Request for Newborn ID Manual - Department of Health & Hospitals
Contents
1. ty Sao Dp ws Phone unter lee matter cone y ica Age OYes ONo Dats Ald bes m Envoyer 1 Father s Information The father s name is the only required information within this section The father can be the policyholder for the private insurance Enrollment of the newborn within the employer sponsored health insurance may need to occur within thirty days of birth therefore accurate contact information is extremely important Page 11 ane Maing Ades oy SZ z Jeter cota under cop O Yes Oha Mame ot Insurance Company Employer Newborn Information Some information on the newborn s will automatically populate via the information supplied the Newborn Eligibility ID Assignment Request form The user should verify the accuracy of the newborn s name first last date of birth birth weight Ibs oz and sex Other information in this section needing verification includes whether the newborn s is adopted NICU or multiple births Accurate birth weight in pounds and ounces is extremely important O on Binh Fm mie Bith Dae Binh Weist Qos wa sw OFemae Shs Gestein age Ove Ore NICU Oe Insurance Plan Information Hospitals are required to notify the Department of Health and Hospitals within seven days of the birth of any child wh2. the web page Page 5 sig Physician Information yy Ped Find SELECT tom fea bs z Zip Pediatrician Information Use Hospital NE EE m im i ET E AddtionaiProvidors CUN El rerresn nis rines ndi en ISTIS Doctor Auto Fill The system may have some of the doctors you commonly use predefined in the system If there are any they will be listed in the Find Doctor area for each associated doctor Simply select the name of the doctor you wish to use there will be small pause while the system retrieves the corresponding information Once the information is populated on your form you may change it if necessary to reflect the specific needs for this filing Any changes you make will only be associated for the current filing Page 6 Fax 1 Address ey site dA E Th Pediatrician information 74 a SELECT DOCTOR Doctor Jack Phone Doster al Fax Doctor John Allies ciy 1 dA F Providers C ERN Adal Providers maan Representative Name Number j Pho ET El uon Reich in nies and 26 conde Sica ian Additional Providers Information Areas Because the information in the Additional Providers fields may not be used for every filing the fields will be hidden by d
3. 2 Px 20950 Caria Angeles Hernandez Angel 3200 PM HS PETE NATASHA LEDET TORN 2008 408 13M Andens Brandin Knight Ran DD AM 201906 Caner Amber Himel Cadence eee 1207 15 FM mem TEST TEST yest Test 186 09 aree TEST TEST TEST TEST 820008 21647 PM Your History This section allows you to review previous month s worth of filings Simply click on the view link next to the filing information to view Department of Health and Modicaid Program bor Eligbity Uni Request for Newborn Medicaid ID Number Farmer yew test ca E Ee hy TEST pm Bank is few TEST TEST 08 02 2008 E View TEST 0713172008 Stank TPL View WIEST TEST 10112008 Tl User Mansal vos TEST TEST 07 31 2008 View TEST TEST 07 31 2008 Page 15 Questions or Comments Please submit any questions or comments that you may have regarding this system to the following 1 888 342 6207 Page 16
4. Department of Health and Hospitals Newborn Eligibility System User Manual Revised August 2008 Table of Contents DHH Newborn Eligibility System Login Process Start new form No to the First Question Yes to the Second Question Newborn Eligibility ID Assignment Request form Phone Fax Fields Date Fields Physician and Pediatrician Information Areas Doctor Auto Fill Additional Providers Information Areas Complete Screen Third Party Liability TPL Notification of Newborn Children Form TPL Notification Input Screen Hospital Information Mother s Information Father s Information Newborn Information Insurance Plan Information Complete Screen Resume TPL Notification Your History Questions or Comments Page 1 DHH Newborn Eligibility System Login Process The login process is very simple Enter a valid ID and password to gain access to the DHH Newborn Eligibility System The Login ID is entered into the Login ID field provided and then the password The password will appear as a series of hidden characters to prevent unauthorized persons from viewing the actual password Once both Login ID and password are entered either click the login button or press enter If any information is incorrect or invalid you will be returned to the login screen and will be prompted to correct it before you may continue Do
5. all the required fields have been completed and the form has been submitted the user will be able to view or print the completed form To view the completed form the user may click on the Click here to view the completed form link on the success page The form will be displayed as a PDF Portable Document Format In order to view PDF s the user must have Adobe Acrobat Reader installed on the local machine The latest version of Acrobat Reader can be downloaded for free at http www adobe com products acrobat readstep2 html Department of Health and Hospitals Medicaid Program lik here to star form The user can also click on the Click here to start a new form This link will take you back to the Start Form page Does te mother have Medicaid Does the naher or father have accesa to employer sponsored heath insurance Ste ON Page 14 Resume TPL Notification This section allows you to resume the TPL process after you completed the Newborn Eligibility ID Assignment Request process You can resume the form by clicking on the number in the open column Resume LaHipp Form Foren special Notes Received m0 TEST TEST TEST TEST 70472008927 16 PM OUS Hudson any Alyn tao ta PN Janice Wendy 5233 OUO nice Wandy Simeon Ayana 08 16921 HERRING BYRUM enna 233 0
6. efault To enter information in these fields click the Include Additional Providers check box and the fields will be displayed If the check box is not checked then the fields will be hidden and any data already entered into them will not be submitted with the filing The check box must be checked for any Additional Provider data to be submitted with the filing Once data is entered into any field for an additional provider the rest of the fields for that provider will become mandatory Page 7 site dA 8 ap Additional Providers Providers Find Doct Z SELECT DOCTOR Phone Fax Ei Address chy Site dA zi CEA Phone Fax ol Address 1 fa 1 senate elastin Sites and seconde Complete Screen Once all the required fields have been filled in and the form has been submitted the user will receive a message that the Newborn Eligibility ID Assignment Request form has been successfully submitted If it was not successful for any reason they will be returned to the input page to correct the problem The user will be given the option to continue to complete the Third Party Liability TPL Notification of Newborn Children form or resume later To resume completion of the Third Party Liability TPL Notification of Newborn Children later simply click the Resume TPL link in the left menu and select the form y
7. ewborn Children form The TPL Notification of Newborn Children form is identified as TPL form The user may choose to fill out the TPL Notification of Newborn Children form at this time or resume later if additional information is needed from the client or to notify someone in your hospital to finalize completion of this process Page 3 of Health and Hospital born Modicaid ID Numbor 1524 has been successfully submitted Press Continue to fill out the LaHipp form Resume TPL Your History In accordance withthe Dopariment of Health and Hospitals Third Paty Liability Newbom Notication Rulo the Blain PL Notification of Newbom form shall be completed by the hospital and submitted wi is days of tho birth of a newborn child Beta PL No to the First Question Yes to the Second Question When the answer to the first login question is no but the answer to the second login question is yes the user will be prompted to complete a TPL Notification of Newborn Children form Please see section 2 4 for directions to complete the TPL Notification of Newborn Children form Newborn Eligibility ID Assignment Request form The Newborn Eligibility ID Assignment Request form provides a web interface for hospitals to quickly submit information to DHH Each field is required to be answered before the form may be submitted Phone Fax Fields All fields which require phone numbers are setup to a
8. llow for quick entry When entering a phone number the system will automatically add in the appropriate formatting for the phone number Each number should be in the format of 999 999 9999 the system will automatically jump from the area code to the main number once three characters are entered into the field Page 4 Date Fields All fields which require dates are setup to allow for quick entry When typing a date the system will automatically add in the appropriate formatting for the date Each date should be in the format of MM DD YYYY Mothor Information Mcthors Namo Resume TPL First MI Las atcaton Mothor s Medicaid No Your History Mothor s gos Mothers SSN Date of Admission aie oiling Address 1 Tip Code Parish of Residence SELECTPARISH Telephone aaa Y T Special 18 Encu ladopion Dota of Meters Dicha Flees ome ot deat ome Physician and Pediatrician Information Areas Because the information in the Physician and Pediatrician fields may often be the same as the hospital s information you may click the Use Hospital button above each area to quickly fill in the fields with the information already available in the system Similarly if the information for either is the same as the other Pediatrician same as Pediatrician and vice versa you may click the Copy button above each area to copy the information already entered on
9. o may meet eligibility provisions for the Medicaid Program It is imperative that accurate information is obtained regarding insurance availability for the newborn child due to time constraints for enrollment within the insurance Verification of insurance coverage for the mother is required The following information pertaining to the insurance coverage for the Page 12 mother is also required The name of the insurance company address phone number and the member and group number are all required Primary and secondary if applicable plan information must be obtained All required fields must be completed before successfully submitting the TPL Notification le mother ousrod under any heath neuranee coverage Yes ONo ih peni have mor than insurance pla please provide information related to he second plan below Mame of surance Company oss Cty Sisto 2o Save No ber o Prone The the O Employee Dependent Spouse Policy Holder Mare of Insuince Company Ciy Ste Zip pr Member Na Phare The Mother he Otmpleyes Dependent Spouse dieta Holder Provide us wih the address and name of person the company fal he wil be maed 10 Insurance Not Compare Name Contact ame Adress oy Sute 2p Eral assess Fax Number Page 13 Complete Screen Once
10. ou wish to resume Page 8 Newborn Eig bli Unt You Hisiory in accordance with the Doparmant cf Health and Hospitals Third Party Liability Newbom Notation Rula the TPL Notieation of Newbom Children form shall be completed by the hospital and submitted wi foe sovon days of tho birth of a newborn child Bon TPL Continue P Usor Manual If for some reason the user needs to correct information on the filing just submitted they may click the back button and the previously entered data will be displayed on the screen including the mother and child s information It is important that this only be done to correct the previous filing and then resubmit If the user is submitting a correction they need to be sure to click the 2nd Request option in the Child Birth Information section to help identify updated Special Notes Twin a filings 2nd Request Owns S LlAdoption ONIcU Child s Name Child s DOB UNU Child Birth Information Page 9 Third Party Liability TPL Notification of Newborn Children Form TPL Notification Input Screen The TPL Notification of Newborn Children Input Screen like the Newborn Eligibility 1D Assignment Request Input Screen provides a web interface for filing out the TPL Notification of Newborn Children form quickly by individual hospitals that have access to the system Each field indicated in red is required field The user will notice that some fields al
11. partmont of Health and Hospitale ign jin ID B LoginID EET Password Passe ue cu trcs Par rampe ropes ad aat Wat you use Mars Eua 00 or above o 00 and above Mz Starta new form After completing the login process the user is prompted to answer two questions about the mothers Medicaid eligibility and the status of insurance for the mother or father These two questions must be answered based on the applicant s current information The user will be directed to complete Page 2 the Newborn Eligibility ID Assignment Request and or a Third Party Liability TPL Notification of Newborn Children based on information provided Login Questions Does the mother have Medicaid Does the mother or father have access to employer sponsored health insurance pra Does the mather have Messi Your History Does the mathar or fathar acces to ik sponsored heath mourn Nester leone Pl User tissus Yes to Both Questions When the answer is yes to both of these questions the user will be prompted to first complete a Newborn Eligibility ID Assignment Request form Please refer to section 2 3 Newborn Eligibility ID Assignment Request form for directions on completion After successfully submitting a completed Newborn Eligibility ID Assignment Request form the user will be prompted to continue and complete a Third Party Liability TPL Notification of N
12. ready populated on the completed Newborn Eligibility ID Assignment Request form will automatically populate Hospital Information Hospital information may populate via information completed on the Newborn Eligibility ID Assignment Request form Phone fax fields are setup to allow for quick entry Date fields require MM DD YYYY format The Hospital Name Contact Person and Phone Number are required Hospital Information ate d mons Hospital Hams Phone Mumbo Contact Person Contact Person Errai Was the in your Yes No Facilty Provera Admission Date of Mentor Chie Discharge Dae Atten ng Browder Name VI the standing por accept heath surance as Primary and Moca Secondary Vias the newbom discharged ro another deci Name Telephone Nia Yes Ne Mother s Information Some information on the mother will populate via the information already supplied on the Newborn Eligibility 1D Assignment Request form The user should verify populated information Page 10 for accuracy and update accordingly Required information in this section includes whether the mother is currently covered by Medicaid or not and whether she will enroll the newborn into the available employer sponsored health insurance plan Enrollment within many employer sponsored health plans must occur within thirty days of birth therefore accurate contact information is extremely important Maling Ades
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