Family and Children's Medicaid MA-3530 CORRECTIVE ACTION AND RESPONSIBILITY FOR ERRORS
II. REQUIREMENTS
A. The Division of Medical Assistance (DMA) is responsible for making corrections in the following:
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(II.A.2.)
c. Post CAP, or other indicator codes,
d. Correct eligibility segments, or
e. Correct other data which affects the payment of claims.
3. Wrong County
When eligibility was authorized in the wrong county in cases of county transfers or incorrect EIS input or when the SDX shows an SSI recipient in the wrong county. DMA will handle on a case-by-case basis in contact with the counties involved. See. III.B.2. and III.F., below.
4. County DSS Refuses to Take Corrective Action
The county dss refuses to take required corrective actions. DMA will handle on a case-by-case basis.
5. Audit
B. County Corrective Actions
1. General
a. Claims will be paid only for individuals with Medicaid authorization in the Eligibility Information System (EIS) for the date(s) a medical service(s) is provided.
(1) A provider must file a claim for payment for a Medicaid covered service within 365 days of the date of service. However, eligibility for the date of service may not have been authorized in time to meet this deadline.
(2) The county department of social services (dss) must request DMA to override the claims filing time limit if the time limit has expired. Refer to III.D., below, for procedures.
2. Incorrectly authorized dates:
a. May not be deleted in a prior period, but
b. May be deleted from a future period provided notice requirements are met.
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(II.B.)
3. Financial responsibility for incorrect authorization must be borne by:
a. The county dss which took the incorrect action (see IV.C., below), or
b. The state, if state error was the sole cause of the incorrect action. See IV.D., below.
4. The county dss must make a correction when:
a. An individual was:
(1) Discouraged from applying for assistance, or
(2) Improperly encouraged to withdraw an application for assistance,
b. An individual's application for assistance was denied improperly,
c. An appeal, court decision, or a Social Security Administration (SSA) reversal overturns an earlier adverse decision,
d. Certification periods of financially responsible persons must be adjusted,
e. It receives from any source verified information which changes a recipient’s:
(1) Deductible amount,
(2) Patient monthly liability (pml) amount,
(3) Period of authorization, or
(4) Eligibility status,
f. Additional medical bills or verified medical expenses establish an earlier Medicaid effective date in deductible cases (see MA-3315, Medicaid Deductible, for procedures),
g. An SSI recipient enters long-term care (ltc) or a Community Alternatives Program (CAP),
h. The county dss makes an administrative error. Correction of administrative error by the county dss is limited to:
(1) Cases terminated or denied in error,
(2) Failure to act properly on information received which would affect eligibility,
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(II.B.4.h.)
(3) Incorrect determinations of:
(a) The period of authorization, or
(b) The Medicaid effective date,
(4) Erroneous data entry, or
(5) M-AD denial which:
(a) Was an adoption of an SSA denial, and
(b) SSA subsequently approves the disability without an appeal or reconsideration hearing (see MA-2525, V.C.), and
(c) The onset of disability is prior to the date of the denial of the adopted decision.
5. The county dss may learn of a change in an SSI/SDX case that affects the recipient's eligibility and the recipient either does not or cannot report the change to SSA. Refer to III.B.2.c., below, for procedures.
6. Correcting eligibility to the recipient's advantage must be made immediately after discovery of the error.
a. Adverse actions must be made only after appropriate notice requirements are met.
b. All actions must be completed at least within 30 days of discovery of the error.
7. Time Limits for Making Corrections
Reopen the case back to the original action. Refer to MA-3215, Processing the Application, section IV.B for procedures regarding time limits for reopening a Medicaid case.
a. When the original determination of eligibility is reversed because of a county or state appeal decision or a court ruling in favor of the a/r, or
b. For a denied Medical Assistance for the Disabled (M-AD) case:
(1) The previous Medicaid denial of a disability application was an adoption of a denial by SSA, and
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(II.B.7.b.)
(2) RSDI or SSI was subsequently approved on appeal to SSA, and
(3) The onset of disability corresponds to or is prior to the date of the denial of the adopted decision (see MA-2525, Disability, for procedures),
c. Either the county dss discovers or monitoring establishes that there was:
(1) Discouragement from applying for assistance,
(2) Improper withdrawal of an application, or
(3) Improper denial of an application.
8. Authorize eligibility for no more than 12 months prior to the month it discovered the need for corrective action when:
a. It receives from any source verified information which changes a recipient's:
(1) Deductible amount,
(2) Patient monthly liability amount,
(3) Period of authorization, or
(4) Eligibility status,
b. Additional medical bills or verified medical expenses establish an earlier Medicaid effective date in deductible cases (see MA-3315, Medicaid Deductible, for procedures), or
c. The county dss makes an administrative error. Correction of administrative error by the county dss is limited to:
(1) Cases terminated or denied in error, or
(2) Failure to act properly on information received which would affect eligibility, or
(3) Incorrect determinations of:
(a) The period of authorization, or
(b) The Medicaid effective date,
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(II.B.8.c.)
(4) Erroneous data entry, or
(5) M-AD denial which:
(a) Was an adoption of an SSA denial, and
(b) SSA subsequently approves the disability without an appeal or reconsideration hearing (see MA-2525, V.C.), and
(c) The onset of disability is prior to the date of the denial of the adopted decision.
9. Reopening and corrective action must be completed no later than 30 days after the county dss learns of any of the conditions in B.4., above, unless good cause exists or policy otherwise states to reopen within 5 days. Good cause is limited to:
a. The need to verify other conditions of eligibility before authorizing eligibility,
b. Inability to locate the a/r, or
c. Timely request for administrative review by DMA when the county dss disagrees with a decision requiring corrective action.
C. Override of the Claims Filing Time Limit
1. Medical providers must file claims for payment by Medicaid within 365 days of the date of service.
2. DMA has limited authority under federal regulations to override or waive the time limit for filing claims and be able to claim the federal share of the payment.
3. DMA is not authorized to use state funds in place of federal funds which cannot be claimed because of delays in timely claims filing. Therefore, attention to the claims filing time limit and notification to DMA of the need to override the time limit in the case of corrective action is critical. Failure of the county dss to notify DMA of the need for an override as specified in this section may result in full financial responsibility for payment of the Medicaid claims by the county dss.
4. If an enrolled Medicaid provider is unable to file claims for reimbursement for services to a Medicaid recipient for reasons beyond the provider's control, such as retroactive approval of eligibility in a case, and there is basis for an override as described in 7., below, the county dss must request an override of the time limit for filing claims.
(II.C.)
5. A request for an override of the claims filing time limit may be necessary if:
a. The 365 day time limit for filing claims has expired, or
b. Less than 60 days remain before the 365 day time limit expires, and
c. Eligibility has been entered into EIS.
6. The request for override of the claims filing time limit must be submitted to DMA by the county dss at the time of disposition of the application in EIS or entry of the corrective action into EIS.
7. The request for an override must meet at least one of the following conditions:
a. Subsequent reversal by SSA of a prior RSDI/SSI disability denial which was adopted for a Medicaid application. Authorization may be from date of onset of disability or 3 months retroactive to the month of the original Medicaid application, whichever is later.
b. Subsequent approval by SSA of an RSDI/SSI disability application that was not adopted by Medicaid and is not the result of a reconsideration/appeal. Authorization is limited to 12 months prior to learning of the subsequent RSDI/SSI disability approval.
c. Subsequent approval by SSA of an SSI Medicaid application which required more than 365 days to process. Approval of an SSI reversal cannot be prior to 01-01-95.
d. Approval by SSA of an SSI application for an individual who has not made a Medicaid application at the county dss and the beginning date of eligibility does not allow medical providers at least 60 calendar days in which to file Medicaid claims. Approval of an SSI Medicaid case cannot be prior to 01-01-95.
e. County or state appeal decision in favor of the a/r.
f. Court order in favor of the a/r.
g. County administrative error.
h. The a/r was discouraged from applying for assistance, encouraged to withdraw an application for assistance, or an application for assistance was improperly denied.
i. The county dss learns of a change in an SSI/SDX case that affects the recipient's eligibility and the recipient either does not or cannot report the change to SSA. See III.B.2., below.
(II.C.)
