Medicaid-pending cases require active management. When applications sit unresolved, verification requests go unanswered, or families are unsure what Medicaid needs, the financial impact on the facility can grow quickly.

We assist with:

• Review of Medicaid-pending resident cases

• Eligibility and application status review

• Identification of missing or outstanding documentation

• Communication with residents and responsible family members

• Document collection and organization

• FSSA/DFR communication and follow-up

• Responses to verification requests

• Asset Verification System (AVS) issues

• Monitoring pending applications

• Review of Medicaid notices and determinations

• Identification of potential eligibility barriers

• Escalation of unresolved cases when appropriate

• Coordination with facility staff throughout the process

Our goal is to identify what is preventing the case from moving forward and take the appropriate steps to help bring the Medicaid-pending period to resolution.

Medicaid Applications & Eligibility

When a resident needs Medicaid, identifying eligibility issues before filing can prevent unnecessary delays and complications later.

We assist with:

• Pre-application eligibility review

• Income and resource analysis

• Medicaid application preparation and submission

• Spend-down planning

• Spousal impoverishment issues

• Transfer and five-year lookback concerns

• Miller Trust requirements

• Property and resource issues

• Application timing

• Document collection and verification

• Authorized Representative services when appropriate

• Application monitoring through determination

• Coordination with residents, families, and facility staff

We approach the application as a complete eligibility case—not simply a form that needs to be submitted.

Denials, Suspensions & Reinstatement

A denial, suspension, or unexpected loss of Medicaid coverage can leave both the resident and the facility facing significant consequences.

We assist with:

• Review of denial and adverse-action notices

• Identification of the reason for the action

• Review of eligibility and case history

• Coverage suspensions and interruptions

• Medicaid reinstatement issues

• Requests for continuation of benefits when applicable

• Missing or unprocessed documentation

• Eligibility and agency processing errors

• Communication and follow-up with FSSA/DFR

• Fair Hearing and administrative appeal support

• Resolution efforts before a hearing

• Monitoring through resolution

We look beyond the notice to determine what happened, what needs to be corrected, and what options are available to move the case forward.

Patient Liability & Coverage Issues

An incorrect Medicaid effective date, patient liability amount, or coverage determination can create billing problems even after a resident has been approved.

We assist with:

• Patient liability review

• Unexpected changes in patient liability

• Medicaid effective-date issues

• Retroactive eligibility questions

• Coverage gaps

• Eligibility-related billing problems

• Medicaid coverage interruptions

• Review of eligibility notices and case information

• Coordination with residents and families

• Communication with Medicaid regarding eligibility-related discrepancies

• Identification of issues affecting facility reimbursement

Medicaid approval does not always mean the case is correct. We help identify and address eligibility issues that may be affecting the resident's coverage or the facility's ability to bill appropriately.

Complex & Problem Medicaid Cases

Some Medicaid cases simply need an experienced set of eyes.

We assist facilities with cases involving:

• Long-standing Medicaid-pending balances

• Complicated financial circumstances

• Prior transfers or unexplained transactions

• Property and unusual assets

• Spousal eligibility issues

• AVS discrepancies

• Repeated verification requests

• Conflicting Medicaid information

• Delayed or unresolved agency action

• Difficult family or documentation circumstances

• Coverage interruptions

• Institutional and HCBS eligibility issues

• Cases that have changed hands multiple times without resolution

• Medicaid policy research and case review

• Development of a strategy for moving the case forward

When a case has become complicated, we reconstruct what happened, identify the remaining barriers, and develop a practical path forward.

Facility Consultation, Training & Ongoing Support

Not every facility needs full case management. Sometimes staff need a reliable Medicaid resource they can call before a problem becomes a significant outstanding balance.

HMS can provide:

• Consultation on individual Medicaid cases

• Review of difficult or high-risk pending cases

• Medicaid eligibility education for facility staff

• Training on common application and documentation problems

• Guidance regarding Medicaid notices and verification requests

• Education regarding income, resources, transfers, and spousal issues

• Assistance identifying cases that may require early intervention

• Periodic review of Medicaid-pending cases

• Support for Business Office and admissions staff

• Coordination with corporate or regional personnel

• Ongoing Medicaid case support tailored to the needs of the facility

Our goal is to become a practical Medicaid resource for your team—helping resolve existing problems while identifying potential issues earlier in the process.