The Clinical Eligibility screen/feature is used to determine the individual’s eligibility criteria to enroll in HCBS-AMH Program. The Clinical Eligibility is completed by the Local Mental Health Authority/State Hospital users in the CMBHS application and submitted to HHSC HCBS-AMH users through CMBHS.
HHSC HCBS-AMH users review the Clinical Eligibility document submitted by the LMHA’s/SH’s and determine the Eligibility of an individual/client.
The Clinical Eligibility document is a multi-purpose document which contains information related to an individual’s Clinical Eligibility and Enrollment in HCBS-AMH program. It summarizes the individual’s clinical history and is used to:
You must be assigned a role that authorizes you to access and save the document in Draft, Ready for Review and Closed Complete Click here 0 to view Read-Only and Read-Write Page Rights according to CMBHS Role.
When you save a Clinical Eligibility in Ready for Review or Closed Complete status, by CLICKING on the Save button, CMBHS validates all the data fields looking for errors.
The Clinical Eligibility feature/menu is available only to the user’s logged into State Hospital and LMHA locations. This screen or feature is not available to the user’s logging from Provider Agencies or Recovery Management Locations.
To access and create Clinical Eligibility in CMBHS, LMHA/State Hospital staff follow the steps below:
To access the existing Clinical Eligibility in CMBHS, follow the steps below:
The Clinical Eligibility screen has the following data input fields
Clinical Eligibility Document Number (Read Only): This field will not be displayed when the page/screen loads for the first time.
This is an auto/system generated field which will be displayed once the document is saved in Draft/Ready for review for the first time and the number will not change with further data edit on the document.
Clinical Eligibility Date (Ready Only)This will be an auto/system generated field.
The system will display the system’s current date when the document was created for the first time and the date will not be changed with further data edits on the document.
Performed By (Required Field)- This is a required, drop-down field. The system will prepopulate the information from Find/Add staff screen along with ‘Other’ option in the list. If Other is selected from the drop-down list, then system display the other field to enter the name.
Is the individual in state hospital? (Required Field)- This question will determine if the individual is coming from State Hospital or LMHA/Community.
This question would have radio options as Yes/No, for the user to select manually.
If the user selects Yes, then the system will consider that the individual is coming from the State Hospital and system should display the Medicaid Eligible question, Prior to hospitalization question and documentation question.
If the user selects No, then the system will consider that the individual coming from the LMHA/Community and system should hide the Medicaid Eligible question, Prior to hospitalization question and documentation question.
The system displays a pop-up message saying: “By selecting No, you are confirming that the client is from the community” when the user selects “No”.
Eligibility Does the individual have a Social Security number? (Read Only)- This data will be prepopulated from Client Profile>SSN field.
The data cannot be edited on the Clinical Eligibility screen. The user should edit the data from the client profile page.
Does the individual have accepted Medicaid type? (Required Field)- This field will have 3 options (Yes/ No/Unknow) for the user to select.
If Yes- Medicaid Number field (Required) will be displayed from the Client Profile and Medicaid type field (Optional) with data from MEV or user can manually enter the Medicaid type.
If No- Medicaid Number and Medicaid Type field will be hidden.
If Unknow- Medicaid Number field (Optional) will be displayed from the Client Profile if any and Medicaid type field (Optional) with data from MEV if any or user can manually enter the Medicaid number/type.
Is the individual enrolled in another home and community-based program? (Required)- This field will have 3 options (Yes/ No/Unknow) for the user to select.
If Yes- The system will display the List program/waiver text field (required)- for the user to enter the data.
If No- The system will hide the List program/waiver text field.
If unknown- The system will hide the List program/waiver text field.
Does the individual require skilled nursing facility? (Required)- This field will have 2 options (Yes/No) for the user to select.
Is the individual Medicaid Eligible? (Required)- This field will have 2 options (Yes/No) for the user to select.
Did the individual receive any income prior to hospitalization? (Required)- This field will have 2 options (Yes/No) for the user to select.
The total income should be <=$791.00 for the individual to become eligible.
Does the individual have supporting documents to verify the Medicaid Eligibility? (Required)- This field will have 2 options (Yes/No) for the user to select.
NOTE- Once the Medicaid Eligible, Prior to Hospitalization income questions are answered by user, then the user must check the attestation which says, “I certify that the individual’s Medicaid history and eligibility have been researched and that the answers I have provided are true and accurate to the best of my knowledge” to save the document in Ready for Review”.
Does the individual meet any of the three population criteria (Long Term Psychiatric Hospitalization, Emergency Department Diversion and Jail Diversion)? (Required)- This field will have 2 options (Yes/No) for the user to select.
Does the individual show in one or more of the MBOW reports? (Required)- This field will have 2 options (Yes/No) for the user to select.
Does the individual have supporting documents to verify the Medicaid Eligibility? (Required)- This field will have 2 options (Yes/No) for the user to select.
Diagnosis Description and Diagnosis code will be display in the Grid format and the data will be prepopulated from the Diagnosis Screen.
View Complete Diagnosis Record hyperlink will be available for the users to view complete diagnosis from the Clinical Eligibility Screen.
In this section, system would pre-populate the HCBS-AMH LOC based on domain rating parameters selected on HCBS-AMH ANSA screen and HCBS-AMH eligibility sorting logic.
Ineligibility Domain Name
The system should display the ineligible domain names in the tabular format based on the HCBS-AMH domain scores.
View complete Assessment record hyperlink will be available for the users to view complete ANSA assessment from the Clinical Eligibility Screen.
The system will determine the ineligibility based on the options selected by the users for the eligibility questions.
When a system determines an ineligibility, then it will select one or more ineligibility criteria from System Ineligibility Criteria Reasons and they are:
The system will determine by selecting the Eligibility from System Eligibility Determination options and they are:
This section will be read only for LMHA/SH users but the HHSC HCBS-AMH users has read/write access.
The Clinical Eligibility screen has Enrollment Status section which can be edited only by the HHSC HCBS-AMH users to determine Individual’s Enrollment Status when the user reviews the saved Ready for Review Clinical Eligibility.
This section has following data fields which can be edited by the HHSC HCBS-AMH users and the users logged in from Recovery Management Entity Locations.
Override Eligibility Determination Reasons (Required)- This field has 2 options (Yes/No) for the users to select, if they want to change or edit the System Eligibility Determination.
When the user selects Other, then the system should display Other text field to enter the reason.
Override Date (Required)- This will be a required, system populated date and can also be edited by the user.
Enrollment Status (Required)- This is a required, drop-down field. This field is used to determine the Enrollment Status of an individual. The different enrollment statuses are:
Enrollment Status Date (Required)- This will be a required, system populated date an can also be edited by the user.
Initial Enrolled Date (Required)- This is a required and system generated date, which cannot be edited. This date will determine the actual Enrollment date.
Authorized Reviewer (Required)- This is a required, drop-down list. The data will be prepopulated from the Find/Add staff screen.
Enrollment Status Change request (Required)- This is a required field drop-down field. The data will be prepopulated when the user selects one of the Enrollment change action buttons from the top right-hand side of the screen.
Enrollment status Change Request would be available only on the “Closed Complete” Clinical Eligibility on Recovery Managers locations.
This field can only be edited by the users log in from RME locations and for other users this field will be a Read Only.
Enrollment Status Change Request Date (Read Only)- This will be a Read only field and the date will be a system generated date when the user selects the Enrollment Status Change request.
Enrollment Status Change Reasons (Required)- This field is a required drop-down field. The system should display the reasons based on the Enrollment status change request, for the user to select.
Recovery Manager Staff (Required)- This is a required drop-down field. The data will be prepopulated from the Find/Add staff screen.
Comment section (Optional)- This section can be used to add any additional comments. The user should be able to add up to 500 characters.
This is a required section with 3 fields to capture the signature and dates.
Signature & Date (Required)-
Legally Authorized Representative (LAR) (Required)-
Staff drop down list with credentials (Required)-
Prior to saving the clinical eligibility in ready for review status, the system checks that HCBS-AMH Documents 'Provider Selection form in ready for review' and 'Notification of Individual's Rights in closed complete status' exists for the client in the 'Client Workspace' under the same business entity.
This section will display the updates/history of the Enrollment status section for the HHSC HCBS-AMH users to review.
This is a scrollable section.
This section will display the document status history for the users to review the following:
This section will have Document status and Document Date fields.
Document Status (Required)- This is a required, drop-down field with Draft, Ready for Review and Closed Complete as drop-down options for the users to select.
Draft and Ready for Review can be used by LMHS’s/SH’s users.
Draft, Ready for Review and Closed Complete can be used by HHSC HCBS-AMH users.
Document Date (Read Only)- A Read only system generated date when the user makes changes to the document.
Progress Note impacts on Closed Complete Clinical Eligibility
There will be no impact of RME Progress Notes on suspending the Client on Closed Complete Clinical Eligibility. The system will not check if the RME Progress Note exists in draft or in closed complete status.
Impact of Progress Notes on Suspension of Client from the Program
Impact of Progress Notes on Disenrollment of Client from the Program
Impact of Progress Notes on RE- enrollment of Client from the Program
There is no impact of RME and PA Progress Notes, in draft and closed complete on the Re-enrollment request made on the Clinical Eligibility.