Adult Medicaid Manual MA-2395 CORRECTIVE ACTION AND RESPONSIBILITY FOR ERRORS

III. PROCEDURES

A. Reopening an Application

1. Reopen the application back to the earliest date allowed for the type of reopen, and

2. Determine eligibility for each subsequent period to the present.

3. Follow instructions in MA-2304, Processing The Application, MA-2525, Disability, and the EIS Manual for reopening applications and establishing certification periods (c.p.).

B. Correcting a Case

1. Make the correction as soon as an error is discovered and request an override of the claims filing time limit if necessary. The process must be completed promptly but no more than 30 days after discovery of the error.

2. When the county dss learns of a change in an SSI/SDX case that affects the beneficiary's eligibility and the beneficiary either does not or cannot report the change to SSA, the IMC must:

a. Follow instructions in MA-1000, SSI Medicaid: Automated Process, and

b. Use DMA-5049, Referral to the Local Social Security Office, to report the information.

c. The following are examples of situations which may affect the beneficiaries SSI and Medicaid eligibility:

(1) Discrepancy in date of birth,

(2) Beneficiaries death,

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(3) Beneficiary enters a public institution, nursing facility, or adult care home (rest home),

(4) SSA has the beneficiary assigned to the wrong county because of mail route numbers or other factors,

(5) Any information that affects the SSI payment, or

(6) DSS suspects fraud.

C. Entering Eligibility in EIS

Enter correct eligibility in EIS and the case record at the time of approval of a case/individual retroactively:

1. If a case is active in EIS, enter eligibility according to EIS instructions.

2. If the case is not active, reopen it following policy for the type of action taken and dispose of it according to EIS instructions.

D. Requesting An Override

Submit a request for approval of an override if the 365 day time limit has expired:

1. Request an override using DMA-5170, Request for Claims Override, for all cases at the time of disposition/correction of an error and entering of changes into EIS. See II.C.4. and 5., above.

2. For ALL override requests include the following:

a. Date of application,

b. Date of disposition,

c. Beneficiary name and individual Medicaid identification number (MID),

d. Reason for override request. Refer to II.C.7., above, for acceptable reasons for overrides. There are NO OTHER acceptable reasons for an override. DO NOT ADD any other reason(s) to the request.

e. Eligible dates for which an override is needed as entered in EIS, so that claims submitted by providers who served the individual on eligible dates of service can be paid.

f. Name and address of person to whom the override approval letter is to be sent.

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3. For disability reversal cases include:

a. All items listed in 2., above, and

b. Date county dss received notice of the disability reversal, and

c. Date of onset of disability.

4. For appeal reversals and court decisions include:

a. All items listed in 2., above, and

b. The date the county dss received DSS-1894, "Notice of Decision," or court decision, for appeal reversal and court decision override requests.

c. Eligibility for appeals or court decisions is not restricted to the 365 days preceding the "Notice of Decision" or court order.

5. For cases involving administrative error include:

a. All items listed in 2., above, and

b. The reason an override is needed:

(1) Information acted on improperly,

(2) Case was denied or terminated in error,

(3) Period authorized was incorrect or erroneously omitted from EIS, or

(4) County dss failed to act on the case.

c. Date error was discovered.

d. Do not authorize eligible dates for more than the 12 months period before the month dss discovers the error.

EXAMPLE: An error discovered on March 12th must be corrected and the override request sent to DMA no later than April 11th. If the override is for administrative error, it cannot be approved for any month prior to March of the previous year.

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6. Submit override requests to:

Division of Medical Assistance

Claims Analysis Unit

2501 Mail Service Center

Raleigh, NC 27699-2501

7. Approval of Override Request

a. If the override request is approved, the DMA Claims Analysis Unit will notify:

(1) The county dss of its decision by the turnaround of the override letter DMA-5170, Request for Claims Override, and

(2) The beneficiary by letter DMA-5171, Approval Notice of Retroactive Medicaid Benefits, instructing him to inform medical providers that they may file claims for services provided during eligible dates.

b. The county dss must notify medical providers of the override approval:

(1) If the beneficiary is deceased or mentally or physically unable to act on his own behalf,

(2) Has no responsible person to act on his behalf, or

(3) If the county has guardianship.

c. Providers must file all claims by the date specified on the beneficiary's override approval letter. They may submit claims by electronic transmission or paper to HP (formerly EDS), the Medicaid contractor at:

HP

P.O. Box 30968

Raleigh, NC 27622

8. Denial of Override Request

If the override request is denied, the DMA Claims Analysis Unit will:

a. Notify the county dss of its decision by the turnaround of the override letter DMA-5170, Request for Claims Override, and

b. Inform the county dss that claims requiring special handling will be charged to the county.

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E. Erroneous Authorization

1. When a keying error results in erroneous authorization of Medicaid benefits for an individual who is not eligible or for dates an individual is not eligible the IMC must:

a. Telephone the Claims Analysis Unit at DMA (919/855-4045) as soon as the error is discovered to request that the authorization be corrected.

b. Contact the beneficiary to inform him of the error. Ask him not to use the Medicaid ID card if one has been issued.

c. Ask the beneficiary to identify any medical providers who were seen in the period covered by the erroneous authorization.

d. Contact all medical providers seen on the ineligible dates:

(1) Inform them of the error, and

(2) Advise them that the a/b is not eligible for services in that period and that services rendered are not eligible for payment, and

(3) Advise them not to file claims for erroneously approved date(s)/ineligible person(s), and

(4) Inform them that the eligibility file is being corrected.

e. Follow up within 10 workdays with a letter to the DMA Claims Analysis Unit.

(1) Identify all providers contacted.

(2) Attach documentation of the error (i.e., screen print copy of the IE screen showing the error and forms/documents giving the correct authorization dates), and

(3) Give a brief explanation of the cause of the error. See DMA-5172, Erroneous Authorization Dates of Medicaid Eligibility, for a sample letter, including documentation of providers contacted with date(s) of contact.

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g. Documentation will be retained by DMA for audit purposes.

2. When claims are paid for ineligible date(s)/persons(s):

a. If providers were notified prior to billing, the claims will be recouped from the provider.

b. If providers were not notified prior to billing, the claims are county responsible and are subject to county charge back procedures.

3. When any notice of authorization or letter of approval is issued with incorrect dates and the county dss discovers the error before anything is keyed into EIS, dss may send a corrected notice or letter within 2 workdays of discovering the error. Otherwise, the county dss will bear full financial responsibility (federal, state, and county share) for any claims.

F. Corrections to Errors in County Transfers/Reassignments

1. County Actions

a. A county dss which receives a profile on a case which was incorrectly transferred or reassigned to a different county must:

(1) Contact the original county to determine the county to which the case should have been transferred or reassigned.

(2) Reassign the case to the correct county.

(3) Write the Claims Analysis Unit at the address in D.6., above, to inform them of the circumstances of the case and request correction of county liability for claims, clearly stating which county has responsibility for dates of authorization to be corrected.

b. If a county dss discovers that the SDX has an SSI beneficiary in the wrong county that county dss must correct the information as instructed in MA-1000 and in II.B.5., above.

2. DMA Actions

The Claims Analysis Unit will make the necessary corrections in EIS.

3. Additional Instructions

Refer to EIS 1200.

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