1310.1 Resolving Conflicting Information

When conflicting or contradictory information is discovered, the eligibility staff person shall research the medical case file and other sources, such as interfaces, to determine if a reasonable explanation exists.

If the discrepancy is not resolved, contact with the consumer is required. First, phone contact must be attempted. If the issue remains unresolved a written request for information is issued, as per 1321(3) below. Eligibility cannot be denied or terminated solely based on the discrepant information until the consumer has been given the opportunity to explain the discrepancy. Unless the consumer consents to negative action based upon their request, a written request for information must be issued prior to any negative action.

Staff are responsible for updating the case file (e.g. journal) with information regarding the discrepancy as well as the resolution. If the staff person made a judgement call regarding a specific situation, an explanation of the facts of the case as well as the factors that lead to the decision are also included in the journal. As each situation is unique, the extent and content of the necessary journal entry will depend upon the circumstance of the case.