SHARED SERVICES
Information Memorandum Transmittal
Medical Assistance Programs
Sandy Dugan, Administrator, DHS – CW/SSP
Field Services
Karen House, Manager of the Office of Client and
Community Services, Medical Assistance
Programs, Oregon Health Authority
Dale Marande, Manager, APD Financial Eligibility
and Waiver Group
Authorized signature
Topic:
Subject:
Forms
Number: SS-IM-13-035
Issue date: 11/15/2013
Due date: 11/15/2013
7210M guidance and new MEDC form
Applies to (check all that apply):
Addictions and Mental Health
All DHS employees
Area Agencies on Aging
Aging and People with Disabilities
Child Welfare Programs
Directors Office
Developmental Disabilities
Other (please specify): CSU ([email protected])
Self Sufficiency
Shared Services
County DD program managers
County mental health directors
Health services
Message:
Effective immediately, the Date of Request and Change Report for OCCS Medical Programs form
(7210M) has been split into two forms:
OCCS DOR form (7210M) will be used only to establish a Date of Request (DOR) for OCCS
medical programs; and
Medical Change form (MEDC) will be used to communicate reported changes between DHS
(SSP and APD)/AAA and OHP Customer Service (5503), and between DHS (SSP and APD)
and AAA offices.
7210M’s submitted prior to this change will still be honored. Duplicates should not be sent.
SS-IM-13-035
MSC 0080 Transmittal
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7210M - Date of Request for OCCS Medical Programs:
The 7210M should be used for current OCCS or APD medical beneficiaries who would like to reapply
for benefits or have experienced a change that appropriately establishes a DOR.
The 7210M will be used internally within OHP Customer Service, for DHS (SSP and APD)/AAA to send
DORs to OHP Customer Service, and for DHS (SSP and APD) and AAA offices to send DORs to one
another.
The 7210M should not be used in the following scenarios:
An individual not currently receiving OCCS or APD medical benefits. Provide a date-stamped
7210 Application for Health Coverage packet (which includes the application and the
application guide) instead.
An individual reports that they are currently receiving benefits through the Oregon Medical
Insurance Pool (OMIP). Provide a date-stamped 7210 and write “OPHP-OMIP” on the top of
the first page of the application.
An individual is found eligible for TANF and would also like medical. TANF eligibility no longer
guarantees medical eligibility. Workers should be careful not to give the impression that
customers will be automatically eligible for medical programs; their eligibility will have to be
determined using new policy as of 10/01/13. Provide a date-stamped 7210 instead.
An individual wishes to add another individual (other than a newborn) to their medical case,
and the individual is not currently receiving OCCS or APD medical benefits. This should be
treated as a request for benefits, not a change report. Provide a date-stamped 7210 instead.
There is record that the individual has recently submitted a DOR or an application that has not
yet been processed. If a DOR or application that has not yet been processed is found,
customers should be referred to contact the OHP Customer Service for follow up.
*Note: If 7210 Application for Health Coverage packets are needed, e-mail
[email protected]. In the email include:
Which form you would like to order (7210 packet);
Quantity of English, quantity of Spanish;
Shipping address; and
Branch number.
Once the order is placed, you can expect delivery in 2-3 business days.
MEDC - Change Report:
The MEDC will be used in the following ways:
DHS/AAA Staff: Use to report a change in circumstances for individuals with a medical case at
OHP Customer Service.
OHP Customer Service Staff: Use to report a change in circumstances to DHS/AAA when
individuals with an OCCS medical case are receiving DHS/AAA program benefits.
To send:
To send forms to OHP Customer Service, fax completed forms to 503-373-7493. Do not email the form.
If unable to fax to OHP Customer Service, 7210s, 7210M’s, and MEDC’s may be sent via
shuttle or mail.
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MSC 0080 Transmittal
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1. Review document for urgent medical need or pregnancy. If the document identifies
urgent medical need or pregnancy, it must be faxed to allow it to be prioritized.
2. If the document does not identify urgent medical need or pregnancy, it may be shuttled
to 5503 or mailed to OHP Customer Service at the following address within the same or
next business day:
Mail to: Oregon Health Plan
PO Box 14520
Salem, OR 97309-5044
To send forms to DHS (SSP and APD)/AAA, e-mail completed forms to the appropriate branch
case transfer e-mail box.
If you have any questions about this policy, contact:
Contact name(s):
Phone:
Email:
Jewel Kallstrom
Christy Garland
Joyce Clarkson
Carol Berg
Yer Vue-Xiong
Vonda Daniels
SS-IM-13-035
503 947 2316
503-947-5519
503-945-6106
503-945-6072
503-945-5855
541-690-6139
To reach the OCCS Medical Policy unit,
please use the new policy e-mail:
[email protected]
MSC 0080 Transmittal
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