Monthly, the Healthy Families Program (HFP) sends out Reimbursement Reports to Enrollment Entities (EEs). EEs sometimes find these reports confusing. In an attempt to reduce confusion surrounding these reports, the HFP has created the Denial Definition chart below. This chart is meant to serve as a glossary by providing the definition of each reimbursement denial reason that may appear on a Reimbursement Report. We hope you will find this chart helpful as you review your Reimbursement Reports and that it may help you decrease your denials in the future!
| EE # missing means that the EE # was not present or clearly written in Section 9 of original joint HFP application or Section 10 of original AER application. |
| CAA # missing means that the CAA # was not present or clearly written in Section 9 of original HFP application or Section 10 of original AER application. |
| App Signature Missing means that the applicant did not sign in Section 9 of original HFP application or Section 10 of original AER application. |
| CAA Signature Missing means that the CAA did not sign in Section 9 of original HFP application or Section 10 of original AER application. |
| Apps Not Assisted means the application did not state the EE number, CAA number, and at least one signature from either the applicant or the CAA. |
| EE not Certified means that EE is currently not active with the HFP. |
| EE not Eligible means that the EE was not active with Healthy Families at the time the HFP application was received. |
| EE is a contracted Community Based Organization means that the HFP received an EE Reimbursement Discontinuance Request Form that allowed Healthy Families to set an EE to a Do Not Pay status. |
| EE is a Health Families Program plan means that EE does not qualify for reimbursement because they are an HFP health/dental/vision plan. |
| Not a valid EE number means that the EE # that was written in Section 9/10 does not match the HFP database. |
| CAA not Certified means CAA is currently not active with an EE. |
| Not a valid CAA number means that the CAA # that was written in Section 9/10 does not match the HFP database. |
| CAA not linked to an EE means that CAA # that was written in Section 9/10 is not listed under the EE number written on the application. |
| CAA not Eligible means that CAA was not active with an EE at the time the HFP application was received. |
| App Denied with No Enrollees means that the applicant did not qualify for either the HFP or Accelerated Medi-cal. |
| App Timeout with MI (Missing Information) means that the HFP application was not complete within 20 days of initial application receipt date. |
| Invalid App Type means the application that was sent to the HFP does not qualify for reimbursement payment. (Add-a-Person, Re-Enrollment, Premium Re-evaluation, and Open Enrollment) |
| Payment Cap reached for Family means each FMN is allowed one joint application Healthy Families outcome, one Medi-cal outcome, and one AER outcome per 12 months. |
| EE/CAA Budget not approved means that the HFP application was received prior to 7/1/2005. |
| App processed with No Enrollees to Pay means the applicant is currently with Medi-cal, had Medi-cal within the past 90 days, is a pregnant woman, or has income too high to qualify for the HFP. |
| AER processed within 90 days means that an EE reimbursement payment has already been paid for an AER application within the past 90 days. |
