Adult Medicaid Manual MA-2306 APPLICATION PROCESSING – CORRECTIVE ACTION PROCEDURES

III. WAIVER REQUESTS FOR FAILING THE ADJUSTED APPLICATION REPORT CARD

Failing the Adjusted Application Report Card affects the frequency of monitoring. The lead monitor may waive annual monitoring if the county department of social services submits and is approved for waivers of report card failures. Counties who fail the report card in any category three or more times in a year will be monitored annually regardless of whether waivers are approved.

For a waiver of a report card failure to be approved, the agency must submit clear and convincing evidence that it took all steps possible to process applications in a timely manner in the categories and months of failure. The county's reasons for not meeting the compliance thresholds must be compelling and must result from factors beyond the control of the agency.

REISSUED 03/01/08 – CHANGE NO. 11-08

(III.)

A. Waiver Criteria and Procedures

1. The waiver must be requested in writing by the 15th of the month in which the report card is issued.

2. The county must prepare a cover letter outlining the reasons that applications went beyond the time standard that resulted in failure of the report card.

3. Accompanying this letter should be a copy of the report card, a copy of the Applications Included report and supporting documentation from case records that shows the steps the county took to process applications timely.

4. The request must also include a recalculation of the percentage of applications processed timely that shows the county would not have failed if these applications were excused. The county would have to have met the appropriate processing thresholds of 90% for Level II and III counties and 85% for Level I counties. Counties don’t need to show that they would have met processing thresholds for 100% of the applications.

5. The county department may not request a waiver of a report card failure, which was caused by reopening improper or incorrect actions found through monitoring.

6. Acceptable reasons for delay are incorrect data entry, monitoring error, EIS downtime, DDS delay, or factors beyond county control.

a. Incorrect Data Entry

Counties are responsible for using the following mechanisms to detect and prevent incorrect calculations of APT and PPT. The general rule is that if any of these mechanisms were available to the county to detect and correct its error and the county failed to do so, the lead monitor will not support a waiver or recalculation of the processing time.

(1) DHREJ ADJ APP MANAGEMENT REPORT available in NCXPTR.

(2) EIS warning message (#49) which appears when a date of application is entered which is more than two months prior to the current date.

(3) Hard copies of the DSS-8124-I (received generally within two days following entry of an application - DSS-8124, into EIS).

Note: Incorrect processing times can occur due to data entry error that is not detected by available mechanisms. In these instances, the field staff supervisor may support a county's request for waiver.

Examples: Failing to enter an application as administrative that should not count in processing compliance or, incorrect data entry at disposition (once an application is dispositioned the county cannot correct errors). In all cases, the recipient must not have suffered any delay in benefits or in receipt of notice of disposition.

REVISED 03/01/08 – CHANGE NO. 11-08

(III.A. 6.)

b. Factors Beyond County/DDS Control

(1) Events that prevent the county/DDS from reasonably anticipating increased workloads and planning to accommodate the increase.

(2) Diminished capacity to take and process applications timely (e.g., epidemic illness).

(3) Client or third party delay in providing information.

(4) Other factors as judged on a case-by-case basis.

(a) Natural disasters (hurricane, flood, tornado, fire, etc.) which:

1) Destroyed the employment base resulting in large, unplanned for increases in the number of applications,

2) Damaged DSS or DDS facilities to the extent that the county's /DDS’ability to operate at or near norm is eliminated, or

3) Severing of links to EIS resulting in county's/DDS’ inability to enter data in a timely fashion.

(b) Local economic disasters such as plant closing that result in a drastic increase in the number of applicants in a short period of time.

(c) Unplanned EIS downtime of two or more successive days in which the county or DDS cannot access EIS due to State or county downtime or a combination of both. This is critical on the 5th workday of each month as applications must by keyed by this date or the system will change the date of disposition to the next month. This occurs regardless of whether a manual notice was sent to the recipient.

(d) The county must explain if it made use of overtime, hired temporary staff, reassigned supervisors to casework, or any other strategy used to ensure benefits were issued as quickly and accurately as possible.

B. Review of Waiver Request

Fax the request to the Field Staff Supervisor at the Division of Medical Assistance for review. The fax number is (919) 715-0801.

REVISED 11/01/11 – CHANGE NO. 17-11

(III.B.)

1. The Field Staff Supervisor will review the materials submitted and notify the county if the request for waiver is approved or denied. Additional information may be requested from the county if deemed necessary.

2. The Program Manager will receive a copy of the waiver request and the decision to approve or deny the report card failure. This information will be used in determining if the county is subject to annual monitoring.

3. The final decision to waive annual monitoring is solely at the discretion of the Program Manager.