Nursing facility request to disenroll from medicaid health plan




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Michigan Department of Health and Human Services


Date of Request:

     

NURSING FACILITY REQUEST TO DISENROLL FROM MEDICAID HEALTH PLAN



The nursing facility may only utilize this form to request disenrollment based on administrative error, i.e., the Medicaid beneficiary was residing in the nursing facility prior to enrollment in a Medicaid Health Plan. The nursing facility must contact the Medicaid Health Plan for disenrollment in all other instances. Medicaid Health Plans must use the Request for Administrative Disenrollment (form MSA-2008) to request disenrollment based on administrative errors.


Instructions:

  • For each beneficiary disenrollment request, complete and submit this form and a copy of the Facility Admission Notice (form MSA-2565-C).

  • MDHHS will return the form to the facility ONLY if the disenrollment is denied.

  • MAIL or FAX this request to:

MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENROLLMENT SERVICES SECTION
PO BOX 30479
LANSING, MI 48909



FAX: (517) 373-1437

NOTE: Only MDHHS processes disenrollment requests. MDHHS CANNOT remove LOC 07.

Beneficiary Name

     

Nursing Facility Name

     


Beneficiary mihealth Card Number

     

Nursing Facility Contact Person

     


Requested Effective Date of MHP Disenrollment (Disenrollment requests will not be retroactively approved for more than six months.)

     



Contact Person Phone Number

     

Facility Fax Number

     

Date of Discharge (if applicable)

     


Health Plan Name

     


MDHHS USE ONLY

DO NOT WRITE BELOW THIS LINE.

 DENIED

Reason for Denial:

 Beneficiary did not reside in nursing facility on date of enrollment in the Medicaid Health Plan

 Insufficient documentation

 Other, Please specify      





Authority:

Completion:

P.A. 368 of 1978.

Required. Failure to file this report may result in regulatory actions as permitted under P.A. 368, or sanctions as permitted under the MHP contract.


The Michigan Department of Health and Human Services is an equal opportunity employer, services and programs provider.







DCH-1185 (05-15) Previous edition may be used.


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