Non-KEES Forms

Notices

KEES Website Notices

• M802 POTENTIAL SPENDDOWN INFORMATION NOTICE
• M834 MA NOTICE OF REPAYMENT
• M836 N836 SPENDDOWN INFORMATION NOTICE
• M837 MA-MEDICAL CARD RETURNED
• N744 WORKING HEALTHY - UMEMPLOYMENT PLAN REQUEST
• N810 WORKING HEALTHY PREMIUM INFORMATION
• N812 WORKING HEALTHY DESK REVIEW
• N832 MEDICAL ASSISTANCE PENDING SSA DECISION
• N838 S838 TERMINATION/DECERTIFICATION ACH FACILITY
• N839 S839 TRANSFER TO ANOTHER NURSING FACILITY
• P408 GENERAL NOTICE OF DISCONTINUANCE
• P600 MP - REINSTATE AFTER SUSPENSION
• P700 MP CHANGE GENERAL
• P803 MP - REPORTING REQUIREMENTS
• POSTMASTER LETTER
• V000 GENERAL VERIFICATION REQUEST
• V001 SCHOOL VERIFICATION REQUEST
• V003 REQUEST FOR EMPLOYMENT INFORMATION
• V005 HEALTH INSURANCE INFORMATION REQUEST
• V006 UNREPORTED INCOME VERIFICATION REQUEST
• V012 INCOMPLETE CHANGE-NEW HOUSEHOLD MEMBER
• V015 POTENTIAL BENEFITS REQUEST
• V025 GENERAL PENDING NOTICE
• V027 ASSESSMENT OF RESOURCES-SPOUSAL IMPOV.
• V032 MEDICAL DETERMINATION PENDING
• V070 ID & CITIZENSHIP VERIFICATION REQUEST
• V075 REQ - AUTH FOR MEDICAL AGENT FOR MINOR
• V080 SSPP REPLACEMENT
• V082 SSPP DIRECT DEPOSIT REQUEST
• V100 APPROVAL LTC-SPOUSAL IMPOV. INFORMATION
• V116 CONDITIONAL ELIGIBILITY APPROVAL
• V117 SSPP APPROVAL
• V118 SSPP APPROVAL WITH DD
• V200 LTC DENIAL-RESOURCES EXCEED SP IM LMT
• V304 FUNERAL AGREEMENT INFO
• V400 BURIAL ASSISTANCE APPROVAL
• V408 SSPP CLOSURE
• V498 CLOSURE - OTHER REASONS
• V600 CERTIFICATE OF CREDITABLE COVERAGE
• V601 SPOUSAL ELECTIVE SHARE REQUEST
• V801 CASE TRANSFER NOTICE
• V828 REPAYMENT AGREEMENT REMINDER
• V830 DEMAND NOTICE AT CLOSURE
• X019 REPORTING THE BIRTH OF YOUR CHILD

KEES Website Notices Facility Notice

• N911 FACILITY NOTICE APPROVAL ACH ONE MONTH
• N912 FACILITY NOTICE APPROVAL ACH TWO MONTHS
• N913 FACILITY NOTICE APPROVAL ACH THREE MONTHS
• NOTICE: S921 SI - FACILITY - GENERAL DENIAL
• C941 N941 S941 FACILITY NOTICE GENERAL CLOSURE
• C971 N971 S971 – FACILITY NOTICE MASS CHANGE
• C972 N972 S972 FACILITY NOTICE CHANGE IN PATIENT LIABILITY
• C973 N973 S973 FACILITY NOTICE SUSPENSION LTC PAYMENT
• N974 FACILITY NOTICE REVIEW COMPLETE REMAINS ELIGIBLE
• N978 FFACILITY NOTICE EXCESS LIABILITY NO SPENDOWN SPENDOWN MET
• C979 TITLE: FACILITY-EXCESS LIABILITY-SPD UNMET
• N980 FACILITY NOTICE REVIEW COMPLETE EXCESS LIABILITY
• C981 CI-FACIL- REV COMP EXCESS LIAB/SPD UNMET
• I009 RETRO PATIENT LIABILITY CHANGE-NF
• I012 FUNERAL AGREEMENT REFERRAL
• N900 MS-FACILITY NOTICE-GENERAL
• N911 S911 FACILITY NOTICE - APPROVAL ACH ONE MONTH
• N912 S912 FACILITY NOTICE - APPROVAL ACH TWO MONTHS
• N914 S914 FACILITY NOTICE-APPROVAL TEMP STAY
• N915 MS-FACILITY-APPROVAL-TEMP STAY FROM HCBS
• N962 MS - FACILITY - REINSTATE ACH PAYMENT
• N975 MS-FACILITY-FAILURE TO COMPLETE REVIEW
• N976 FACILITY- ACH PAYT END-TRANS TO NEW ACH
• N983 FACILITY NOTICE-LIABILITY CHANGE TWO MONTHS
• N985 TITLE: FACILITY - ACH PAYT END-MOVE TO IND LVG
• N987 FACILITY - ZERO LIABILITY-QMB

KEES Website Notices Medikan

• D100 MEDIKAN APPROVAL
• D200 MEDIKAN DENIED - FAIL TO PROVIDE INFO
• D204 MEDIKAN DENIED - FAMILY OF DECEASED
• D400 MEDIKAN CLOSURE - FAIL TO PROVIDE INFO
• D701 MEDIKAN TO MEDICAID - SSA APPROVED
• D832 OPEN MEDIKAN - MEDICAID PENDING
• D854 MEDIKAN TIME LIMIT INFORMATION