section .0200 application processing, monitoring and corrective action



(a) The county department of social services shall comply with the following standards in processing applications:

(1) A decision on an individual's eligibility for Medicaid shall be made within 45 calendar days from the date of application for Medicaid except for applications in which a disability determination has already been made or is needed. For those applications, a decision on an individual's eligibility shall be made within 90 days from the date of application. These timeframes shall apply in accordance with 42 CFR 435.911.

(2) Only require information or verification necessary to establish eligibility for assistance;

(3) Make at least two requests for all necessary information from the applicant or third party;

(4) Allow at least 12 calendar days between the initial request and a follow-up request and at least 12 calendar days between the follow-up request and denial of the application;

(5) Inform the client in writing, and verbally when possible, of the right to request help in obtaining information requested from the client. The county department of social services shall not discourage any client from requesting such help;

(6) An application may pend up to six months for verification that the deductible has been met or disability established.

(7) When a hearing decision reverses the decision of the County Department of Social Services on an application, the application shall be reopened within five working days from the date the final appeal decision is received by the County Department of Social Services. If no additional information is needed, the application must be processed within five additional working days. If additional information is needed pursuant to the final decision, the county shall make such requests in accordance with rules for all applications. The first request for the additional information shall be made within five working days of receipt of the final appeal decision. The application shall be processed within five workdays of receipt of the last piece of required information.

(b) The county department of social services shall obtain verification other than the applicant's statement for the following:

(1) Any element requiring medical verification. This includes verification of disability, pregnancy, incapacity, emergency dates for aliens referenced in 10A NCAC 23E .0102(c), incompetence, and approval of institutional care;

(2) Proof a deductible has been met;

(3) Legal alien status;

(4) Proof of the rebuttal value for resources and of the rebuttal of intent to transfer resources to become eligible for Medicaid. When an applicant or recipient disagrees with the determination of the county department of social services on the value of an asset, then the applicant/recipient must provide proof of what the value of the asset is;

(5) Proof of designation of liquid assets for burial;

(6) Proof of legally binding agreement limiting resource availability;

(7) Proof of valid social security number or application for a social security number;

(8) Proof of reserve reduction when resources exceed the allowable reserve limit for Medicaid;

(9) Proof of earned and unearned income, including deductions, exclusions, and operational expenses when the applicant or Income Maintenance Caseworker has or can obtain the verification; and

(10) Any other information for which the applicant does not know or cannot give an estimate.

(c) The county department of social services shall verify or obtain an item of information when:

(1) A fee must be paid to obtain the verification;

(2) It is available within the agency;

(3) The county department of social services is required by federal law to assist or to use interagency or intra-agency verification aids;

(4) The applicant requests assistance; or

(5) The applicant is physically, mentally, or otherwise incapable of obtaining the information, or is unable to speak English or read and write, or is housebound, hospitalized, or institutionalized, and a representative does not accept responsibility for obtaining the information.


History Note: Authority G.S. 108A-54; 42 C.F.R. 435.911; Alexander v. Flaherty, V.S.D.C., W.D.N.C., File No. C-C-74-183, Consent Order Filed 15 December 1989; Alexander v. Flaherty Consent Order filed February 14, 1992; Alexander v. Bruton Consent Order dismissed Effective February 1, 2002;

Eff. September 1, 1984;

Amended Eff. April 1, 1993; August 1, 1990;

Temporary Amendment Eff. March 1, 2003;

Amended Eff. August 1, 2004;

Transferred from 10A NCAC 21B .0203 Eff. May 1, 2012.