A101

TAF - Approval for 1 Month Only

A102

TAF - Approval for 1st and 2nd Months

A103

TAF - Approval for 1st, 2nd and 3rd Months

A104

TAF - Denial 1st Month - Approval 2nd Month - CSE Assignment

A105

TAF - Denial 1st Month, Approval 2nd and 3rd Months

A106

TAF - Review Complete

A107

TAF - Approval 1 Month Only - No CSE Assignment

A108

TAF - Approval 1st and 2nd Months - No CSE Assignment

A109

TAF - Approval 1st, 2nd and 3rd Months - No CSE Assignment

A110

TAF - Denial 1st Month - Approval for 2nd Month - No CSE Assignment

A111

TAF - Denial 1st Month - Approval for 2nd and 3rd Months - No CSE Assignment

A115

TAF - Approval - TM Closure

A120

TAF - Approval for 1st and 2nd Months - Remote Pin

A128

TAF Approval, no Work Programs

A191

TAF and FS - Approval for 1 Month Only

A192

TAF and FS - Approval for 1st and 2nd Months

A193

TAF and FS - Approval for 1st, 2nd and 3rd Months

A196

TAF and FS - Reviews Completed

A197

TAF and FS - Approval for 1 Month Only - No CSE Assignment

A198

TAF and FS - Approval for 1st and 2nd Months - No CSE Assignment

A199

TAF and FS - Approval for 1st, 2nd and 3rd Months - No CSE Assignment

A200

TAF - Failure to Provide Information

A201

TAF - Failure to Cooperate

A202

TAF - Residency Requirement Not Met

A203

TAF - Loss of Contact

A206

TAF Denial - Excess Income

A207

TAF - Resources Exceed Maximum

A208

TAF - Denial - Other Reasons

A209

TAF - Application Withdrawn

A210

TAF - Ineligible Assistance Unit

A211

TAF - Citizenship/Alien Status

A213

TAF - Work Related Requirements Not Met

A216

TAF Denial - CSE Requirements Not Met

A230

TAF Denial - 60 Month Time Limit

A240

TAF - Failure to Apply for Potential Benefits

A290

TAF and FS Denial - Failure to Provide Information

A291

TAF and FS Denial - Failure to Cooperate

A292

TAF and FS Denial - Residency Requirement Not Met

A293

TAF and FS Denial - Loss of Contact

A296

TAF and FS Denial - Excess Net Income

A297

TAF and FS Denial - Resources Exceed Maximum

A298

TAF and FS Denial - Other Reasons

A299

TAF and FS Denial - Applications Withdrawn

Back to the Top

A400

TAF - Failure to Provide or Verify Information

A401

TAF - Failure to Cooperate

A402

TAF - Residency Requirement Not Met

A403

TAF - Loss of Contact

A404

TAF - To the Family of the Deceased

A406

TAF - Closure - Excess Income

A407

TAF - Resources Exceed Maximum

A408

TAF - Closure - Other Reasons

A409

TAF - Closure at Client's Request

A410

TAF - Ineligible Assistance Unit

A411

TAF - CS Income Exceeds Maximum - Eligible EM

A412

TAF - Closure - Work Penalty

A416

TAF - Closure - CSE Penalty

A420

TAF - Closure - Excess Earnings

A428

TAF Closure - No Work Programs

A430

TAF - Closure - 60 Month Time Limit

A431

TAF - Closure and FS Change - 60 Month Time Limit

A440

TAF - Failure to Apply for Potential Resources

A443

TAF - No Eligible Child

A450

TAF - Failure to Complete Review

A451

TAF - 4 Month Extended Medical Closure

A480

TAF -Closure and FS Change - Work Penalty

A485

TAF, FS and CC Closure - Excess Income

A490

TAF and FS Closure - Failure to Provide Information

A491

TAF and FS Closure - Failure to Cooperate

A492

TAF and FS Closure - Residency Requirement Not Met

A493

TAF and FS Closure - Loss of Contact

A496

TAF and FS Closure - Excess Income

A497

TAF and FS Closure - Excess Resources

A498

TAF and FS Closure - Other Reasons

A499

TAF and FS Closure - Client's Request

Back to the Top

A600

TAF - Reinstate After Suspension

A601

TAF - Erroneous Discontinuance

A602

TAF - Benefits Paid Pending Hearing Decision

A603

EM - Reinstate After Suspension

A690

TAF and FS - Reinstatement Notice

A701

TAF - Change in Benefits - Other Reasons

A702

TAF - Supplemental Benefits

A703

TAF - Change in Household Members - Benefits

A704

TAF - Change in Benefits - Income Change

A705

TAF - Change in Benefits - Work Program Allowance

A706

TAF - Change in Benefits - Living Arrangements

A712

TAF - Change to Zero Benefits - Information Pending

A713

TAF - Change in Benefits - Recoupment

A740

TAF - Change Due to Cooperation With CSE

A741

TAF - Change - CSE Penalty

A744

TAF - Change Due to Cooperation - Work Programs

A745

TAF - Change - 1st Work Penalty

A747

TAF - Change Due to Cooperation - HIPPS

A748

TAF - Change - Non-cooperation With HIPPS

A750

TAF and FS Benefits and Income Changes

A751

TAF and FS Change in Household Members

A752

TAF and FS Change to Zero Benefits - Information Pending

A753

TAF and FS Change in Benefits - Recoupment

Back to the Top

A801

TAF - Caseload Transfer

A821

TAF - Successful Families Notice

A822

TAF - Work Readiness Screening

A827

TAF - Fraud Disqualification - Nonparticipating Individual

A828

TAF - Fraud Disqualification - Permanent

A830

TAF - Fraud Disqualification - Recipient

A831

TAF - Repayment Agreement - Fraud - Recipient

A832

TAF - Repayment Agreement - Agency/Client Recipient

A834

TAF - Repayment Agreement - Non-recipient

X004

Landlord/Residency Verification Request
*Must be manually requested on the ADDR Screen.

X014

Denial - Failure to Complete Interview Process

X015

Closure - No Review Return

X021

Successful Families Notice

X049

Important Information - New Way to Report Changes

X086

An Important Reminder from SRS

X087

School Lunch Notice

X088

Notice of TAF Months Used

Z046

TAF Mass Change

, Z054, Z055, Z056

Back to the Top

C100

CI - Approval With or Without Spenddown

C121

CI - Approval LTC - 1 Month

C122

CI - Approval LTC - 2 Months

C123

CI - Approval LTC - 3 Months

C127

CI - Review Complete

C128

CI - Approval - Excess Liability - Spenddown Met

C129

CI - Approval - Excess Liability - Spenddown Unmet

C130

CI - Review - Spenddown Met - Excess Liability

C131

CI - Review - Spenddown Unmet - Excess Liability

C132

CI - Approval - Excess Liability

C133

CI - Review - Excess Liability

C208

CI - Denial - General

C400

CI - Closure - General

C504

CI - Suspension of LTC Payment - General

C600

CI - Reinstate After Suspension

C702

CI - Change in Patient Liability

C707

CI - Spenddown Met - Excess Liability

C708

CI - Enter ACH - Excess Liability - Spenddown Met

C709

CI - Enter ACH - Excess Liability - Spenddown Unmet

C717

CI - Enter ACH - Excess Liability

C837

CI - Medical Card Returned

C911

CI - Facility Notice - Approval LTC - 1 Month

C912

CI - Facility Notice - Approval LTC - 2 Months

C913

CI - Facility Notice - Approval LTC - 3 Months

C921

CI - General Denial

C941

CI - General Closure

C961

CI - Reinstate After Suspension

C971

CI - Mass Change

C972

CI - Facility Notice - Change in Patient Liability

C973

CI - Suspension LTC Payment

C974

CI - Review Complete - Remains Eligible

C978

CI - Facility - Excess Liability No Spenddown - Spenddown Met

C979

CI - Facility - Excess Liability - Spenddown Unmet

C980

CI - Review Complete - Excess Liability - Spenddown Met

C981

CI - Review Complete - Excess Liability - Spenddown Unmet

X019

Reporting the Birth of Your Child

X024

Failure to Complete Interview Process

X025

Closure for Failure to Return Review

X056

Immunization Notice

X057

Immunization Notice - 12 Months

X086

An Important Reminder from SRS

Z047

CI Mass Change in Patient Liability

F101

FS Approval for 1 Month Only

F102/102F

FS Approval for 1st and 2nd Months

F103/103F

FS Approval for 1st, 2nd and 3rd Months

F104

FS Denial 1st Month Approval for 2nd Month

F105

FS Denial 1st Month Approval for 2nd and 3rd Months

F106/106F

FS Review Complete

F107/107F

FS Review Complete + Simplified Reporting Requirements

F111

FS Approval for 1 Month Only + Simplified Reporting Requirements

F112

FS Approval for 1st and 2nd Months + Simplified Reporting Requirements

F113

FS Approval for 1st, 2nd and 3rd Months + Simplified Reporting Requirements

F114

FS Denial 1st Month - Approval 2nd Month + Simplified Reporting Requirements

F115

FS Denial 1st Month - Approval 2nd and 3rd Months + Simplified Reporting Requirements

F120

FS Approval for 1st and 2nd Months - Remote Pin

F121

Expedited Food Stamps - Postponed Verification

F200

FS - Failure to Provide Information - Reactivate Application

F201

FS - Failure to Cooperate

F202

FS - Residency Requirement Not Met

F203

FS - Loss of Contact

F205

FS - Gross Income Exceeds Standard

F206

FS - Net Income Exceeds Standard

F207

FS - Resources Exceed Maximum (English and Spanish)

F208

FS - Denial - Other Reasons

F209

FS - Application Withdrawn

F210

FS - Does Not Meet Household Requirement

F211

FS - Citizenship/Alien Status

F216

FS - ABAWD Requirements Not Met

F221

FS - Student Eligibility Criteria Not Met

Back to the Top

F400

FS - Failure to Provide or Verify Information

F401

FS - Closure - Failure to Cooperate

F402

FS - Residency Requirement Not Met

F403

FS - Loss of Contact

F404

FS - To the Family of the Deceased

F405

FS - Gross Income Exceeds Standard (English and Spanish)

F406

FS - Net Income Exceeds Standard

F407

FS - Resources Exceed Maximum

F408

FS - General Closure - Other Reasons

F409

FS - Closure at Client Request

F410

FS - No Longer Meets Household Requirement

F412

FS - Closure - Work Penalty

F416

FS - Closure - ABAWD Requirements Not Met

F421

FS - Student Eligibility Criteria Not Met

F422

FS - Residing in an Institution

F424

FS - One Person Household Disqualified for Fraud

F426

FS - Added to Another Active Case

F448

FS - Interim Report Non-receipt Notice (English and Spanish)

Back to the Top

F600

FS - Reinstate after Suspension

F601

FS - Erroneous Discontinuance

F602

FS - Benefits Paid Pending Hearing Decision

F604

FS - Interim Report Reinstatement (English and Spanish)

F701

FS - Change in Benefits - Other Reasons

F702

FS - Supplemental Benefits

F703

FS - Change in Household Members

F704/704F

FS - Change in Benefits - Income Change

F705

FS - Change in Benefits - Income Change - No Dependent Care Verification

F706

FS - Interim Report Review Complete (English and Spanish)

F707

FS - Interim Report Review Complete (SSI)

F708

FS - Change in Benefits - Change in Household Deductions

F709

FS - Change - Work Penalty

F711

FS - Change in Benefits - Citizenship/Alien Status

F712

FS - Change to Zero Benefits - Information Pending

F713

FS - Change in Benefits - Recoupment

F716

FS - Change in Benefits - ABAWD Requirements

F744

FS - Change Due to Cooperation - Work Programs

F745/745F

FS - Mass Change - Benefits Change

F746

FS - Change in Benefits - 2 Months

Back to the Top

F801

FS - Caseload Transfer

F827

FS - Fraud Disqualification - Nonparticipating Individual

F828

FS - Fraud Disqualification - Permanent

F830

FS - Fraud Disqualification - Participating Individual

F831/831F

FS - Repayment Agreement - Fraud Participating Household

F832/832F

FS - Repayment Agreement - Agency/Client - Participating Household

F833/833F

FS - Repayment Agreement - Agency/Client - Nonparticipating Household

F834/834F

FS - Repayment Agreement - Fraud - Nonparticipating Household

F835/835F

FS - Repayment Agreement

F839

FS - Notice of Lost Benefits

F841

FS - Notice of Lost Benefits With Offsetting

F842

FS - Eligibility for Free School Meals

F843/843F

FS - Interim Report Form

F844

FS - Notice of Restored Benefits

F845

FS - Important Information (ABAWD)

F846

FS - Change Report Form

F847/847F

Interim Report - Incomplete Notice

F849

FS - Important Information - ABAWD - ICT

F850

FS - Adjustment Notice

X004

Landlord/Residency Verification Request
*Must be manually requested on the ADDR Screen.

X019

Reporting the Birth of Your Child

X043

Notice of Canceled Food Stamps

X044

Denial Failure to Complete Interview Process

X045

Notice of Missed Interview

X048

Interim Report Non-receipt Notice (English and Spanish")

X049

Important Information - New Way to Report Changes

X056

Immunization Notice

X057

Immunization Notice - 12 Months

X087

School Lunch Notice

X843

FS - Interim Report Form

X853

SSI Report Form

Z048

FS - Change in Benefits (English and Spanish)

Back to the Top

G101

GA - Approval for 1 Month Only

G102

GA - Approval for 1st and 2nd Months

G103

GA - Approval for 1st, 2nd and Third Months

G104

GA - Denial 1st Month - Approval for 2nd Month

G105

GA - Denial 1st Month - Approval for 2nd and 3rd Months

G106

GA - Review Complete

G107

GARN - Approval

G113

GA - Hardship Review Approval for Age or GARN

G114

GA - Hardship Review Approval - SS Application

G115

GA - Hardship Review Approval - VR

G191

GA and FS - Approval for 1 Month Only

G192

GA and FS - Approval for 1st and 2nd Months

G193

GA and FS - Approval for 1st, 2nd and 3rd Months

G196

GA and FS - Reviews Complete

G200

GA - Failure to Provide Information

G201

GA - Failure to Cooperate

G202

GA - Residency Requirement Not Met

G203

GA - Loss of Contact

G204

GA - To the Family of the Deceased

G205

GA - Income Exceeds Maximum

G206

GA - Excess Net Income

G207

GA - Resources Exceed Maximum

G208

GA - Denial - Other Reasons

G209

GA - Application Withdrawn

G210

GA - Ineligible Assistance Unit

G211

GA - Citizenship/Alien Status

G212

GA - GA Denial - 24 Month Time Limit

G213

GA - Work Related Requirements Not Met

G214

Failure to Meet Disability Criteria

G215

GA - Failure to Cooperate With HIPPS

G220

GA Denial - Non Coop with PMDT

G240

GA - Failure to Apply for Potential Benefits

G290

GA and FS Denial - Failure to Provide Information

G291

GA and FS Denial - Failure to Cooperate

G292

GA and FS Denial - Residency Requirement Not Met

G293

GA and FS Denial - Loss of Contact

G294

GA and FS Denial - To the Family of the Deceased

G295

GA and FS Denial - Income Exceeds Maximum

G296

GA and FS Denial - Excess Net Income

G297

GA and FS Denial - Resources Exceed Maximum

G298

GA and FS Denial - Other Reasons

G299

GA and FS Denial - Applications Withdrawn

Back to the Top

G400

GA - Failure to Provide or Verify Information

G401

GA - Failure to Cooperate

G402

GA - Residency Requirement Not Met

G403

GA - Loss of Contact

G404

GA - To the Family of the Deceased

G405

GA - Income Exceeds Maximum

G406

GA - Excess Net Income

G407

GA - Resources Exceed Maximum

G408

GA - Closure - Other Reasons

G409

GA - Closure at Client's Request

G410

GA - Ineligible Assistance Unit

G411

GA - Closure - No Longer GA Vulnerable

G412

GA - Closure - 24 Month Time Limit

G413

GA - Hardship Closure

G416

GA - Closure - Failure to Cooperate With HIPPS

G417

GA - Closure - SSI Approval

G420

GA - Closure - Non Coop with PMDT

G440

GA - Failure to Apply for Potential Benefits

G450

GA - Failure to Complete Review

G452

GA - Time Limited Program - GARN

G453

GA - Left DT Facility - GADT

G490

GA and FS Closure - Failure to Provide Information

G491

GA and FS Closure - Failure to Cooperate

G492

GA and FS Closure - Residency Requirement Not Met

G493

GA and FS Closure - Loss of Contact

G494

GA and FS Closure - To the Family of the Deceased

G495

GA and FS Closure - Income Exceeds Maximum

G496

GA and FS Closure - Excess Net Income

G497

GA and FS Closure - Excess Resources

G498

GA and FS Closure - Other Reasons

G499

GA and FS Closure - At Client's Request

Back to the Top

G600

GA - Reinstate After Suspension

G601

GA - Erroneous Discontinuance

G602

GA - Benefits Paid Pending Hearing Decision

G701

GA - Change in Benefits - Other Reasons

G702

GA - Supplemental Benefits

G703

GA - Change in Household Members

G704

GA - Change in Benefits - Income Change

G706

GA - Change in Benefits - Living Arrangements

G707

GA - Change in Benefits - Loss of Income Disregards - Deductions

G712

GA - Change to Zero Benefits - Information Pending

G713

GA - Change Benefits - Recoupment

G750

GA and FS - Benefits and Income Changes

G751

GA and FS - Change in Household Members

G752

GA and FS - Change to Zero Benefits - Information Pending

G753

GA and FS - Change in Benefits - Recoupment

G801

GA - Caseload Transfer

G827

GA - Fraud Disqualification - Nonrecipient

G828

GA - Fraud Disqualification - Permanent

G830

GA - Fraud Disqualification - Recipient

G831

GA - Repay Agreement - Fraud - Recipient

G832

GA - Repay Agreement - Agency/Client Recipient

G834

GA - Repayment Agreement - Non Recipient

G854

GA - Time Limit Information

X004

Landlord/Residency Verification Request
*Must be manually requested on the ADDR Screen.

X019

Reporting the Birth of Your Child

X045

Notice of Missed Interview

X054

Failure to Complete Interview Process

X055

Closure for Failure to Return Review

X086

An Important Reminder From SRS

Back to the Top

Z049

GA Mass Change

L101

GP - Approval

L104

GP - Denial 1^st Month, Approval 2^nd Month

L106

GP - Review Complete

L118

GP - Support Services Approved

L197

GP and FS - Approval for One Month

L198

GP and FS - Approval for 1^st and 2^nd Month

L199

GP and FS - Approval for 1^st, 2^nd and 3^rd Month

L200

GP - Failure to Provide Information

L201

GP - Failure to Cooperate

L202

GP - Residency Requirement Not Met

L203

GP - Loss of Contact

L206

GP - Income Exceeds Maximum

L208

GP - Denial - Other Reasons

L209

GP - Application Withdrawn

L210

GP - No Legal Custody

L211

GP - Citizenship/ Alien Status

L212

GP - Caretaker Age

L213

GP - Relationship Status

L214

GP - Child not in Household

L215

GP - Parent in Household

L216

GP - Child in State Custody

L217

GP - Funding Not Available

L218

GP - Support Services Denied

L400

GP - Failure to Provide or Verify Information

L401

GP - Failure to Cooperate

L402

GP - Residency Requirement Not Met

L403

GP - Loss of Contact

L406

GP - Income Exceeds Maximum

L408

GP - Closure - Other Reasons

L409

GP - Closure at Customer’s Request

L410

GP - No Legal Custody

L411

GP - Citizenship/ Alien Status

L412

GP - Caretaker Age

L413

GP - Relationship Status

L414

GP - Child not in Household

L415

GP - Parent in Household

L416

GP - Child in State Custody

L450

GP - Failure to Complete Review

L601

GP - Erroneous Discontinuance

L602

GP - Benefits Paid Pending Hearing Decision

L690

GP - GP and FS - Reinstatement Notice

L701

GP - Change in Benefits - Other Reasons

L702

GP - Supplemental Benefits

L703

GP - Change in Household Members

L801

GP - Caseload Transfer

L827

GP - Fraud Disqualification - Non Recipient

L828

GP - Fraud Disqualification - Permanent

L830

GP - Fraud Disqualification - Recipient

L831

GP - Repayment Agreement - Fraud - Recipient

L832

GP - Repayment Agreement - Agency/Client Recipient

L834

GP - Repayment Agreement - Non Recipient

M102

MA - Medically Needy Approval With Spenddown Met

M103

MA - Medically Needy Approval With Spenddown Not Met

M104

MA - CM - Approval - No CSE (English and Spanish)

M105

MA - CM - Approval With CSE (English and Spanish)

M106

MA - CM - Approval Due to TAF Eligibility (English and Spanish)

M107

MA - Prior Medically Needy Approved - Spenddown Met

M108

MA - Prior Medically Needy Approved - Spenddown Not Met

M110

MA - Medically Needy Review Spenddown Met

M111

MA - Medically Needy Review Spenddown Not Met

M112

MA - CM - Review Completed No CSE (English and Spanish)

M113

MA - CM - Review Completed (English and Spanish)

M114

MA - CM - Prior Medical Approval (English and Spanish)

M115

MA - CM - Prior Medical Approval Partial Denial No CSE

M116

MA - CM - Prior Medical Approval Partial Denial

M117

MA - CM - Prior Medical Approval - No CSE (English and Spanish)

M118

MA - CM - Expedited Pregnant Woman - No CSE (English and Spanish)

M119

MA - CM - Approval - Partial Denial

M123

MA - CM - Approval - Partial Denial - No CSE

M124

PE Ends / MA CM Approval No CSE (For Clearinghouse Use Only)

M125

PE Ends / MA CM Approval with CSE (For Clearinghouse Use Only)

Back to the Top

M200

MA - Failure to Provide Information

M201

MA - Failure to Cooperate

M202

MA - Residency Requirement Not Met (English and Spanish)

M203

MA - Loss of Contact (English and Spanish)

M205

MA - Excess Income - Unlikely to Meet Spenddown

M206

MA - CM - Denial - Excess Income (English and Spanish)

M207

MA - Resources Exceed Maximum

M208

MA - Denial - Other Reasons

M209/209M

MA - Application Withdrawn

M211

MA - Citizenship/Alien Status

M212

MA - CM - Prior Medical Denial

M214

MA - CM - Denial Residency Requirement Not Met (English and Spanish)

M215

MA - CM - Denial Other Reasons

M216

MA - CM - Denial Loss of Contact (English and Spanish)

M217

MA - CM - Denial Citizenship/Alien Status (English and Spanish)

M218

MA - CM - Denial Application Withdrawn (English and Spanish)

M219

MA - CM - Denial Failure to Cooperate

M220

MA - CM - Denial Failure to Apply for Potential Benefits

M221

MA - CM - Denial Failure to Provide Information

M222

PE Ends / MA CM Denied Failure to Provide Information (For Clearinghouse Use Only)

M223

PE Ends / MA CM Denied Income Exceeds Maximum (For Clearinghouse Use Only)

M224

PE Ends / MA CM Denied Residency or Citizenship (For Clearinghouse Use Only)

M225

PE Ends / MA CM Denied Other Reasons (For Clearinghouse Use Only)

M240

MA - Failure to Apply for Potential Benefits

Back to the Top

M400

MA - Failure to Provide or Verify Information

M401

MA - Failure to Cooperate

M402

MA - Residency Requirements Not Met

M403

MA - Loss of Contact

M404

MA - To the Family of the Deceased

M405

MA - Spenddown Not Met

M406

MA - CM Closure Excess Income Medical Continue (English and Spanish)

M408

MA - Closure - Other Reasons

M409

MA - Closure at Client's Request

M411

MA - CM - Failure to Complete Review

M412

MA - CM - Failure to Cooperate

M414

MA - CM - Failure to Provide Information

M415

MA - CM - No Eligible Individual

M416

MA - CM - Closure Client's Request

M417

MA - CM - Residency Requirements Not Met

M418

MA - CM - Closure Other Reasons

M419

MA - CM - To the Family of the Deceased (English and Spanish)

M440

MA - Failure to Apply for Potential Benefits

M443

MA - No Eligible Child

M450

MA - Failure to Complete Review

M451

MA - EM Extended Medical Closure

M500

MA - Suspend - General

M501

MA - Suspend - New Spenddown

M502

MA - CM - Suspend General

Back to the Top

M600

MA - Reinstate After Suspension

M601

MA - Erroneous Discontinuance

M602

MA - Benefits Paid Pending Hearing Decision

M603

MA - CM - Erroneous Discontinuance (English and Spanish)

M604

MA - CM - Benefits Paid Pending Hearing Decision (English and Spanish)

M605

MA - CM - Reinstate after Suspension No CSE (English and Spanish)

M606

MA - CM - No CSE Benefits Paid Pending Hearing Decision (English and Spanish)

M607

MA - CM - No CSE - Erroneous Discontinuance (English and Spanish)

M608

MA - CM - Reinstate After Suspension

M700

MA - Change - General

M701

MA - Medially Needy Change Spenddown Amount

M702

MA - CM - To Extended Medical

M703

MA - CM - Approval - TransMed - No CSE& (English and Spanish)

M704

MA - Medically Needy Spenddown Now Met

M706

MA - CM - Excess Income - Medical Continues for Some Household Members

M707

MA - CM - First CSE Penalty

M709

MA - CM - Reinstatement Following CSE Penalty

M710

MA - CM - Approval TransMed Closure(English and Spanish)

M711

MA RM - Excess Income - Eligible Extended Medical

M712

TransMed End - Excess Income - Medical Continues

M713

MA - Prior Medically Needy Spenddown Now Met

M714

MA - Prior Medically Needy Change Unmet Spenddown

M715

MA to TransMed With 6 Month Eligibility

M716

TransMed Close - Fail Return Income - Medical Continues for Some Members

M717

TransMed Close - Fail to Provide Information - Medical Continues for Some Members

M718

TransMed 6 Month Review - Medical Continues

M719

TransMed 6 Month Income Review Letter

M720

TransMed Denial - Information Untimely - Medical Continues

M750

MA - Mass Change - Change in Unmet Spenddown

M751

MA - Mass Change - Change in Met Spenddown

M752

MA - Mass Change - Results in Spenddown

M801

MA - Caseload Transfer

M803

Reporting Requirements for Family Medical (send for all MACM approvals)

M834

MA - Notice of Repayment

M836

MA - The Medically Needy Health Plan

M837

MA - Medical Card Returned

Back to the Top

X019

Reporting the Birth of Your Child

X020

SSN Reminder

X056

Immunization Notice

X057

Immunization Notice - 12 Months

X064

Failure to Complete Interview Process

X065

MA - CM Closure for Failure to Return Review

X086

An Important Reminder From SRS

X095

HealthWave - 21 and HealthWave 19 - HealthConnect Kansas - Closure Failure to Return Review

Z050

MA Mass Change - Change in Unmet Spenddown

Z051

MA Mass Change - Change in Met Spenddown

Z052

MA Mass Change - Results in Spenddown

Z053

MS Mass Change/Spenddown Change

Z054

MS Mass Change/Spenddown Change

Z055

MS Mass Change/Spenddown Change

MS Mass Change/Change in Client Obligation

Presumptive Eligibility Approval Information (For Clearinghouse Use Only)

PE Ends / Other Reasons (For Clearinghouse Use Only)

PE Ends / Prior PE within 12 Months (For Clearinghouse Use Only)

PE Reinstatement (For Clearinghouse Use Only)

P100

Expedited PW-Postponed Verification English & Spanish

P101

MP HealthWave 19 - HealthConnect Kansas Approval (English and Spanish)

P102

MP Approval - Pregnant Woman Medicaid (English and Spanish)

P103

MP HealthWave 19 - HealthConnect Kansas Approval - Partial Denial

P105

MP Prior Medical Approval (English and Spanish)

P106

HealthWave 21 Only - Approval  (English and Spanish)

P107

HealthWave 21 and HealthConnect Kansas Approval (English and Spanish)

P108

HealthWave 21 Only Approval - Partial Denial

P109

HealthWave 19 and HealthConnect Kansas Review Completed (English and Spanish)

P110

HealthWave 21 Review Complete (English and Spanish)

P111

HealthWave 21, 19 & HealthConnect Kansas Late Review (English and Spanish)

P112

HealthWave 21 - Late Review Complete (English and Spanish)

P113

HealthWave - HealthConnect Kansas Review Complete - Coverage Change  (English and Spanish)

P114

HealthWave 21, 19 & and HealthConnect Kansas Review Complete (English and Spanish)

P115

HealthWave and HealthConnect Kansas Late Review Coverage Change       (English and Spanish)

P116

Prior Medical Approval - Partial Denial

P117

Pregnant Woman Approval - Added to an Open Case

P118/118P

About Your Insurance

P119

PE Ends / HW 19 or HCK approved (For Clearinghouse Use Only)

P120

PE Ends / HW 21 approved (For Clearinghouse Use Only)

P121

PE Ends / Blended HW 19 or HCK & HW 21 approved (For Clearinghouse Use Only)

Back to the Top

P200

MP - HealthWave - Failure to Provide Information

P201

MP - HealthWave - Failure to Cooperate

P202

MP - HealthWave - Residency Requirements Not Met (English and Spanish)

P203

MP - HealthWave - Loss of Contact (English and Spanish)

P204

MP - Prior Medical Denial

P205

MP - HealthWave - Income Exceeds Maximum (English and Spanish)

P206

PE Ends / MP Denied Failure to Provide Information (For Clearinghouse Use Only)

P207

PE Ends / MP Denied Income Exceeds Maximum (For Clearinghouse Use Only)

P208

MP - HealthWave Denial - Other Reasons

P209

MP - HealthWave - Application Withdrawn (English and Spanish)

P210

PE Ends / HW 21 Denied Health Insurance or State Employee (For Clearinghouse Use Only)

P211

MP - HealthWave - Citizenship/Alien Status Met (English and Spanish)

P213

PE Ends / MP Denied Residency or Citizenship (For Clearinghouse Use Only)

P215

Failure to Cooperate With HIPPS

P216

HealthWave 21 Denial - Health Insurance (English and Spanish)

P217

HealthWave 21 Denial - State Employee

P218

HealthWave 21Denial - Current HealthWave or HealthConnect Kansas Coverage (English and Spanish)

PE Ends / MP Denied Other Reasons (For Clearinghouse Use Only)

P400

Failure to Provide or Verify Information

P401

MP, HealthWave & HealthConnect Kansas - Closure Failure to Cooperate

P402

HealthWave 21, 19 and HealthConnect Kansas - Residency Not Met (English and Spanish)

P404

HealthWave and HealthConnect - To the Family of the Deceased Child (English and Spanish)

P405

MP - HealthWave - Income Exceeds Maximum

P408

HealthWave 21, 19 and HealthConnect Kansas - Closure Other Reasons

P409

MP, HealthWave HealthConnect Kansas - Closure at Client's Request  (English and Spanish)

P416

Closure - Failure to Cooperate With HIPPS

P443

HealthWave 21, 19 and HealthConnect Kansas - No Eligible Individual

P444/444P

HealthWave 19 and HealthConnect Kansas - Postpartum Period Closure

P445

PP Closure - Newborn Not Reported

P450

HealthWave 21, 19 and HealthConnect Kansas - Failure to Complete Review

P451

HealthWave 21 - Failure to Pay Premiums

P452

HealthWave 21 - Other Health Insurance Coverage

P500

HealthWave 21, 19 and HealthConnect Kansas Suspend - General

Back to the Top

P600

HealthWave & HealthConnect Kansas - Reinstate After Suspension

P601

MP, HealthWave & HealthConnect Kansas - Erroneous Discontinuance

P602

Benefits Paid Pending Hearing Decision

P700

MP and HealthWave 21/19 - HealthConnect Kansas - Change General

P701

HealthWave 21/19 - HealthConnect Kansas - Child Added

P702

HealthWave - 21 - Premium Now Required

P703

HealthWave - 21 - Premium Amount Change

P704

HealthWave - 19 and HealthConnect Kansas Child Added

P705

HealthWave - 21 Child Added

P707/707P

Insurance Information After Review - Change

P801

Medical - Caseload Transfer

P803

Reporting Requirements for Children's Medical (send for all MP approvals)

P834

MP - HealthWave - Notice of Repayment

P837

MP - HealthWave 19 - HealthConnect Kansas - Medical Card Returned

X019

Reporting the Birth of Your Child

X020

SSN Reminder Notice

X056

Immunization Notice

X057

Immunization Notice - 12 Months

X065

MA/CM Close for Failure to Return Review

X094

MP - Failure to Complete Interview Process

X095

Closure for Failure to Return Review

Back to the Top

N101

MS Approval Without Spenddown

N102

MS Approval With Spenddown Met

N103

MS Approval With Spenddown Not Met

N104

TB Approval

N105

Working Healthy Approval - No Premium

N106

Working Healthy Approval - With Premium

N107

HCBS Approval - No Obligation

N108

HCBS Approval - with Obligation - 1 Month

N109

MS Review Complete Without Spenddown

N110

MS Review Complete With Spenddown

N111

MS Review Complete With Spenddown Not Met

N112

Approval - Special Medical Program

N113

MS Review-Spenddown Not Met - QMB Benefits Continues

N114

MS - Prior Medical Approval Without Spenddown

N115

MS Prior Medical Approval with Spenddown Met

N116

MS Prior Medical Approval with Spenddown Unmet

N117

WH Prior Medical - No Premium

N118

WH Prior Medical - With Premium

N119

;WH-MI Approval - No Premium

N120

WH-MI Approval - With Premium

N121

NF Approval - One Month

N122

NF Approval - Two Months

N123

NF Approval - Three Months

N124

Approval - NF Deny - 1st Mo/ Approve 2nd Mo

N125

Approval - NF Deny - 1st & 2nd Mo/ Approve 3rd Mo

N126

Approval - NF Deny - 1st Mo/ Approve 3nd & 3rd Mo

N127

MS-AC Review Complete

N128

MS Approval/Excess Liability/Spenddown Met

N129

MS Approval/Excess Liability/Spenddown Unmet

N130

MS Review/Excess Liability/Spenddown Met

N131

MS Review/Excess Liability/Spenddown Unmet

N134

HCBS Approval - with Obligation - 2 Months

N135

MS HC App-1 mo with Oblig-Prior Met Spenddown

N136

HCBS App -2 Mo- with Oblig -Prior Met Spenddown

N137

HCBS App -1 Mo- with Oblig -Prior Unmet Spenddown

N138

MS HC App-2 mo with Oblig-Prior Unmet Spenddown

N139

Approval - Subsidy D Only

N140

Review - Subsidy D Only

N141

Approval for Expanded LMB and Subsidy D Benefits

N142

BCC Approval

N143

PACE Approval No Obligation

N144

PACE Review Complete

N145

TB Review

N146

WH-MI Review - No Premium

N147

PACE Approval One Month With Obligation

N148

Pace Retro Approval - Existing Case

N149

PACE Approval - Two month With Obligation

N150

Working Healthy Review - No Premium

N151

Working Healthy Review - With Premium

N152

WH Desk Review Complete - No Premium

N153

WH Desk Review Complete - With Premium

N154

MS-HC Review Complete - No Obligation

N155

MS-HC Review Complete - With Obligation

N170

Denial - LMB/Subsidy D Approval

N171

Denial for QMB/Subsidy D Approval

N172

Denial - Expanded LMB/Subsidy D Approval

N173

Review Complete for Expanded LMB-Only Benefits

N192

MS/FS Approval-No Spenddown-FS 1st & 2nd Mos.

N193

Approval for LMB and Subsidy D Benefits

N194

Review Complete for LMB-Only Benefits

N195

Review Complete - Spenddown Not met - LMB Cont

N196

MS/FS Review Completed - No Spenddown

N197

Approval for QMB and Subsidy Benefits

N198

Review Complete for QMB-Only Benefits

N200

MS Failure to Provide Information

N201

MS Failure to Cooperate

N202

MS - Residency Requirement Not Met

N203

MS Loss of Contact

N205

MS Excess Income/Won't Meet Spenddown

N207

MS - Resources Exceed Maximum

N208

MS Denial - Other Reasons

N209

MS Application Withdrawn

N217

MS Deny LTC Payment - Transfer of Property

N239

Denial - Part D Subsidy Only

N240

MS - Failed to Apply For Potential Benefits

N246

MS - Residing In An Institution

N247

MS - Aged, Blind or Dis Crit Not Met

N255

MS-WH Denial - Other Reasons

N256

TB Denial

N260

MS Change in Living Arrangement - Left ACH

N261

MS - Fail to Meet LTC Criteria

N262

Denial For QMB-Only Benefits

N263

Denial For LMB-Only Benefits

N264

Denial - Expanded LMB

N270

Denial - LMB and Subsidy D

N271

Denial - For QMB and Subsidy D

N272

Denial - Expanded LMB/Subsidy D

N290

MS/FS Denial Failure to Provide Information

N291

MS/FS Denial - Failure to Cooperate

N292

MS/FS Denial - Residency Requirement Not Met

N293

MS/FS Denial - Loss of Contact

N297

MS/FS Denial - Resources Exceed Maximum

N298

MS/FS Denial - Other Reasons

N299

MS/FS Denial - Applications Withdrawn

N400

Failure to Provide/Verify Information

N401

Failure to Cooperate

N402

MS Residency Requirement Not Met

N403

MS Closure/Loss of Contact

N404

MS - To the Family of the Deceased

N405

MS Closure/Spenddown Not Met

N407

MS Closure - Resources Exceed Maximum

N408

MS Closure - Other Reasons

N409

MS Closure At Client's Request

N425

WH Closure - Other Reasons

N440

Failure to Apply for Potential Benefits

N447

Disability Criteria No Longer Met

N450

Failure to Complete Review

N451

Closure QMB/Subsidy D Continues

N452

MS Closure - QMB/ Subsidy D Continues

N453

Closure - LMB/Subsidy D Continues

N454

MS Closure - LMB/ Subsidy D Continues

N455

Closure - Subsidy D Only

N470

Closure LMB and Subsidy D

N471

Closure QMB and Subsidy D

N490

Closure Failure to Provide Information - MS & FS

N491

Closure Failure to Cooperate - MS & FS

N492

Closure Residency Requirement Not Met - MS & FS

N493

MS and FS Closure/Loss of Contact

N494

To the Family of the Deceased - MS & FS

N497

MS and FS Closure/Resources Exceed Maximum

N498

MS and FS Closure/Other Reason

N499

MS and FS Closure/Client's Request

N500

MS Suspend - General

N504

MS-Discontinued ACH/HCBS Payment - General

N600

Reinstate After Suspension

N601

Erroneous Discontinuance

N602

Benefits Paid Pending Hearing Decision

N603

Reinstate ACH/HCBS Payment

N700

MS Change - General

N701

MS - Change in Unmet Spenddown Amount

N702

MS - Change in ACH/HCBS Liability - 1 Month

N703

MS - Change in ACH/HCBS Liability - 2 Months

N704

MS - Change Spenddown - Spenddown Met

N705

MS - NF Payment Start - Shorten Base

N706

MS - NF Payment Start

N713

MS - Prior Medical Spenddown Met

N715

MS-HC Payment Start - No Obligation

N716

MS-HC Payment Start - 1 Mo W/ Obligation

N717

MS-HC Payment Start - 2 Mo W/ Obligation

N721

NF Payment Discontinued - LOC Not Met

N722

Retro Client Obligation Change - HCBS

N723

Retro Client Obligation Change - ACH

N725

Change in ACH Liability to Zero-QMB

N726

MS - PACE Obligation Change

N727

MS - PACE Change, General

N728

Subsidy D Change

N730

HCBS to ACH - Temp Stay W/O Obligation

N731

HCBS to ACH - Temp Stay W/ Obligation

N732

HCBS to ACH - Without Obligation

N733

HCBS to ACH - 2 Months With Obligation

N734

ACH to HCBS - No Obligation

N735

ACH to HCBS - 2 Months With Obligation

N740

Change - MS to WH Without Premium

N741

Change - MS to WH With Premium

N742

Working Healthy Premium Change

N743

Change - Working Healthy Premium Levels

N744

WH - Unemployment Plan Request

N753

MS Mass Change - Change Spenddown Amount

N754

MS Mass Change - Change Met Spenddown

N756 

MS Mass Change - Liability/Obligation Change

N801

Caseload Transfer

N810

Working Healthy Premium Information

N811

WH Conversion With Premium

N812

Working Healthy Desk Review

N832

Medical Assistance Pending SSA Decision

N834

MS Notice of Repayment

N836

MS Spenddown Informational Notice

N837

Medical Card Returned

N838

Termination/Decertification of ACH Facility

N839

Transfer to Another Nursing Facility

N900

MS - Facility Notice - General

N911

MS - Facility Notice - Approval ACH One Month

N912

MS - Facility Notice - Approval ACH 2 Months

N913

MS - Facility Notice - Approval ACH 3 Months

N914

MS - Facility Notice - Approval Temp Stay

N915

MS - Facility Approval - Temp Stay From HCBS

N921

MS - Facility - General Denial

N941

MS - Facility - General Closure

N961

MS - Facility - Reinstatement After Suspension

N962

MS - Facility - Reinstate ACH Payment

N971

MS - Facility - Mass Change

N972

MS - Facility Notice - Liability Change - 1 Month

N973

MS - Facility - Suspension ACH Payment

N974

MS - Facility - ACH Review Complete/Remains Eligible

N975

MS - Facility - Failure to Complete Review

N976

MS - Facility - ACH Payment Ending - Transfer to New ACH

N978

MS - Facility - Excess Liability - No Spd/Spd Met

N980

MS - Facility - Review Complete/Excess Liability

N983

MS - Facility - Liability Change - 2 Months

N985

MS - Facility - ACH Payment Ending - Move to Ind Living

N986

MS - Facility - Retro Patient Liability Change - NF

N987

MS - Facility - Zero Liability - QMB

Back to the Top

X019

Reporting the Birth of Your Child

X056

Immunization Notice

X057

Immunization Notice - 12 Months

X074

Failure to Complete Interview Process

X075

Closure for Failure to Return Review

Z053

MS - Mass Change - Change in Unmet Spenddown

Z054

MS - Mass Change - Change in Met Spenddown

Z055

MS - Mass Change - Results in Spenddown

Z056

MS - Mass Change - Change in Patient Liability

R101

RE Approval for One Month Only

R102

RE Approval for 1st and 2nd Months

R103

RE Approval for 1st, 2nd and 3rd Months

R104

RE Denial for 1st Month - Approval for 2nd Month

R105

RE Denial for 1st Month - Approval for 2nd and 3rd Months

R106

RE Review Complete

R191

RE and FS Approval for One Month Only

R192

RE and FS Approval for 1st and 2nd Months

R193

RE and FS Approval for 1st, 2nd and 3rd Months

R196

RE and FS Reviews Complete

R200

RE - Failure to Provide Information

R201

RE - Failure to Cooperate

R202

RE - Residency Requirement Not Met

R203

RE - Loss of Contact

R205

RE - Income Exceeds Maximum

R206

RE - Excess Net Income

R207

RE - Resources Exceed Maximum

R208

RE - Denial - Other Reasons

R209

RE - Application Withdrawn

R210

RE - Ineligible Assistance Unit

R213

RE - Work Related Requirements Not Met

R215

RE - Failure to Cooperate With HIPPS

R240

RE - Failure to Apply for Potential Benefits

R290

RE and FS Denial - Failure to Provide Information

R291

RE and FS Denial - Failure to Cooperate

R292

RE and FS Denial - Residency Requirement Not Met

R293

RE and FS Denial - Loss of Contact

R295

RE and FS Denial - Income Exceeds Maximum

R296

RE and FS Denial - Excess Net Income

R297

RE and FS Denial - Resources Exceed Maximum

R298

RE and FS Denial - Other Reasons

R299

RE and FS Denial - Applications Withdrawn

Back to the Top

R400

RE - Failure to Provide or Verify Information

R401

RE - Failure to Cooperate

R402

RE - Residency Requirement Not Met

R403

RE - Loss of Contact

R404

RE - To the Family of the Deceased

R405

RE - Income Exceeds Maximum

R406

RE - Excess Net Income

R407

RE - Resources Exceed Maximum

R408

RE - Closure - Other Reasons

R409

RE - Closure at Client's Request

R410

RE - Ineligible Assistance Unit

R411

RE - Closure - Time Expired

R412

RE - Close - 1st Work Penalty

R413

RE - Close - 2nd+ Work Penalty

R416

RE - Closure - Failure to Cooperate With HIPPS

R440

RE - Closure - Failure to Apply for Potential Benefits

R450

RE - Closure - Failure to Complete Review

R451

RE - Extended Medical Closure

R490

RE and FS - Closure - Failure to Provide Information

R491

RE and FS - Closure - Failure to Cooperate

R492

RE and FS - Closure - Residency Requirements Not Met

R493

RE and FS - Closure - Loss of Contact

R495

RE and FS - Closure - Income Exceeds Maximum

R496

RE and FS - Closure - Excess Net Income

R497

RE and FS - Closure - Excess Resources

R498

RE and FS - Closure - Other Reasons

R499

RE and FS - Closure - Client's Request

Back to the Top

R600

RE - Reinstate After Suspension

R601

RE - Erroneous Discontinuance

R602

RE - Benefits Paid Pending Hearing Decision

R701

RE - Change in Benefits - Other Reasons

R702

RE - Supplemental Benefits

R703

RE - Change in Household Members

R704

RE - Change in Benefits - Income Change

R705

RE - Change in Benefits - Work Program Allowance

R706

RE - Change in Benefits - Living Arrangement

R711

RE - Change - Excess Income - Eligible Extended Medical

R712

RE - Change to Zero Benefits - Information Pending

R744

RE - Change Due to Cooperation With Work Programs

R745

RE - Change - 1st Work Penalty

R746

RE - Change - 2nd+ Work Penalty

R750

RE and FS Benefits and Income Changes

R801

Caseload Transfer

R827

RE - Fraud Disqualification - Nonrecipient

R830

RE - Fraud Disqualification - Recipient

R831

RE - Repay Agreement - Fraud - Recipient

R832

RE - Repay Agree - Agency/Client Recipient

R834

RE - Of Repayment Agreement - Non Recipient

X004

Landlord/Residency Verification Request
*Must be manually requested on the ADDR Screen.

X019

Reporting the Birth of Your Child

X020

SSN Reminder Notice

X056

Immunization Notice

X057

Immunization Notice - 12 Months

X084

RE - Failure to Complete Interview Process

X085

RE - Closure for Failure to Return Review

Z057

RE - Mass Change

Back to the Top

S101

SI Approval

S107

SI HCBS Approval

S121

SI NF Approval

S122

SI NF Approval - Two Months

S192

SI and FS Approval - 1st and 2nd Months

S208

SI - General Denial

S261

SI - Fail to Meet Long Term Care Criteria

S298

SI & FS Denial/General

S402

SI Closure/Residency Requirement Not Met

S403

SI Closure/Loss of Contact

S404

To the Family of the Deceased (SI)

S408

SI Closure/Other Reasons

S409

SI Closure at Client's Request

S410

No Longer Receiving SSI

S492

SI/FS Closure Residency Requirement Not Met

S493

SI/FS Closure - Loss of Contact

S494

To the Family of the Deceased - SI & FS

S498

SI/FS Closure/Other Reasons

S499

SI/FS Closure/Client's Request

S500

SI - Suspend - General

S502

SI-Discontinued ACH/HCBS Payment - General