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

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101.09 Disposition of Applications/Active Cases (Eff. 03/01/12)

As part of the initial and continuing eligibility process, the information provided by the applicant/beneficiary and/or obtained from other sources must be verified, documented in the case record, and evaluated in accordance with the program requirements. Components of this process are explained below.

The DHHS Form 3313, Medicaid Eligibility Worker Checklist, must be completed for every Medicaid eligibility determination except for deeming infants. This form is required before an Act on Decision is completed in the Medicaid Eligibility Determination System (MEDS). Completion of the DHHS Form 3313 serves as verification by the Medicaid eligibility worker performing the Act on Decision in MEDS that all of the criteria listed on the form have been considered and/or verified; or determined not applicable.

101.09.01 Verification (Rev. 10/01/13)

Verification is the substantiation, confirmation, authentication, or validation of an assertion, a claim, or previously submitted information. Refer to MPPM Chapter 102 and program specific instructions for verification procedures.

  • The applicant/beneficiary has the primary responsibility for providing documentary evidence to support statements made on the application or if necessary, to resolve any questionable information.

  • The Medicaid eligibility worker will accept any reasonable documentary evidence provided by the applicant/beneficiary and will be primarily concerned with how adequately the verification proves the statements on the application or review form.

  • Documentary evidence provided by the applicant/beneficiary must never be discarded, destroyed, ignored, or altered by the Medicaid eligibility worker.

  • If the applicant/beneficiary is unable (physically, emotionally, mentally, or due to circumstances beyond his control) to obtain information necessary to establish eligibility in a timely manner, the eligibility worker must offer assistance.

  • When the applicant/beneficiary claims no income or resources, the eligibility worker must fully document the facts provided to substantiate these claims in the notes screen.

Collateral Contacts
If it is necessary to request information from banks, insurance companies, or other sources that do not disclose information without authorization, such authorization must be obtained in writing from the applicant/beneficiary using DHHS Form 943, Information Release Form.

  • However, permission from the applicant/beneficiary for needed verifications other than those specified above is not necessary, if the applicant/beneficiary (or a responsible person acting on his behalf if he/she is incapacitated or incompetent) signs a dated application form.

  • Public records or records available from other agencies may be consulted without the consent of the applicant/beneficiary.

  • When information is sought from a collateral source, the applicant/beneficiary must be given a clear explanation of the information needed, what the information is needed for, and how it will be used.

  • When the applicant/beneficiary has a valid objection to the use of a particular source, his reasons for objecting should be considered and another source selected, if reasonable.

  • However, certain sources such as the employer of the applicant/beneficiary can be contacted over his objection.

  • If someone has definite facts relating to certain eligibility criteria, he/she may be used as a collateral source of information. He/she must be advised of the necessity to reveal his identity to the applicant upon request, if the information provided results in an adverse action.

  • If the collateral source does not agree to have his identity revealed, the information obtained from him/her may not be used to take action. This information may only be used as a lead toward securing other evidence.

  • Documentary evidence provided by a collateral source must never be discarded, destroyed, ignored, or altered by the Medicaid eligibility worker.

101.09.02 Documentation (Rev. 10/01/10)

Documentation is the written record of verified information methods used. All information pertaining to the eligibility of the applicant/beneficiary must be recorded in the case record. Documentation provided by an applicant/beneficiary must never be discarded, destroyed, ignored, or altered by the Medicaid eligibility worker.

  • The information is evaluated, taking into consideration legal requirements and program limitations, to determine if all eligibility criteria are met.

  • If several source’s give conflicting information, the reliability of each source must be evaluated and the case record should specify which source was accepted and why. The final determination of eligibility is made based on the most reliable source available.

  • The applicant must be informed of his responsibility to cooperate in supplying the information and documentation necessary to complete the eligibility process.

  • The eligibility worker will provide to the applicant, in writing, an outline of the information that the applicant is responsible for obtaining. DHHS Form 1233 ME, Medicaid Eligibility Checklist, may be used for this purpose. A copy of the request for information should be placed in the case file.

  • If an applicant does not provide the information necessary to determine eligibility or continued eligibility within the specified timeframe, the eligibility worker should take action to deny/close. MEDS will then send an appropriate notice to the applicant/beneficiary.

  • The notice will inform the applicant/beneficiary that assistance is being denied or discontinued because of failure to provide information necessary to determine or re-determine eligibility.

  • Current documentation is required to make an eligibility determination. Unless otherwise specified, documentation is considered current if it is dated within 35 days prior to and including the:

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