| 1 |
Transferred to another HH |
Member or potential member is working with or wants to work with another Health Home agency |
A transfer to another HH could be due to member choice, ability of a different Health Home to better serve the member or another reason. |
A |
B |
| 2 |
Individual opted-out (pre-consent only) |
Individual has voluntarily opted out. Individual does not want to be a Health Home member and receive Health Home services |
To be used for individuals who choose not to enroll into Health Home, as explained in Access to/Sharing of Personal Health Information (PHI) and the Use of Health Home Consents HH0009. |
A |
O |
| 3 |
Transferred to another CMA |
Individual is working with another Care Management Agency within the same Health Home |
A transfer to another CMA could be due to member choice, ability of a different CMA to better serve the member, or for another reason. This is not a disenrollment segment end code. |
A |
B |
| 4 |
Individual deceased |
HH has been informed that the individual is deceased |
|
D |
B |
| 5 |
Individual has a new CIN |
The individual is assigned a new Medicaid CIN |
If the Medicaid CIN changes for a Health Home enrolled/outreached individual, the segment should be: 1) ended under the old CIN using this reason, 2) the new CIN should be typed in the comments box, and 3) a new segment should be created using the new CIN. |
A |
B |
| 7 |
Closed for health, welfare, and safety concerns |
Disenrollment due to health, welfare, and safety concerns for member and/or staff (formerly for behavior) |
Member can no longer be disenrolled from HH program for "behavior" or "non-compliance." Behaviors should be addressed by the HH care manager and/or the member's care team following protocols set out in Member Disenrollment From the Health Home Program HH0007. |
D |
B |
| 9 |
Individual moved out of state |
Member moved out of New York State |
D |
B |
| 11 |
Individual incarcerated |
Individual is incarcerated where the length of stay is anticipate to be longer than 6 months |
Individual should be disenrolled as addressed in Continuity of Care and Re-engagement for Enrolled Health Home Members HH0006. |
D |
B |
| 13 |
Individual is in an inpatient facility |
Member is in an excluded setting and the length of stay is anticipated to be longer than 6 months. |
The individual is in an excluded setting such as inpatient, hospitalization, institution or residential facility, nursing home, etc.) as outlined in Continuity of Care and Re-engagement for Enrolled Health Home Members HH0006. |
D |
B |
| 14 |
Enrolled Health Home member disengaged from care management services |
Member is considered disengaged when diligent and continued search efforts do not result in location of the member. |
Member is considered disengaged from care management services when diligent and continued search efforts do not result in location of the member as outlined in Continuity of Care and Re- engagement for Enrolled Health Home Members policy. |
D |
E |
| 16 |
Inability to contact/locate individual |
Individual is unreachable during outreach attempts. |
See Interim Guidance Addressing Outreach Modification, October 2017. |
A |
O |
| 18 |
Member interested in HH at a future date |
For individuals not yet ready for HH services who express future interest |
Individual in outreach is not interested in Health Home services, but indicates that they may be interested in Health Home services in the future. |
A |
O |
| 19 |
Individual doesn't meet HH eligibility and appropriateness criteria |
Individual does not/no longer meets eligibility criteria required for enrollment/continued enrollment |
Individual does not/no longer meets the elibility criteria of at least two chronic conditions or one single qualifying condition, and doesn't meet approporiateness criteria, per Member Disenrollment From the Health Home Program policy. |
D |
B |
| 21 |
Member has graduated from HH program |
Individual can successfully self-manage and monitor their chronic conditions. |
Individual no longer meets the appropriateness criteria, in that they can successfully self-manage and monitor the chronic conditions that made him/her eligible for the Health Home program, as referenced in Member Disenrollment From the Health Home Program policy. |
D |
E |
| 24 |
Individual is not/no longer eligible for Medicaid |
Individual no longer qulaifies or meets eligibility requirements for Medicaid. |
This code should be used only when appropriate measures have been initiated to reinstate benefits, as noted in Member Disenrollment From the Health Home Program policy. |
D |
B |
| 25 |
Individual moved from Outreach to Enrollment (can be system generated) |
System generated – When an enrollment segment is created prior to the end of an outreach segment the system will automatically end date the outreach segment on the last day of the month prior to the start date of the enrollment segment using this reason code. User selected – When user ends an outreach segment because the individual has been found during outreach. |
When user selected, end outreach segment when individual is found and eligible for Health Home services and begin enrollment segment. |
A |
O |
| 28 |
Health Home change MMIS ID Provider ID |
CMA or HH MMIS ID changes within MAPP HHTS |
This code is used to indicate that the individual's segment is ended under the old ID and will be started under the new ID with no loss to Health Home services for the individual. |
A |
B |
| 29 |
Member withdrew consent to enroll |
Member chooses to disenroll from the Health Home program. |
This code is used when the member chooses to disenroll from the Health Home program, as noted in Member Disenrollment From the Health Home Program policy. |
D |
E |
| 32 |
Provider Closed |
For use when HH or CMA closes business and member is transferred to another HH and/or CMA |
Use when a Health Home or CMA closes business and member must be transferred to new Health Home and/or CMA. |
A |
B |
| 33 |
Merger |
In the instance of a merger between two HH or CMAs |
This is used in the instance of a merger between two Health Homes or CMAs. Notification of Change Form is used to inform the NYS Department of Health of any changes made to Health Home from originally approved Health Home application and designation letter. |
A |
B |
| 41 |
Coverage not compatible |
Individual's Medicaid coverage is not compatible with HH |
See Guide to Coverage Codes and Health Home Services for examples of Medicaid coverage that is not compatible with the Health Home program. |
D |
B |
| 42 |
Program not compatible |
Individual chooses to move to another program not compatible with HH program |
Individual chooses to move to another program not compatible with Health Home program or individual is found to be currently enrolled in non- compatible program. See the Guide to Restriction Exception (RE) Codes and Health Home Services for examples of programs that are not compatible with the Health Home program. |
D |
B |
| 43 |
Individual moved between HHSC and HHSA |
When a member who previously received services as a child transitions to adult, or an adult transitioning back to HHSC. |
An individual previously receiving Health Home services as a child or adult is transitioned to the other program based on individual preferences or age (i.e. child in HHSC services transitions to adult HH services). |
A |
B |
| 44 |
Segment Correction |
For use only if directed by DOH in order for HH RE codes to be correctly attributed to the member |
Only use if directed by DOH - This code should be used when it is necessary to end a segment and create a new one in order for Health Home RE codes to be correctly attributed to the member. |
A |
E |
| 99 |
DOH Use Only |
Reason not listed. Comments related to end reason must be included |
Formerly "Other" can no longer be used by Health Homes – For DOH Only. Reach out to DOH if you are unable to find the appropriate code. |
A |
B |
