ODH Form 13411341A for Take Charge 2 Have the Take Charge Eligibility Form ODH No 1341 and Take Charge Eligibility Form ODH No 1341A Spanish in front of you for easy reference Plan on completing the skill assessment at the end of the training ID: 1029093
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1. New Centralized Eligibility Process (ODH Form 1341/1341A) for Take Charge!
2. 2Have the Take Charge! Eligibility Form ODH No: 1341 and Take Charge! Eligibility Form ODH No: 1341A (Spanish) in front of you for easy referencePlan on completing the skill assessment at the end of the trainingAllow approximately 20 minutes for training (including completion of the skill assessment)Please do not work as a groupBefore Proceeding with Training
3. All individuals who assist with Take Charge! related clients and services Patient NavigatorReceptionistAdministrative AssistantMedical AssistantBilling/Invoice Personnel Licensed healthcare provider (DO, MD, PA, Nurse Practitioner, RN, LPN, etc.) who provides Take Charge! services for Take Charge! eligible womenWho is Required to Take the New Centralized Eligibility Process Training?
4. 4Goal and ObjectivesGoal Provide an opportunity to gain knowledge and skill in completion of the Take Charge! Eligibility Form ODH No. 1341 and Take Charge! Eligibility Form ODH No. 1341AObjectivesUpon completion of this self-study training participants will be able to:Describe the process of utilizing the Take Charge! Eligibility Form Correctly complete the ODH Form No. 1341 or ODH No. 1341A
5. 5OverviewThe new Centralized Eligibility Process for Take Charge! will:Allow multiple opportunities to establish Take Charge! eligibility Maintain requirement to follow Federal Office of Management and Budget (OMB)
6. 6Take Charge! Centralized EligibilityGeneral EligibilityOklahoma residentAge 21 - 65 years old (under 50 must have a tubal litigation or hysterectomy)No insuranceNo Medicaid/MedicareUnderinsured with unmet deductible of $150 or higherMeet the income guidelines Women served in County Health Departments may qualify for dysplasia services
7. 7Take Charge! Centralized Eligibility OptionsPick one of the three options to determine Take Charge! Eligibility:Call Take Charge! Patient Navigator toll free at 1 - 888 - 669 - 5934Mail Take Charge! Eligibility Form ODH No: 1341 or Take Charge! Eligibility Form ODH No: 1341A (Spanish version) to Take Charge! Program, 1000 NE 10th Street, Oklahoma City, OK 73117-1299, Attention: Take Charge! Eligibility UnitSubmit Fax ODH Form No. 1341 or ODH Form No. 1341A via fax (405-271-6315) or upload through Take Charge!’s BOX account*If you are requesting a quick turn around, it may be helpful to send an email or call Take Charge! administrative staff to advise that a fax was sent.This option should be used while the woman is in the healthcare provider’s office prior to receiving Take Charge! funded breast and cervical cancer screening services*Contact Take Charge! administrative office at 405 - 271 - 3619 for assistance
8. 8Take Charge! Centralized Eligibility Notification ProcessFaxed eligibility requests will receive a fax response backRegardless of which option used to apply for Take Charge! services, all eligible clients will receive a Take Charge! Eligibility Packet mailed to the address provided
9. 9Take Charge! Centralized Eligibility PacketEligible clients will receive a Take Charge! eligibility letter in their Take Charge! packetEligibility letter expires 60 days post issuancePacket contains list of available Take Charge! facilitiesApproved women should receive the Take Charge! packet within 7-10 business days
10. 10Take Charge! Eligibility Established Prior to Funded Services Being RenderedTake Charge! eligibility must be determined before receiving Take Charge! funded servicesTake Charge! will not pay for services provided without proof of Take Charge! letter or approved Centralized Eligibility Form at time of serviceEligibility must be re-established if letter has expired
11. 11Completing ODH Form No. 1341 or ODH Form No. 1341ATake Charge! Eligibility Forms are available in English and SpanishForms can be ordered on the Take Charge! supply order listForms can be completed online or printed Forms can be faxed or mailedThe form is comprised of multiple sections:Facility informationPatient informationTake Charge! Administrative Office Use
12. 12New Centralized Eligibility Form (ODH Form No. 1341)
13. 13New Centralized Eligibility Form (ODH Form No. 1341A)
14. 14Facility InformationTake Charge! contractor and/or County Health Department staff must complete all of the fields in the facility information sectionForm will be returned if it is incompleteInformation provided in the facility information section will be utilized if additional information is needed to determine eligibility
15. 15Facility InformationIf the client indicates they heard about Take Charge! through a postcard with an identification number, write the number on the form in the Postcard identification number section
16. 16Patient Information SectionTake Charge! contractor and/or the County Health Department staff may assist the client in completing fields in this areaHave client provide their legal name as listed on photo/identification cardsHave client review the description of household income to facilitate accurate reporting
17. 17If client has an abnormal finding, such as an abnormal Pap report, it is required to be submitted with the eligibility formPatient Information Section
18. 18Take Charge! Administrative Office Section Take Charge! Administrative Office will review the ODH Form No. 1341 or ODH Form No. 1341A along with abnormal resultsTake Charge! will determined eligibility based on the information provided on the formIt is possible that a follow-up call will be made if the information is incomplete or unclear
19. 19Take Charge! Administrative Office Section Take Charge! will determine which services the client is eligible to receiveTake Charge! will indicate the date eligibility expiresTake Charge! will return the form with eligibility indicated
20. 20Take Charge! Contractor Roles and ResponsibilitiesA current Take Charge! letter or ODH Form No. 1341/ODH Form No. 1341A is required prior to providing breast/cervical cancer screening servicesA copy of Take Charge! letter or ODH Form No. 1341/ODH Form No. 1341A is required to be submitted with invoice as indicated in Take Charge! contract
21. 21Take Charge! Patient Navigator Role and ResponsibilitiesProvide timely and professional customer serviceDetermine eligibilityFacilitate timely access to quality breast and cervical screening, diagnostics and initiation of treatment services
22. 22Skill AssessmentPlease complete the electronic skill assessment located at the Take Charge! website atTake Charge! Centralized Eligibility TrainingFor issues with the skill assessment, contact: Take Charge! administrative staff at 405-271-3619.
23. 23Take Charge! toll free number 1-888-669-5934Center for Chronic Disease Prevention and Health Promotion 405-271-3619Email CancerPCP@health.ok.gov(Please do not email protected health/confidential information)Fax Number405-271-6315Take Charge! websiteTake Charge! (oklahoma.gov)Take Charge! Contact Information