provide proof of FICA/IMRF payment or its equivalent. Usted no presentó comprobante de empleo. Usted no proveyó comprobante de pago de FICA/IMRF o su equivalente.
C5	Applicant is eligible for another Medicaid program without a spenddown.	You are ineligible for Health Benefits for Workers with Disabilities. You qualify for a different program. To find out where to apply, call 1-800-226-0768. Usted no es elegible para Beneficios de Salud para Trabajadores con Deshabilidades. Usted califica para un programa diferente. Para información sobre dónde solicitar, llame al 1-800-226-0768.
C6	Applicant is under 16 or over 64.	You do not meet the age requirement of the Health Benefits for Workers with Disabilities. Usted no reúne los requisitos de edad para Beneficios de Salud para Trabajadores con Deshabilidades.
C7	Applicant not disabled.	You do not meet Department definition of disabled. If you wish to get more information about the reason for this decision, call 1-800-226-0768. Usted no reúne la definición de discapacitado del Departamento. Si usted desea más información sobre la razón para esta decisión, llame al 1-800-226-0768.
D2 (PE only)	Declared family income is above income standard	Form 3818A sent.
D3 (PE only)	Received PE within last 12 months	Form 3818A sent.
D4 (PE only)	Insufficient information provided	Form 3818A sent.
D5 (PE only)	Immigration status not met	Form 3818A sent.
E3	Applicant failed to provide signature page.	We cannot decide if you can get the benefits you applied for. We did not receive the page with your signature or other information we asked for. PM 02-04, 02-07
E6	Applicant already receiving requested assistance.	You are already receiving the benefits you requested. PM 02-04-09
V1	Applicant is not eligible for Veterans Care.	You do not qualify for Veterans Care. PM 06-25 Family Community Resource Center sends the notice.