10A NCAC 23G .0204. RESPONSIBILITY FOR ERRORS

(a)  The Division of Medical Assistance shall be financially responsible for the erroneous issuance of benefits and Medicaid claims payments when:

(1)           Policy interpretations given by Division of Medical Assistance or its agents are erroneous and that is the sole cause of any erroneous benefits or payments; or

(2)           Information Services operations staff fail to manually remove Medicaid ID cards from outgoing mail subsequent to the county DSS's timely authorization of a termination or reduction in benefits; or

(3)           A systems failure at the state computer center occurs on the last cutoff date of the month preventing the county DSS from data entering case terminations or adverse actions; or

(4)           Any other failure or error attributable solely to the state occurs.

(b)  The county department of social services shall be financially responsible for the erroneous issuance of benefits and Medicaid claims payments when it:

(1)           Authorizes retroactive eligibility outside the dates permitted by regulations or Rule .0203 of this Section; or

(2)           Fails to send required notices of patient liability or deductible balance to medical providers; or

(3)           Fails to end-date special coverage indicators such as CAP, or HMO in the state eligibility information system; or

(4)           Enters an authorization date in the eligibility system that is earlier than the determined date of eligibility; or

(5)           Fails to determine the availability of or fails to data enter third-party resource information in the state eligibility information system; or

(6)           Terminates a case or individual after the Medicaid ID card has been issued; or

(7)           Issues a county-typed Medicaid ID card that has erroneous dates of eligibility; or

(8)           Fails to initiate application for Medicare Part B coverage for recipients who are eligible, but refuse or are unable to apply for themselves; or

(9)           Takes any other action that requires payment of Medicaid claims for an ineligible individual, for ineligible dates or in an amount that includes a recipient's liability and for which the state cannot claim federal participation.

(c)  The amounts to be charged back to the county department of social services for erroneous payments of claims shall be the state and federal shares of the erroneous payment, not to exceed the lesser of the amount of actual error or claims payment.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 433.32; 42 C.F.R. 435.904;

Eff. June 1, 1990;

Amended Eff. May 1, 1992;

Transferred from 10A NCAC 21A .0604 Eff. May 1, 2012.