South carolina department of health and human services medicaid policy and procedures manual

101.20 Medicaid Eligibility Quality Assurance (MEQA) (Rev. 03/01/13)

The South Carolina Department of Health and Human Services (SC DHHS) has contracted with the Center for Health Services & Policy Research (CHSPR) at the University of South Carolina (USC) to conduct eligibility monitoring reviews that will identify and/or develop:

1. 
   Error trends
   
2. 
   The need for policy clarifications
   
3. 
   The need for additional training
   
4. 
   Employee performance standards
   

USC submits written requests for files to be reviewed. SCDHHS must take the following steps within 15 days of receiving the request:

1. 
   Locate the requested file
   
2. 
   Complete DHHS Form 1259, Quality Assurance Case Review Checklist, and attach it to the front of the file
   
3. 
   Ensure that the most current action and the action for the date to be reviewed are included in the file
   
4. 
   Attach a copy of the email if the file is sent in response to a specific request from a reviewer
   
5. 
   Attach a copy of the original request if file was not located and sent timely
   
6. 
   Indicate if the file is sent to MEQA, PERM, or EQUIP
   

101.20.01 Quality Measurements (Eff. 03/01/13)

The quality measurements used by USC to conduct SC DHHS eligibility reviews are:

1. 
   Eligibility Quality Improvement Process (EQUIP)
   
2. 
   Medicaid Eligibility Quality Assurance (MEQA)
   
3. 
   Payment Error Rate Measurement (PERM)
   

101.20.01A Eligibility Quality Improvement Process (EQUIP) (Eff. 03/01/13)

EQUIP is an internal eligibility review process that is used by the agency without contact with the beneficiary. EQUIP is limited to errors that were identified in PERM/MEQA reviews, and includes Alerts that report eligibility issues not included in the scope of the review. The primary objectives of EQUIP are:

1. 
   1.Identify and address error trends
   
2. 
   Develop employee performance standards
   

101.20.01B Medicaid Eligibility Quality Assurance (MEQA) (Eff. 03/01/13)

Medicaid Eligibility Quality Assurance (MEQA) is a federally mandated study. The primary objectives of MEQA are:

1. 
   To measure, identify, and eliminate or reduce dollar losses as a result of erroneous eligibility determinations
   
2. 
   To ensure that clients receive all of the benefits to which they are entitled
   

101.20.01C Payment Error Rate Measurement (PERM) (Eff. 03/01/13)

Payment Error Rate Measurement (PERM) is a federally mandated study. The primary objectives of PERM are:

1. 
   To review fee for service, managed care, and Medicaid and SCHIP eligibility
   
2. 
   To provide results of the reviews to be used to produce a national error rate
   

101.20.02 Report of Eligibility Findings for EQUIP (Eff. 03/01/13)

EQUIP findings include any procedural and/or eligibility errors, and Alerts that identify eligibility information that falls outside of the scope of the review. Alerts provide changes and/or information that were discovered during the review but not considered by the eligibility worker who completed the determination. Alerts may or may not be the result of worker error.

101.20.02A USC will report EQUIP findings in the following ways (Eff. 03/01/13)

1. 
   Correct
   
2. 
   Incorrect
   
   1. 
      Eligibility Errors – Medicaid eligibility was incorrectly determined for a single member, or all members of a budget group
      
   2. 
      Procedural Errors-Medicaid eligibility was correctly determined but policy and/or procedures have been overlooked or misinterpreted. A procedural error may or may not result in an eligibility error.
      
3. 
   Unable to locate
   
4. 
   Dropped
   

101.20.02B SC DHHS Response to EQUIP Findings (Eff. 03/01/13)

The Quality Manager will retrieve EQUIP findings from SharePoint, and submit a report of error and Alert findings for each supervisory unit to the following:

1. 
   The Eligibility supervisor
   
2. 
   The appropriate Regional Administrator
   
3. 
   The appropriate Division Director
   
4. 
   The appropriate Regional Trainer
   
5. 
   The Director of Eligibility Training
   
6. 
   The Director of Eligibility Policy
   
7. 
   The Performance Manager
   

Within five (5) calendar days of receiving the EQUIP findings, the supervisor must schedule a conference with the appropriate worker to review all error findings. The worker must complete the following action(s) within ten (10) calendar days of receiving the EQUIP error and/or Alert findings:

1. 
   Correct all eligibility errors
   
   1. 
      The supervisor and eligibility worker must schedule a conference with the Quality Manager to discuss the finding and corrective action(s)
      
2. 
   Correct all procedural errors
   
   1. 
      If necessary, the supervisor and/or eligibility worker may contact the Quality Manager to ask questions or obtain clarifications regarding the findings
      
3. 
   Initiate or complete required actions needed to address any reported finding that was not considered in the eligibility determination.
   

Within fifteen (15) calendar days of receiving an error finding, the supervisor must:

1. 
   Review the case to ensure the required corrective action(s) are completed, and verification regarding any new findings is requested and/or acted upon, if required. Following the review, submit DHHS Form 947, Response to Preliminary QA Findings via GroupLink ticket to the Eligibility, Enrollment and Member Services designee. The response must explain:
   
   1. 
      The corrective action(s) initiated or completed, and/ or
      
   2. 
      A rebuttal of the Preliminary Findings, including a detailed rationale and documentary evidence to support the disagreement
      
2. 
   The Eligibility, Enrollment and Member Services designee will distribute the DHHS Form 947, Response to Preliminary QA Findings to:
   

1. 
   The eligibility supervisor
   
2. 
   The appropriate Regional Administrator
   
3. 
   The appropriate Division Director
   
4. 
   The appropriate Regional Trainer
   
5. 
   The Director of Eligibility Training
   
6. 
   The Director of Eligibility Policy
   
7. 
   The Performance Manager
   
8. 
   The Quality Manager
   

3. 
   The Quality Manager must take the following action when the DHHS Form 947, Response to Preliminary QA Findings reports a disagreement with the review:
   
   1. 
      Submit any supported disagreement to the USC MEQA Staff Manager for reconsideration
      
   2. 
      Respond to any unsupported disagreement
      
4. 
   Alert disputes are sent to the Quality Manager, who must take one of the following actions:
   
   1. 
      Inform USC and the eligibility staff of supported findings, or
      
   2. 
      Inform the eligibility staff of unsupported findings
      

101.20.03 Report of Eligibility Findings for MEQA and PERM (Eff. 03/01/13)

At the completion of each case review, the USC reviewer will submit DHHS Form 946, Preliminary QA Findings, including any procedural errors and eligibility errors.

The USC reviewer will submit a report of the MEQA or PERM findings to:

1. 
   The eligibility worker who completed the action
   
2. 
   The supervisor of the eligibility worker who completed the action
   
3. 
   The supervisor of the current eligibility worker*
   
4. 
   The Director of Eligibility Training
   
5. 
   The Director of Eligibility Policy
   
6. 
   The appropriate Regional Administrator
   
7. 
   The appropriate Division Director
   
8. 
   The appropriate Regional Trainer
   
9. 
   The Performance Manager
   
10. 
    The Quality Manager
    

*The current worker is responsible for the completion of any corrective action(s).

101.20.03A USC will report MEQA and PERM findings in the following ways (Eff. 03/01/13)

1. 
   Eligible – Medicaid eligibility was correctly determined. Policy and/or procedures may have been overlooked or misinterpreted, but did not result in an eligibility error.
   
2. 
   Ineligible – Medicaid eligibility was incorrectly determined for all members of a budget group
   
3. 
   Ineligible budget group member(s) – Medicaid eligibility was incorrectly determined for one or more members of a budget group.
   
4. 
   Eligible – Liability overstated (when an institutionalized individual’s recurring liability is determined to be more than it should be)
   
5. 
   Eligible – Liability understated (when an institutionalized individual’s recurring liability is determined to be less than it should be)
   

101.20.03B SC DHHS Response to MEQA and PERM Error Findings (Eff. 03/01/13)

Within five (5) calendar days of receipt, the supervisor must schedule a conference with the eligibility worker to review the case findings. The following issues must be discussed and documented

1. 
   Policy relative to the eligibility finding
   
2. 
   Actions that must be taken to correct any procedural and/or eligibility error(s) identified, or
   
3. 
   The decision to rebut the findings, if applicable, including policy and supporting documentation that supports the disagreement
   

Upon completion of this discussion, a response to the findings is provided on the DHHS Form 947, Response to Preliminary QA Findings, that supports

1. 
   Agreement With the Review Findings
   

1. 
   Within ten (10) calendar days of the conference, the eligibility worker must take the required actions to correct the case.
   
2. 
   Within fifteen (15) calendar days of receiving the error finding, the supervisor must:
   

1. 
   Review the case to ensure the required corrective action(s) are completed and/or initiated, and verification regarding any new findings is requested and/or acted upon
   
2. 
   Submit DHHS Form 947 via GroupLink ticket that explains the corrective action(s) discussed in the conference and completed by the eligibility worker
   

2. 
   Rebuttal of the Review Findings
   

1. 
   Within ten (10) calendar days of the conference, the supervisor must report the decision to rebut the error finding via GroupLink ticket
   

2. 
   The rebuttal must include policy and supporting documentation that supports the disagreement
   

3. 
   If the rebuttal is not supported following review, the Quality Manger will schedule a conference within ten (10) calendar days with
   

1. 
   The eligibility worker
   
2. 
   The eligibility supervisor
   
3. 
   The Regional Trainer
   

4. 
   If the rebuttal is supported following review, the Quality Manager will submit the rebuttal to USC MEQA/PERM and schedule a conference within ten (10) calendar days with
   

1. 
   The eligibility supervisor
   
2. 
   The Regional Trainer
   
3. 
   A representative from USC MEQA/PERM
   

5. 
   If an agreement is reached between all parties during the conference that supports the review findings, the eligibility worker must follow the procedures for Agreement with the Review Findings to complete the corrective action(s).
   

6. 
   If an agreement is not reached between all parties during the conference, the Quality Manager will schedule a conference with the following:
   

1. 
   The eligibility supervisor
   
2. 
   A representative from USC MEQA/PERM
   
3. 
   The Director of Eligibility Training, or designee
   
4. 
   The Director of Eligibility Policy, or designee
   

When an agreement is reached between all parties during this conference that supports the review finding, the eligibility worker must follow the procedures for Agreement With the Review Findings to complete the corrective action(s).

101.20.03C Corrective Action Plan for MEQA and PERM Quality Management (Eff. 03/01/13)

1. 
   The Eligibility, Enrollment and Member Services will provide the completed tracking document within sixty (60) calendar days to
   
   1. 
      The Director of Eligibility Policy
      
   2. 
      The Director of Eligibility Training
      
   3. 
      The Regional Administrators
      
   4. 
      The Division Directors
      
   5. 
      The Performance Manager
      
   6. 
      The Quality Manager
      

2. 
   USC will provide a final report within sixty (60) calendar days to
   
   1. 
      The Director of Eligibility Policy
      
   2. 
      The Director of Eligibility Training
      
   3. 
      The Regional Administrators
      
   4. 
      The Division Directors
      
   5. 
      The Performance Manager
      
   6. 
      The Quality Manager
      
   7. 
      The Program Director
      

3. 
   Within thirty (30) calendar days of receiving the USC Final Report, each region, CEP, and CIU will develop its own Corrective Action Plan (CAP) to address the trends that were identified from the tracking document and the USC Final Report. The CAP must address, but is not limited to the following:
   

1. 
   Additional training (should contain specific information regarding who will conduct the training, length of the training, who will attend, and the topic of the training)
   
2. 
   Special monitoring efforts by the supervisor (should contain specific information regarding the length of the monitoring effort, the method used to conduct the effort, and issue(s) being monitored)
   
3. 
   Staff meetings to go over policy clarifications that were provided in the form of manual clarifications or Medical Support Mailbox answers
   

4. 
   The Corrective Action Plan will be sent to
   
   1. 
      The Eligibility, Enrollment and Member Services Director
      
   2. 
      The Division of Eligibility Training Director
      
   3. 
      The Division Directors
      
   4. 
      The appropriate Regional Administrator
      
   5. 
      The Performance Manager
      
   6. 
      The Quality Manager
      

101.20.04 Beneficiary Error (Eff. 03/01/13)

If an eligibility error is the result of an action by the beneficiary and results in an overpayment of benefits, within five (5) business days of discovery of the error, DHHS Form 928, Notice of Overpayment Referral, must be sent to the beneficiary. At the end of ten (10) calendar days, a copy of DHHS Form 928, DHHS Form 3252, Overpayment of Medicaid Benefits, and DHHS Form 947, Response to Preliminary QA Findings, must be submitted to the Eligibility, Enrollment and Member Services. Upon review, the Eligibility, Enrollment and Member Services will take one of the following actions:

1. 
   Determine that the overpayment is supported
   
   1. 
      Forward the overpayment summary to the Division of Program Integrity
      
   2. 
      Inform the supervisor
      
   3. 
      Inform the Quality Manager
      

2. 
   Determine that the overpayment is unsupported and inform the following of the reason
   
   1. 
      The supervisor
      
   2. 
      The eligibility worker
      
   3. 
      The Quality Manager
      

101.20.05 Beneficiary Cooperation (Eff. 03/01/13)

All Medicaid beneficiaries are required to cooperate with USC/MEQA/PERM during their review process. When a beneficiary fails to cooperate, USC/MEQA/PERM will notify the supervisor and eligibility worker.

1. 
   For SSI-related categories
   
   1. 
      Initiate a full review of the beneficiary’s eligibility, requesting the information that was not provided within ten (10) calendar days
      
   2. 
      If the beneficiary provides all of the requested information, it must be forwarded to USC/MEQA/PERM within five (5) business days.
      
   3. 
      If the requested information is not provided to complete the review, close the case for failure to provide requested information.
      
      1. 
         For beneficiaries residing in a nursing home, work closely with the facility to avoid closure, if possible.
         

2. 
   For FI-related categories
   
   1. 
      If the beneficiary is an eligible adult in Low Income Families, initiate an annual review, requesting the information that was not provided within ten (10) calendar days
      
   2. 
      If the requested information is not provided to complete the review, the worker must initiate closure for the adult members of the budget group for failure to provide requested information.
      
      1. 
         The eligibility of children is protected and must not be terminated for one year from the date of the decision unless it is determined that eligibility was approved inaccurately.
         
      2. 
         The children remain eligible in the LIF budget group until the next review date.
         
   3. 
      If information is returned that would affect the child’s current eligibility, but there is no evidence that eligibility was approved inaccurately, file the information in the case record. Act on the information at the next annual review to determine if it is still valid.
      
   4. 
      The eligibility of a pregnant woman is protected until the end of the post-partum period and cannot be terminated unless it is determined that eligibility was approved inaccurately. File the information in the case record.