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

IV. FINANCIAL RESPONSIBILITY

A. When an error results in the issuance of incorrect benefits, the county dss or the state may have to assume full financial responsibility for the erroneous benefits, because FFP is not available for payment of claims for ineligible individuals.

B. Claims will be paid to a medical provider who in good faith renders services to an individual who:

1. Presents a valid Medicaid ID card for the date(s) of service or to whom a DMA-5016 or DMA-5020 has been issued, or

2. Is authorized in EIS on the date(s) of service and the provider verified eligibility through the eligibility verification system, but eligibility is deleted after provider verification and prior to filing the claim(s).

C. County DSS Responsibility

The county dss will bear full financial responsibility (federal, state, and county shares) for payment of Medicaid claims resulting from erroneous issuance of benefits when dss takes any one of the following actions:

1. Fails to issue timely or incorrectly issues a DMA-5016/5020 to medical providers informing an individual of a pml or a deductible balance,

2. Fails to issue a corrected notice of approval within 10 work days after the original notice was issued,

3. Fails to enter ending dates in EIS for special coverage under CAP or Carolina Access,

4. Enters in EIS an authorization date which is earlier than the correct date of eligibility,

5. Terminates a case or individual after the Medicaid ID card has been issued,

6. Fails to determine availability or to enter in EIS information regarding third party resources (refer to MA-2400, Third Party Recovery),

7. Fails to inform the Third Party Recovery Section of DMA when it is aware that an a/r has been involved in an accident where there was a third party resource and failure to make the information known results in the state's being unable to recoup Medicaid expenditures,

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(IV.C.)

8. Gives a recipient a county-issued Medicaid identification card indicating authorization for dates for which the recipient is ineligible,

9. Fails to apply for Medicare Part B coverage for eligible persons who are deceased or are physically or mentally unable to apply and have no responsible person to apply on their behalf, or for whom the county dss has guardianship (refer to MA-2410, Medicare Enrollment & Buy In, VIII.C. D. and E.) or

10. Provides erroneous information to an a/r or takes or fails to take an action which requires payment of Medicaid claims for

a. An ineligible individual,

b. Ineligible dates,

c. An amount for which the recipient is responsible and for which the state cannot claim FFP,

d. County authorized eligibility for administrative error for a period over 12 months prior to discovery of the error in an ongoing case or disposition of an application, or

11. Fails to request an override and correct an error in eligibility within at least 30 days of discovery of an error in an ongoing or terminated case if an override of the claims filing time limit is needed and as a result FFP cannot be claimed. See II.B.4. and II.C.4., above.

12. Fails to request an override at the time of disposition of an application if an override of the claims filing time limit is needed and as a result FFP cannot be claimed. See II.B.4., above.

D. State Responsibility

1. DMA will bear full financial responsibility (federal, state, and county share) for payment of Medicaid claims resulting from erroneous issuance of benefits when:

a. DMA staff issues an incorrect interpretation of policy in the Medicaid eligibility manual(s) and that interpretation is the sole cause of an erroneous benefit or payment,

b. Medicaid identification cards are mailed because state staff failed to remove cards from outgoing mail subsequent to the timely termination or reduction in benefits by county dss staff.

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(IV.D.1.)

c. A system failure in the state computer center occurs on the last cutoff date of the month, preventing data entry of terminations or other adverse actions by the county dss,

d. Other errors occur which are the sole responsibility of the state office.

2. DMA will recoup from provider(s) any claims paid for ineligible date(s) of service or ineligible individual(s) if the county dss notified providers prior to billing that the individual was not eligible and the provider filed claims.

3. DMA will notify the county dss by letter if there is to be a charge back.

4. The county dss is entitled to a review if it does not agree with any charge back action taken by DMA. It must request a review in writing and include all necessary documentation to support the county's actions within 30 days of the action.

5. Send requests for reviews to:

Division of Medical Assistance

Claims Analysis Unit

2501 Mail Service Center

Raleigh, NC 27699-2501

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