Reports and Publications

Maryland Medical Programs

Updated
December 20, 2011

Enrollment and Capitation Modification Manual

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CONTENTS

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TOPIC

DOCUMENTS
Form-fillable PDFs!

DATE

Long Term Care
Disenrollment after 30 Days in a Nursing Facility or Chronic Hospital
	Instructions for MCOs – Health Choice Long Term Care (LTC) Disenrollment Form	May 2011
	HealthChoice LTC Disenrollment Form	May 2011
	Sample – LTC Disenrollment Form	May 2011
	COMAR 10.09.67.12 Benefits – Long-Term Care Facility Services

Newborns
1184 Newborn Report Form	Instructions for MCOs – 1184 Hospital Report of Newborns	To be updated
	1184 Hospital Report of Newborns	August 2008 (to be updated)
	Sample – 1184	August 2008 (to be updated)
Very Low Birth Weight (VLBW)	Instructions for MCOs – Report of VLBW Newborn	September 2011
	Report of VLBW Newborn (OPF2005VLBW)	September 2011
	Sample – Report of VLBW Newborn	September 2011
	Health Insurance Claim Form CMS-1500	August 2005
	Sample Letter to MCO from DHMH regarding inability to process transaction	September 2011
HIV/AIDS
HIV Positive	Instructions for MCOs – HIV Positive Enrollee Notification	June 2011
	Notification from MCO of HIV Positive Enrollee	June 2011
	Sample- Notification of HIV Positive Enrollee	June 2011
	COMAR 10.09.65.10 Special Needs Populations – Individuals with HIV/AIDS
HIV Exposed Newborn	Instructions for MCOS- HIV Positive Exposed Newborn Notification	June 2011
	Notification from MCO of HIV Positive Exposed Newborn	June 2011
	Sample – Notification of HIV Positive Exposed Newborn	June 2011
HIV Positive Enrollee (Pediatric patients less than 13 years of age at time of diagnosis, excluding newborns)	Instructions for MCOs – HIV Positive Pediatric Notification	June 2011
	Notification for MCO of HIV Positive Enrollee (Pediatric)	June 2011
	Sample – HIV Positive Pediatric Notification	June 2011
AIDS	Instructions for MCOs – AIDS Defined Enrollee Notification	June 2011
	Notification from MCO of AIDS Defined Enrollee	June 2011
	Sample – Notification of AIDS Defined Enrollee	June 2011
Information Required by the CDC	Instructions for MCOs – Information Required by the CDC	June 2011
	Patient History Form	June 2011
	Sample – Patient History Form	June 2011
Change of Address
HealthChoice Recipient Address Change	Instructions for MCOs – HealthChoice Recipient Address Change Report	May 2011
	MCO HealthChoice Recipient Address Change Report	May 2011
	Sample – HealthChoice Recipient Address Change Report	May 2011
Primary Adult Care (PAC) Recipient Address Change	Instructions for MCOs – PAC Recipient Address Change Report	May 2011
	PAC Recipient Address Change Report	May 2011
	Sample – PAC Recipient Address Change Report	May 2011
Conflicting Data
HealthChoice Conflicting Data	Instructions for MCOS – HealthChoice Recipient Conflicting Data Report	May 2011
	HealthChoice Recipient Conflicting Data Report	May 2011
	Sample – HealthChoice Recipient Conflicting Data Report	May 2011
PAC Conflicting Data	Instructions for MCOs – PAC Recipient Conflicting Data Report	May 2011
	PAC Recipient Conflicting Data Report	May 2011
	Sample – PAC Recipient Conflicting Data Report	May 2011
RARE AND EXPENSIVE CASE MANAGEMENT (REM) PROGRAM
REM Intake and Referral	Instructions for Completion of REM Intake/Referral Form	July 2011
	Intake and Referral Form	July 2011
	Rare and Expensive Disease List	July 2011

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