Get Case Activity Report

The Case Activity Report is an essential document used when a Medicaid applicant or member interacts with a facility. This guide provides clear, step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to complete the Case Activity Report online

1. Click 'Get Form' button to access the form and open it in your preferred editor.
2. Enter the member data in the appropriate fields. This includes the full name of the Medicaid applicant or member, their Social Security number, state ID, and the date they entered the facility.
3. Fill out the facility data section. Provide the name, provider number or NPI number, address, city, state, and zip code of the facility. Be sure to include the signature of the person completing the form and the date you completed it.
4. Indicate the level of care for the member. This will depend on information from the IME Medical Services Unit, Medicare, or a managed care contractor. Specify if the level of care relates to PMIC Mental Health or PMIC Substance Abuse.
5. Complete the Medicare information if applicable. Indicate whether the stay is expected to be covered by Medicare and provide the expected dates of coverage. If there are changes in coverage, plan to notify the county DHS office.
6. For discharge data, fill in the discharge date, last month in the facility (if transferring), along with billing details including days in facility, reserve bed days, non-covered days, and total billing days on the claim to the fiscal agent.
7. Lastly, indicate the reason for discharge by checking the appropriate box and providing any relevant details about the new living arrangement or other pertinent information.
8. After filling out all sections, ensure you save your changes. You can then download, print, or share the completed form as needed.

Complete the Case Activity Report online today to ensure timely processing of Medicaid applications and member changes.