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MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |512 Effective Month: December 2016 101.15.08 EXPARTE REVIEWS Any recipient under review who is losing eligibility in one category of assistance is entitled to have eligibility reviewed and evaluated under any/all available coverage groups. The term “exparte review” means to review information available to the agency to make a determination of eligibility in another coverage group without requiring the individual to come into the office or file a separate application.

When to Complete an Exparte Determination For an exparte determination to be made, the specialist must be in the process of making a decision on a current application, review or reported change. If the specialist is denying or closing for failure to return information or failure to complete the review process, an exparte determination is not applicable.

Example: Jane Doe’s CHIP eligibility will terminate because the family reports she is now covered under other health insurance. The specialist must review the record to see if it contains information which indicates the child has potential eligibility under another coverage group. Example: Recipient Tom Smith failed to comply with the annual review requirement and his eligibility must be terminated. The specialist does not complete an exparte determination.

Basis for the Exparte Review The decision of whether the recipient is eligible under a different coverage group must be based on information contained in the case record. This may include income, household or personal information in the physical record which indicates the ineligible adult or child has potential eligibility in another coverage group. It also includes information received through electronic matches with other state/federal agencies such as a disability onset date or prior receipt of benefits based on disability.

Obtaining Information to Make the Determination When potential eligibility under another coverage group is indicated, but the specialist does not have sufficient information to make an eligibility determination, the recipient must be allowed a reasonable opportunity to provide necessary information.