Family and Children's Medicaid MA-3217 EVALUATING COUNTY/DDS PERFORMANCE

V. MONITORING TOOLS

A. Report Cards

Report cards are generated monthly by EIS based on applications dispositioned in a month. Report cards are run on the night of the 5^th working day of the month. Included in the report card are applications with disposition dates in the prior month. For example, a report card run on the night of the 5^th working day in February would include applications with a January disposition date.

In order to be included in the monthly report card for the month of disposition, an application must be dispositioned in EIS by the 5^th workday of the month following the month of disposition. If the application is not keyed by the 5^th workday of the month following the month of disposition, it will be included on the next month’s report card even if the automated notice is overridden and a manual notice was sent.

For example, an application is approved on January 30^th and a manual DSS-8108 is sent to notify the applicant. The DSS-8125 must be keyed in EIS no later than the 5^th workday in February with an override of the automated notice for the application to be included on the January report card.

The monthly report card is available in XPTR beginning the 6^th working day of the month following the report month.

1. County DSS Report Cards

a. Medicaid

For reporting purposes, applications for Medicaid are divided into two categories based on the aid program/category. The report card shows the county’s average processing time and percentage processed timely for all applications disposed of that month in each category. Those categories are:

(1) Other Category

The “Other” category includes applications dispositioned in the following aid program/categories:

(a) MAF

(b) MIC

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(V.A.1.a.(1))

(c) MPW

(d) AAF (Work First)

(e) MAA

(f) MAB

(g) MQB-Q, B, and E.

(2) MAD Category

The MAD category includes all applications for individuals applying as a disabled person.

b. NC Health Choice for Children

The report card for NCHC is run following the same guidelines as the Adjusted Application Report Card for Medicaid. The report card shows the county’s average processing time and percentage processed timely for all NCHC applications disposed of during the prior month.

c. Applications Excluded from the County DSS Report Card

(1) Administrative applications are excluded from the calculation of processing times. These applications are identified either by the application type that is entered in EIS, information entered on the date screen, or by entering a “Y” in the “Administrative Application” field on the DSS-8124. Administrative applications include:

(a) Auto Newborns

(b) Presumptive Applications

(c) Program transfer of active cases regardless of whether the transfer occurs between allowable or non-allowable program categories.

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(V.A.1.c.(1))

(d) Transfer of an individual from an open case to another case, including establishing a new administrative case for the individual.

(e) Actions to post eligibility to a terminated/denied case within one year of the termination/denial.

(f) Reopening cases terminated in error or reopening terminated cases as allowed by policy.

(2) State/County Appeal Reversals and Remanded Appeals

Since the original application processing time has already been counted, these cases are not included in the APT or PPT for the report month.

State/County Appeal reversals are not administrative applications but are excluded from the report card. Appeal reversals and remanded appeals are subject to review by the monitors.

2. DDS Report Cards

The report card for DDS is run following the same guidelines as the county‘s report card. DDS is measured statewide and not on a county-by-county basis. The DDS report card shows the statewide APT for all dispositions in a month and two statewide PPTs, one for Level I counties and one for Level II and III counties.

3. Actual Time and Adjusted Application Report Cards

Two separate report cards are run for Medicaid, NCHC and DDS.

a. Actual Time Report Card

The Actual Time Report Card shows the county/DDS APT and PPT using actual processing time. The actual processing time excludes no days. Also, no adjustments are made when the 45^th /70^th /90^th day falls on a state/county holiday or weekend.

The actual report card for DDS is available in XPTR under the name DHREJ Actual DDS Report Card. The actual report card for the county is also available in XPTR under the name DHREJ Actual Time Report. Refer to EIS-2400.

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(V.A.3.)

b. Adjusted Application Report Card

(1) County DSS

The Adjusted Application Report Card for the county DSS shows the county’s APT and PPT using adjusted processing time. The adjusted report card for the county is available in XPTR under the name DHREJ ADJ APP Report Card. Refer to EIS-2400.

For the county’s Adjusted Application Report Card, the APT is calculated by:

(a) Excluding days allowed by policy based on information from the EIS date screen. This is not applicable to NCHC applications.

And

(b) Adjusting the time when the 45th/90th day falls on a state/county holiday or weekend for the county.

EIS calculates the APT by subtracting the excluded time from the actual number of days the application pended.

(2) DDS Agency

The Adjusted DDS Report Card shows the agency’s APT and PPT using adjusted processing time. The adjusted report card for DDS is available in XPTR under the name DHREJ ADJ DDS Report Card.

For the Adjusted DDS Report Card, the APT is calculated by:

(a) Excluding days allowed by policy based on information from the DDS screen. This is applicable to MAD applications only. DDS can exclude days when an applicant delays the processing time by not attending or rescheduling a consultative exam.

And

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(V.A.3.b.(2))

(b) Adjusting the time when the 70th day falls on a state holiday or weekend for DDS.

EIS calculates the APT by subtracting the excluded time from the actual number of days the application pended for a disability decision.

c. Calculation of APT and PPT for Reopened Cases

Applications are reopened if the original action was determined to be improper by county or state monitoring or as the result of an appeal reversal. The processing time for these reopened applications is used in calculating the report card as follows:

(1) Improper/Incorrect Actions (Denial, Withdrawal, Discouragement) Found by the County

In calculating the APT for improper/incorrect actions discovered and corrected by the county, the time between the improper denial, withdrawal or discouragement and the date the case was reopened is not counted in the processing time.

The days counted in the original processing time and the days from the point the case is reopened until it is dispositioned are used in calculating the APT and PPT for the reopened case. Days may be excluded for the reopened application as allowed by policy.

(2) Improper Actions (Denial, Withdrawal, Discouragement) found by the State Monitors

In calculating the APT for improper actions discovered by the monitors, the time between the improper denial, withdrawal or discouragement and the date the case was reopened is counted in the processing time.

The APT and PPT is calculated using the original date of application or discouragement through the date of disposition of the reopened case. Days may be excluded for the original application and the reopened application as allowed by policy.

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(V.)

B. Monitoring

Individuals employed by the Division of Medical Assistance monitor the compliance of each DSS and the DDS. Records are requested from the county and shipped via UPS to the monitoring section for review.

1. Frequency of Monitoring

a. The monitors review county records every 2 years when the county meets the APT and PPT thresholds in both the MAD and Other categories on the Adjusted Application Report Card for each month in the calendar year.

b. The monitors review county records every year if the county fails to meet either the APT or PPT threshold on the Adjusted Application Report Card due to:

(1) Failure to meet the compliance threshold for 3 or more months in the calendar year in either the MAD or Other category.

Or

(2) Failure to meet the compliance threshold for 1 or 2 months in the calendar year in either the MAD or Other category. In this situation, the lead monitor may waive the annual monitoring when the county DSS requests a waiver and provides clear and convincing evidence that the failure was beyond the control of the agency. Refer to MA-2306, Application Processing-Corrective Action Procedures.

c. Frequency of DDS monitoring is determined using the same criteria as that used for the county.

d. If the DSS or DDS fails the Actual Report Card, the Medicaid Program Representatives may review records to ensure that time is excluded correctly and may also take other corrective action.

2. Record Selection

A random sample of records is selected for review. The sampling is based on the following criteria.

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(V.B.2.)

a. Cases selected, excluding State/County Appeal reversals, are pulled from the Adjusted Applications Included Report. State/County Appeal Reversals are pulled from the Actual Applications Excluded Report.

b. Cases selected, excluding MQB-QI2, are pulled from EIS based on a disposition date within the 12 months prior to the month monitoring is begun. MQB-QI2 cases are pulled from the county’s monthly logs for the 12 months prior to the month monitoring is begun.

c. Twenty-five percent of the approvals and denials must be from the MAD category. Seventy-five percent of the approvals and denials must be from the Other category. No WFFA approvals or zero day dispositions are included in the sample.

d. The number of cases to be selected is based on the county size. The table below summarizes the number to be included in the sample.

County Level	Approvals	Denials	Withdrawals	Inquiries
I	25	30	10	10
II	40	45	20	20
III	60	65	30	30

3. Record Review

Monitors review records for compliance by both DSS and DDS.

a. DSS records are monitored and cited for:

(1) Improper denials,

(2) Improper withdrawals,

(3) Improper inquiries,

(4) Improper exclusion of processing time,

(5) Discouragement.

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b. DDS records are monitored and cited for:

(1) Improper exclusion of processing time,

(2) Incorrect entry of date of receipt in EIS.