Adult Medicaid Admin. Letters

DMA ADMINISTRATIVE LETTER NO. 18-03, NEW MEDICAID PROFILE INDICATOR AND FOLLOW-UP CASE MANAGEMENT REPORT

(EPICS)

TO: County Directors of Social Services

DATE: January 23, 2003

RE: New Medicaid Profile Indicator and Follow-up Case Management Report

EFFECTIVE

DATE: February 10, 2003

EPICS created a new Medicaid Profile Indicator field on the Claim Detail screen that program integrity investigators can use to trigger a monthly case management report to notify them when it is time to request a follow-up Medicaid Recipient Profile. Prior to this change, investigators had to rely on a manual process to remind them to reorder recipient profiles.

I. REQUESTING FOLLOW-UP MEDICAID RECIPIENT PROFILES

A. The actual or final overpayment amount for a Medicaid overpayment claim is based on the medical claims paid by Medicaid during the period of ineligibility. Before investigators can determine the actual overpayment amount for most Medicaid claims, the investigator must request an initial Medicaid Recipient Profile from the Division of Medical Assistance (DMA) to determine the amount of claims Medicaid has paid to date for an individual or individuals during the specified overpayment period.

B. Medicaid providers have one year from date of service to file claims for payment of medical services; therefore, investigators often need to request a follow-up recipient profile before establishing the final overpayment amount for an EPICS claim since the Medicaid overpayment is based in part on the amount of medical claims paid by Medicaid during the specific period of ineligibility.

1. If the potential overpayment is less than or equal to the total paid claims reflected on the initial Medicaid Recipient Profile(s), there is no need to request a follow-up Medicaid Recipient Profile(s). The actual overpayment for the period of ineligibility is the amount paid by Medicaid or the amount of the potential overpayment, whichever is less.

2. If the potential overpayment is greater than the amount of paid claims reflected on the initial Medicaid Recipient Profile(s), the investigator must request a follow-up profile 12 months after the last month of the overpayment period to determine whether additional claims have been paid by Medicaid. The actual overpayment is the amount paid by Medicaid or the amount of the potential overpayment, whichever is less.

3. Each new recipient profile provides the total claims paid for the individual during the specified overpayment period as of the date the profile was printed.

4. Follow the instructions for calculating the overpayment and ordering Medicaid Recipient Profiles in MA-2900, XVII. and MA-3535, XVIII., NC Title XIX. Medicaid Recipient Profiles.

C. Investigators can use the new indicator field when they need to request a follow-up recipient profile. When the indicator is set to ‘Y,’ the system displays the Medicaid claim on a case management report 12 months after the last month of the overpayment period.

D. When a claim appears on this case management report, investigators need to submit a request to the Division of Medical Assistance for a follow-up profile on the DMA-7063 for the recipient(s) for all months of ineligibility.

II. MEDICAID PROFILE INDICATOR

A. A new optional field entitled ‘MED PROFILE IND’ is displayed on the Claim Detail screen. The valid values for this field is ‘Y’ (follow-up profile needed) or ‘N’/‘space’ (no follow-up profile needed). No value is displayed unless entered. When ‘Y’ is entered, a date is calculated based on the ‘TO’ date of the overpayment period. This date indicates when the claim is to be displayed on the Medicaid Profile Follow-up Case Management Report. This calculated date is not displayed on the screen but is 12 months from the ‘TO’ date. For example, if the ‘TO’ date keyed is 12/30/2002, the calculated date is 12/2003.

FR29 NC DHHS - ENTERPRISE PROGRAM INTEGRITY CONTROL SYSTEM 12/19/2002

FRD0290 CLAIM DETAIL 12:31:11

REFERRAL ID: __________ + REFERRAL TYPE: _ REFERRAL STATUS: __

NAME: ____________ _ ________________________________________

INDIVIDUAL ID: _________ _ SSN: _________

DOB: __________ RACE: _ SEX: _

COUNTY: ___ PROGRAM: ________ CASE ID: _________ COUNTY CASE #: _______

REFERRAL DATE: __________ INVESTIGATOR ID: _____

CURRENT BALANCE: 0.00__________ SERVICE CODE: __ +

CLAIM TYPE: ____ + AGENCY ERROR TYPE: _ CIVIL JUDGEMENT DATE: __________

CRIMINAL JUDGEMENT DATE: __________

OP/OI PERIODS: FROM __________ TO __________ MED PROFILE IND _

__________ __________ MED PROFILE IND _

OVERPAYMENT AMOUNT: ______________ SUBSTANTIATION METHOD: _ +

COMPROMISE AMOUNT: ______________ DELETE REASON: ________ +

ESTABLISHMENT DATE: __________ U/P CREATION DATE: __________

F1=HELP F2=CLEAR F3=EXIT F4=LIST F5=DEBTOR F9=UPDATE F10=DELETE 11=REACTIVATE

F12=CANCEL

B. The Medicaid Profile Indicator ‘Y’ is allowed for all ‘OP/OI’ periods displayed on the claim if the calculated date has not expired. The claim is displayed on the Medicaid Profile Followup Case Management Report.

EXAMPLE: The current date is 01/08/03. The ‘TO’ date keyed is 01/31/02, and the calculated date is 01/2003. In this example, the Medicaid Profile Indicator is allowed. The calculated date has not expired. The claim is displayed on the report created the last work night in January 2003.

EXAMPLE: The current date is 01/08/03. The ‘TO’ date keyed is 12/31/2001, and the calculated date is 12/2002. In this example, the Medicaid Profile Indicator is not allowed. The calculated date has expired.

C. The Medicaid Profile Indicator ‘Y’ is not allowed if the calculated date has expired. If the indicator is keyed and the calculated date has expired, the following error message is displayed: ‘THE OP IS MORE THAN 12 MONTHS IN THE PAST. ORDER A MEDICAID PROFILE NOW.’

D. The Medicaid Profile Indicator is not allowed when no overpayment period is displayed on the claim. If the Medicaid Profile Indicator ‘Y’ is keyed with no ‘OP/OI’ period present, the following error message is displayed: ‘MEDICAID PROFILE INDICATOR NOT ALLOWED, NO OP/OI DISPLAYED.’

E. The program code cannot be AFDC, FS, TANF, MICJ, MICL, MICS, MQBB, or MQBE. If one of these program codes is present on the claim and the Medicaid Profile Indicator ‘Y’ is keyed, the following error message is displayed: ‘MEDICAID PROFILE INDICATOR NOT ALLOWED, INVALID PROGRAM CODE.’

F. The claim type must be IHE or IPV. If the claim type is not IHE or IPV and the Medicaid Profile Indicator ‘Y’ is keyed, the following error message is displayed: ‘MEDICAID PROFILE INDICATOR NOT ALLOWED, INVALID CLAIM TYPE.’

G. The Medicaid Profile Indicator may be changed from ‘Y’ to ‘N’ or vice versa when the calculated date has not expired.

EXAMPLE: The ‘OP/OI’ period is 01/31/2001 - 06/30/2002. The current date is 01/08/2003. The calculated date is 06/2003. The change from ‘Y’ to ‘N’ is allowed.

EXAMPLE: The ‘OP/OI’ period is 01/31/2001 - 06/30/2002. The current date is 01/08/03. The calculated date is 06/2003. The change from ‘N’ to ‘Y’ is allowed.

H. EPICS resets the Medicaid Profile Indicator from ‘Y’ to space if the ‘OP/OI’ ‘TO’ date is changed. The original calculated date is recalculated based on the new ‘TO’ date keyed. The message: ‘ACTION COMPLETED SUCCESSFULLY’ is displayed. If the new calculated date has not expired, you may enter a ‘Y’ if a follow-up profile is needed. If the new calculated date has expired, you may not enter a ‘Y.’

EXAMPLE: The original ‘TO’ date was 3/31/02. The calculated date was 03/2003. A ‘Y’ had previously been keyed for the Medicaid Profile Indicator. The worker changes the ‘TO’ date to 01/31/02. The Medicaid Profile Indicator is reset to space. The new calculated date is 01/2003. The current date is 01/08/03. A ‘Y’ may be entered. The calculated date has not expired.

EXAMPLE: The original ‘TO’ date was 3/31/02. The calculated date was 03/2003. A ‘Y’ had previously been keyed for the Medicaid Profile Indicator. The worker changes the ‘TO’ date to 12/31/01. The Medicaid Profile Indicator is reset to space. The new calculated date is 12/2002. The current date is 01/08/03. No entry is allowed in the Medicaid Profile Indicator field. The calculated date has expired.

III. MEDICAID PROFILE FOLLOW-UP CASE MANAGEMENT REPORT

For each claim that contains a ‘Y’ for the Medicaid Profile Indicator with an EDS Date of the current month, the claim with all ‘OP/OI’ periods present on the claim is displayed on the ‘MEDICAID PROFILE FOLLOW-UP CASE MANAGEMENT REPORT’. The report is created the last work night of the month. The report is available in NCXPTR under the name ‘DHRFRD FRD470 DMA PROFILE RPT’. Twelve versions of the report are retained. No paper copy of the report is generated.

EXAMPLE: The ‘OP/OI’ period is 06/2001 – 01/31/2002 and the EDS date is 01/2003. The claim appears on the report created the last work night in 01/2003. This segment and all ‘OP/OI’ periods that are displayed on the claim are also displayed on the report.

A. Report Data

The following data fields are displayed on the Medicaid Profile Follow-up Case Management Report.

1. County Code

2. Investigator ID Number

3. Casehead Name

4. Referral Number

5. Program Code

6. Overpayment Period (OP/OI)

7. Original Overpayment Amount

8. Current Claim Balance

The report is sorted by county, investigator ID, and in alphabetical order with investigator ID.

B. Report Layout

The layout of the Medicaid Profile Follow-up Case Management Report is as follows.

IV. IMPLEMENTATION INSTRUCTIONS

Existing claims are not reflected on the Medicaid Profile Follow-up Case Management Report when a recipient profile is needed unless a ‘Y’ indicator is entered on the Claim Detail screen for the overpayment period. Investigators can use the FRD420, Caseload Detail by Investigator ID/County Report, to help identify existing claims in which they need to request a follow-up profile in the future. The investigator can use the claim establishment date to help identify Medicaid referrals in which the overpayment period could be within the past 12 months.

If you have system questions, please contact Economic Independence Automation Staff at (919) 733-7831. If you have Medicaid policy questions, please contact a DMA Recipient Investigations Coordinator in the Quality Assurance Section at (919) 733-3590.

Sincerely,

Pheon E. Beal, Director

Division of Social Services

Nina M. Yeager, Director

Division of Medical Assistance

PB/NY/BA/bh

For questions or clarification on any of the policy contained in these manuals, please contact your local county office.