Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - MAPS Intranet Version

Revised SAAI display

Revised Appeal Input Screen (APIS)

1

Revised Appeals Results Screen (APRS)

Revised MEDQ Default Screen (QDIS)

99999999999

2

Revised QDIS display: Client Data section (Part A tab)
Client Data

Name:
MBI:
Title2 Claim#:
SSI Claim#:
RRB Claim#:
Date of Birth:
Sex:
Address:
Source of Address:
Phone Number:
Couples X ref#:
Preferred Language:
- Spoken:
- Written:

JIMMY D MITCHELL
99999999999
594041307A
02/22/1940
Male
408 W WHEELER ST, ROCKWOOD , TN, 37854-2029
MBR
(865)062-2901 Other
English
English

Revised QDIS display: Client Data section (Part B tab)
Client Data

Name:
MBI:
Title2 Claim#:
SSI Claim#:
RRB Claim#:
Date of Birth:
Sex:
Address:
Source of Address:
Phone Number:
Couples X ref#:
Preferred Language:
- Spoken:
- Written:

JIMMY D MITCHELL
99999999999
594041307A
02/22/1940
Male
408 W WHEELER ST, ROCKWOOD , TN, 37854-2029
MBR
(865)062-2901 Other
English
English

Revised QDIS display: Client Data section (Part C tab)
Client Data

Name:
MBI:
Title2 Claim#:
SSI Claim#:
RRB Claim#:
Date of Birth:
Sex:
Address:
Source of Address:
Phone Number:
Couples X ref#:
Preferred Language:
- Spoken:
- Written:

JIMMY D MITCHELL
99999999999
594041307A
02/22/1940
Male
408 W WHEELER ST, ROCKWOOD , TN, 37854-2029
MBR
(865)062-2901 Other
English
English

3

Revised QDIS display: Applicant Data section (Part D & ‘All’ tab)
Applicant Data

Current Application Status:
Deemed:

Medicare Savings Program (Referral):
Name:
MBI:
Title2 Claim#:
SSI Claim#:
RRB Claim#:
Date of Birth:
Sex:
Type of Application:
Contact Type:
Source of Application:
Address:
Source of Address:
Phone Number:
Couples X ref#:
Preferred Language:
- Spoken:
- Written:

Completed - Determined/Done
2019 No
2018 No
2017 No
Yes
JIMMY D MITCHELL
99999999999
594041307A
02/22/1940
Male
Couple
Paper
408 W WHEELER ST, ROCKWOOD , TN, 37854-2029
MBR
(865)062-2901 Other
English
English

Revised QDIS display: Spouse Data section (Part D & ‘All’ tab)
Spouse Data

Current Application Status:
Deemed:
Medicare Savings Program (Referral):
Name:
MBI:
Title2 Claim#:
SSI Claim#:
RRB Claim#:
Date of Birth:
Sex:
Type of Application:
Contact Type:
Source of Application:
Address:
Source of Address:
Phone Number:
Couples X ref#:
Preferred Language:
- Spoken:
- Written:

Completed - Determined/Done
2019 No
2018 No
2017 No
Yes
CLARA L MITCHELL
99999999999
426422504A
05/06/1947
Female
Couple
Paper
408 W WHEELER ST, ROCKWOOD , TN, 37854-2029
MBR
(865)062-2901 Other
594041307
English
English

4