Get Medical Review Of Emergency Services For Establishing Sobra Eligibility (except Labor And

Filling out the Medical Review of Emergency Services form is a crucial step in establishing eligibility for SOBRA benefits. This guide will provide clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to effectively complete the form.

1. Press the ‘Get Form’ button to access the document and open it in your preferred editor.
2. In the first section, titled 'Request for Information,' complete the individual's name, birthdate, case number, and Medicaid ID number. This information is essential to identify the person applying for medical assistance.
3. Next, the local Department for Children and Families (DCF) office will need to provide their specialist's name, phone number, and office location. Make sure this section is filled out to ensure proper communication.
4. In the 'Verification of Emergency Services' section, the healthcare provider must complete the form. They should provide details regarding the emergency services rendered. This includes indicating whether the services were inpatient, outpatient, or from an emergency room.
5. Document the necessary history, physical, admission and discharge summary, and any exam notes. This information substantiates that the services met the required emergency criteria.
6. The provider should then indicate the date or dates in which emergency services were provided.
7. Once the form is completed, it must be signed by the provider or their designee. Additionally, include the provider’s name and contact number.
8. Finally, the completed form should be mailed along with supporting documents to the Kansas Medical Assistance Program at the specified address, ensuring it is done within 30 days for timely processing.
9. Upon receipt of the form, the SOBRA Manager or designated Fiscal Agent staff will complete their review and decision. This section will require their signature and date.
10. Once everything is processed, remember to save changes. You can then download, print, or share the completed form as needed.

Complete your documents online today to ensure a smooth eligibility process.