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Effective Date: 
7/2007

Documents

Instructions

Updated: 9/2010

Purpose

To notify an applicant and a facility administrator of a delay in certification when:

  • the applicant has not been in the facility or a §1915(c) waiver for 30 consecutive days.
  • a decision regarding medical necessity (MN) for nursing care or level-of-care (LOC) for intermediate care facility for mental retardation has not been received.
  • a disability decision has not been received for a person who is less than age 65 and must have HHSC determine disability.
  • the nursing facility certification is pending.
  • new resource/income information is received after the 30th day of the pending application.
  • the applicant is doing resource spend-down. The applicant is over the resource limit at the time of application, but is expected to be eligible within 90 days from the original application due date.
  • there is some other reason such as one of the following:  
    • miscellaneous;
    • CC pending;
    • documentation of citizenship and identity; or
    • legal review of documents.

Procedure

When to Prepare

Prepare Form H1247 when certification of an applicant is delayed beyond the 45th day or the 90th day, based on criteria outlined in Section B-6400, Processing Deadlines.

Always prepare Form H1247 when a delay in certification is necessary and has been approved by the supervisor.

Always follow up with Form H1020, Request for Information or Action, in conjunction with Form H1247 to establish what is necessary and to establish the date by which the applicant is to provide the missing information or meet other criteria, such as be in a Medicaid certified facility or have an MN or LOC established.

Number of Copies

Complete an original and three copies.

Transmittal

Send the original and first copy to the applicant or responsible party, send the second copy to the nursing facility and file the third copy in the case record.

Form Retention

Keep the copy in the case record.

Detailed Instructions

Form H1247 may be typed or legibly handwritten.

Inside Address — Enter the name of the applicant and mailing address or that of the applicant's responsible party.

Date — Self-explanatory.

HHSC Staff — Self-explanatory.

Office Address and Telephone Number — Self-explanatory. Include the telecommunications device for the deaf (TDD) telephone number if the office is equipped with TDD.

A determination of your eligibility ... — for the following reason — Check the appropriate box. If appropriate, enter the date the 30-consecutive-day requirement will be met.

Page 2: HHSC Staff, Mail Code, Office Address and Telephone Number — Enter the HHSC staff member's name, mail code, complete office address and telephone number. Include the TDD telephone number if the office is equipped with TDD.