Family and Children's Medicaid MA-3410 TERMINATIONS, DELETIONS AND EX PARTES

VII. SECOND PARTY REVIEW OF WORK FIRST FAMILY ASSISTANCE AND BENEFIT DIVERSION DENIALS AND TERMINATIONS

A second party review is required any time Work First Family Assistance, Benefit Diversion or Transitional Medicaid terminates and all assistance unit members are not authorized for Medicaid or NC Health Choice.

A. The director determines which staff in the agency will conduct the second party review. The review might be done by supervisory staff, either Work First or Medicaid, or the director may wish to establish a second party review team to share the responsibility. (See DMA-5139, Second Party Review Plan-WF to Medicaid)

B. Second Party Review Requirement

1. Conduct a second party review if all assistance unit members are not authorized for Medicaid/NC Health Choice when Work First is denied or terminated. This also includes individuals not approved for Medicaid when Work First approves other members of the assistance unit.

2. Conduct a second party review when any individual is deleted from an ongoing WFFA/Benefit Diversion/Transitional Medicaid case and the individual is not approved for Medicaid or NC Health Choice.

3. Conduct a second party review if it appears action was not taken timely during the Work First/Benefit Diversion ex parte review process.

4. Evaluate for Medicaid and second party reviews prior to the 45th day for denied Work First/Benefit Diversion applications.

5. Use the “Second Party Review Sheet”, DMA-5140, Second Party Review Sheet, for documentation of all second party reviews (required).

Remember that all Medicaid application processing time standards apply from the date of the Work First /Benefit Diversion application. For any Work First/Benefit Diversion application pending on the 45th day, the county must have established a timeframe by which the case was evaluated and second party reviewed for Medicaid eligibility.

Once the review sheet has been completed, it must be signed by the person conducting the review and placed in the case record. The county may choose to design its own checklist; however, it must contain all the required information as outlined on the DMA-5140- Second Party Review Sheet. The form should be updated as policy changes.