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, as described in 10A NCAC 23C .0101;

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

(3)           The certification periods of financially responsible persons need to be adjusted to coincide with the individual's certification period;

(4)           Information received from any source undergoes verification, as defined in 10A NCAC 23A .0102, by the county department of social services and is found to change the amount of the recipient's deductible, patient liability, authorization period, or otherwise affect the recipient's eligibility status;

(5)           Additional medical bills or medical expenses that are verified by the county department of social services establish an earlier Medicaid effective date;

(6)           The agency made an administrative error including:

(A)          An eligibility error, as defined by 42 CFR 431.804, that resulted in assistance being incorrectly terminated or denied;

(B)          Failure to act on information received; or

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

(7)           Monitoring of application processing by the Division of Health Benefits (Division), as required by 42 C.F.R. 431, Subpart P, shows an application was denied, withdrawn, or a person was discouraged from applying for assistance; or

(8)           The Division determines the county failed to follow federal regulations or State rules to authorize eligibility.

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

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

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

(3)           An audit report from State auditors or the Division shows verified errors in the Medicaid eligibility history.

History Note:        Authority G.S. 108A-54; 108A-54.1B; 42 C.F.R. 431.246; 42 C.F.R. 431, Subpart P; 42 C.F.R. 435.903;

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;

Readopted Eff. June 1, 2019.