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

IV. MONITORING

For all counties and the DDS, monitoring thresholds are 80% for each category of denials, withdrawals, inquiries and discouragement.

• A county shall be monitored every other year when the adjusted application report card shows the county passed the APT/PPT in each MA category (Other and MAD), or, the county failed the APT/PPT in MAD due to DDS delay.
• When a county or DDS fails the Adjusted Application Report Card threshold for one or two months in any Medicaid category; the county or DDS shall be monitored on an annual basis, provided no waivers of the report card failures were submitted and approved.
• When a county or DDS fails the report card three or more times in a year; the county or DDS will be monitored annually regardless of the reason for delay, or, whether waivers are approved.

A. Monitoring Report

Upon completion of monitoring of the county dss, the monitoring unit will complete a report of findings. Copies will be sent electronically to the county dss, MPR, and field staff supervisor. Only the documents used to cite improper actions will be returned to the agency.

1. If the dss falls below the 80% threshold for denials, withdrawals, inquiries or discouragement, the agency must complete an in-depth analysis on the reasons for non-compliance. The agency must prepare and implement a corrective action plan, if necessary, and document findings, corrective action and action taken in the central file or notebook. Use the DMA-5168, Actions Taken On Improper Denials, Withdrawals, or Inquiries Identified In Monitoring, to document action taken on cases required to be reopened. This also includes any inquiries or discouragement cases.

REVISED 11/01/11 – CHANGE NO. 17-11

(IV.A.1.)

Always indicate the date the report was received. Submit the DMA-5168, Actions Taken On Improper Denials, Withdrawals, or Inquiries Identified In Monitoring, to the MPR when all cases are disposed. Keep this information in the central file or notebook in chronological order so the MPR can view it.

2. The MPR will review the analysis and provide input. State staff may also assist in further analysis and review the corrective action plan and documentation of action taken to ensure actions are appropriate.

B. Disputing Monitoring Findings

Upon receipt of the findings, the county or DDS may dispute the monitoring findings within 10 work days of receipt of the findings. Written documentation to support the reason for the dispute must be provided.

The findings of the monitors may be disputed only for:

• The accuracy of the days excluded or included in determining timely processing, or

• A change in Medicaid policy that caused the county to be out of compliance, or

• An EIS problem that caused the county to be out of compliance.

The agency does not have to reopen cases until the final decision is received.

1. Required Information for Dispute

Submit the request to dispute monitoring findings to:

North Carolina Division of Medical Assistance

Application Monitoring Unit

2501 Mail Service Center

Raleigh, NC 27699-2501

Attention: Program Manager

Fax Number (919) 715-0801

2. With the request, the county must submit:

a. A list of the cases for which the county disputes the findings of the monitors. The county is not required to dispute findings on all cited cases and should reopen the cases that are not disputed.

b. Documentation to support the county's argument that cases were processed correctly. This documentation may include the argument that changes in policy caused the cases to be out of compliance, citing policy in the manual section that supports the agency’s argument, documentation of EIS problems that resulted in failure, etc.

REISSUED 03/01/08 – CHANGE NO. 11-08

(IV.)

C. Finalization of Findings

Monitoring findings become final if not disputed based on the date of the letter or upon the date of the response of the lead monitor to the disputed findings.

D. Corrective Action

The county dss must take corrective action within 30 calendar days of the final monitoring results. Cases must be reopened following procedures in MA-2304, Processing the Application.