10A NCAC 23G .0202. CORRECTIVE ACTIONS

(a)  Corrections in an applicant's or recipient's case shall be made by the county department of social services when:

(1)           An individual was discouraged from filing an application; or

(2)           An appeal or court decision overturns an earlier adverse decision; or

(3)           The certification periods of financially responsible persons need to be adjusted to coincide; or

(4)           Information received from any source is verified and is found to change the amount of the recipient's deductible, patient liability, authorized period or otherwise affect the recipient's eligibility status; or

(5)           Additional medical bills or verified medical expenses establish an earlier Medicaid effective date; or

(6)           The agency made an administrative error due to:

(A)          Assistance was terminated or denied in error; or

(B)          Failure to act properly on information received; or

(C)          Incorrect determination of the authorization period, Medicaid effective date, or erroneous data entry; or

(7)           Monitoring under application processing requirements determines an application was denied, withdrawn or a person was discouraged from applying for assistance without following the requirements in Alexander v. Burton U.S.D.C., File No. C-C-74-183-M, Consent Order dismissed effective February 1, 2002.

(8)           The Medicaid Eligibility Section determines the county failed to follow federal or state regulations to authorize eligibility or follow requirements in this Chapter.

(b)  Corrections in an applicant's or recipient's case shall be made by the Division of Medical Assistance when:

(1)           Information is received from county departments of social services, medical providers, public, clients or Division of Medical Assistance staff showing that a terminated case has errors in the Medicaid eligibility segments, Buy-In effective date, eligible case members, CAP or HMO indicators and effective dates or other data that is causing valid claims to be denied; or

(2)           The county department of social services refuses to take required corrective actions; or

(3)           An audit report from State auditors hired by the county departments of social services shows verified errors in the Medicaid eligibility history or recipient identification number.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 431.246; 42 C.F.R. 435.904; Alexander v. Bruton, U.S.D.C., File No. C-C-74-183-M, Consent Order dismissed effective February 1, 2002;

Eff. June 1, 1990;

Temporary Amendment Eff. March 1, 2003;

Amended Eff. August 1, 2004;

Transferred from 10A NCAC 21A .0602 Eff. May 1, 2012.