Application Process

Application to the Cancer Control Program is made by submitting the appropriate forms to the Purchase of Medical Care Services Office:

	Submit the completed Financial Eligibility form (DHHS 3014).
	Submit the completed Medical Authorization Request form (DHHS 3056).
	Attach required documentation.
	Mail to: PURCHASE OF MEDICAL CARE SERVICES 1904 Mail Service Center Raleigh, North Carolina 27699-1904

Patients must have a Financial Eligibility Application (DHHS 3014) completed annually by a financial interviewer. The interviewer may be an employee of the patient's hospital, physician's office or the local health department. Once approved, the individual will remain financially eligible for a period of twelve months from the date of application unless there is a change in the individual's family size or in the family's financial resources during that period. If there is a change, financial eligibility must be re-determined at that point. Otherwise, financial eligibility is re-determined at the end of the twelve-month eligibility period.

Required Documentation

Documentation of earned income is required if inpatient services are requested or if the interviewer or POMCS staff questions the validity of the self-declared income.

When the eligibility application is incomplete, a Request for Additional Information/Denial of Financial Eligibility (DHHS 3053) is sent to the applicant and the financial interviewer. This form specifies the information or documentation that must be received before financial eligibility can be determined. POMCS sends a system-generated Reply to Financial Eligibility application to the applicant and the financial interviewer if the applicant is found to be either eligible or ineligible for program.

Block 9 on DHHS 3014 should reflect the number of countable household members which may differ from the number of persons residing in the home. First, determine who is the applicant. Then use this criterion to determine who is counted.

Criteria for Determining Family Member
	Is related to the applicant by blood, marriage, or adoption.
	Lives in the same household as the applicant.
	Is financially responsible for the applicant or the applicant is responsible for him or her.

Frequently Referenced Household Situations

If the applicant is less than 18 years old and unmarried, count:

	Applicant
	Parents of the applicant
	Step-parents of the applicant (If they do not have any income)
	Siblings or half siblings of the applicant,
	-	if they are unmarried and less than 18 years old
	-	if they are 18 years or over and have no income
	-	if they are married and neither they nor spouse have any income
	Step-siblings of the applicant, if they are without income and their biological parent is counted.
	Other individuals (i.e. grandparents, great grandparents, aunts, uncles, cousins, nieces, nephews, etc.) living in the household who are related to the applicant by blood, marriage or adoption and do not have any income. Other individuals are not counted if they have a parent or spouse with income and live in the same household.

If the applicant is less than 18, or 18 and over and married, count:

	Applicant
	Spouse of applicant
	Children of applicant
	Step-children…if they have no income
	Parents of the applicant, if they live with and are supported by the applican
	Other individuals (i.e. grandparents, great grandparents, aunts, uncles, cousins, nieces, nephews, etc.) living in the household who are related to the applicant by blood, marriage or adoption and do not have any income. Other individuals are not counted if they have a parent or spouse with income and live in the same household.

If the family includes a student who is living away from home while attending school, the student is considered to be living in the permanent home and is counted

If the applicant is a child who is not living with his or her parent(s), the child should be counted as a family of one, since the child is not living with a relative who has legal responsibility for his financial support. Neither relatives nor legal guardians should be counted.

If the applicant is the legal guardian of a minor, the child is regarded as an "other individual" and counted as a family member if the child has no income.

Adopted children are treated as biological children and counted as family members. A child with special post-adoption coverage through Children Special Health Services is counted as a family of one.

If the applicant was recently married, include the spouse's income from the past year even though the two were not living together during the entire12 months.

If the applicant recently separated or divorced, only count the income of the responsible family members who live with the applicant at the time of application.

A common law spouse is not counted as a family member.

Countable Sources of Income

Sources of Income Not Counted

	Irregular Income that a child earns from babysitting, lawn mowing or other tasks
	Proceeds from the sale of an asset
	Withdrawals from a bank account
	Gifts
	Inheritances
	Life insurance proceeds or one-time settlements

Computing the Family's Gross Income

	The start date is the date of the application or the date of service being requested, whichever is first. If the date of service precedes the date of application, note the date in Block 14 of DHHS 3014.
	If the wage earners have been continuously employed or had a consistent source of unearned income, add the income received during the 12 months prior to the start date.
	If the wage earners are unemployed on the start date or have been unemployed for at least 30 consecutive days during the previous 12 months, total countable income during the previous six months and projected income for future 6 months which may equal zero. This formula is also used when the applicant has transitioned from earned to unearned income (unemployment compensation, Social Security, retirement, etc.) or when earnings have increased/decreased due to a change in job or work schedule. In cases where the application is completed after-the-fact, 'future' six months may reference actual rather than projected earning.

Documentation of Income

Documentation is required when:

	Coverage for inpatient services is requested.
	The financial interviewer questions the applicant's statement of income.
	Purchase of Medical Care Services requests it.

Acceptable forms of documentation:

	Pay check stubs
	W-2 forms or 1099's
	Federal income tax returns and all related schedules from the most recent calendar year. North Carolina Form D-400 is not acceptable for documenting total gross income.
	Written statements from employers

Once the applicant's income has been computed, financial eligibility is determined by the Program's income scale. It is generally appropriate to use the current year income scale. However, when an application is filed retroactively, it may be necessary to reference an earlier scale that was in effect at the time of the requested dates of services. Income scales are updated annually and distributed by Purchase of Medical Care Services in their Provider Bulletin prior to the July 1 effective date. An interviewer, who determines an applicant's income exceed the cut-off, need not submit the application to POMCS unless it is necessary to verify or document for another organization that the applicant is ineligible for the Cancer Control Program.

Following this process when completing an Authorization Request will ensure more timely processing since it will not have to be returned for additional information:

Mail completed forms to:

Authorization or Denial of Services

Once the requested service has been reviewed, all designated providers will receive a Reply to Authorization Request from the Purchase of Medical Care Services Office. Providers should review this document carefully, paying particular attention to dates and types of service. This form may indicate authorization of the service, a reason for denial, or request for additional information. If additional information is requested, the provider must respond within 30 days from the date of the reply or one year from the date of service, whichever is later.

Replies on the status of an authorization will be generated by the Purchase of Medical Care Services Office. Occasionally, the Cancer Control Program Office in the Division of Public Health may also write the provider requesting clarification or more information to be used for medical review. Requests from the Cancer Control Program Office (not POMCS) should be returned to the Cancer Control Program office.

If a specific authorization has been denied and the provider believes that the case warrants reconsideration by the Medical Consultant for the Cancer Control Program, a letter to the Program Manager can be written, with additional information, to request further medical review.

Request for Change on Completed Authorization

A service request which has been authorized may sometimes change. If so, the provider identified on on Line 27 of the Authorization Request must submit to Purchase of Medical Care Services a written request to change the service request . A copy of the current authorization should accompany the request for change.

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