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H-130 Division of Welfare and Supportive Services PRESUMPTIVE ELIGIBILITY Medical Assistance Manual TIME FRAMES

23 Oct 01 MTL 04/23 H-130 TIME FRAMES

The hospital must enter the presumptive eligibility determination into the DWSS PE system within five (5) days of the application date. This process serves as notification of the eligibility decision.

Note: The PE system will update the DHCFP Medicaid Eligibility Verification System (EVS). This process takes a minimum of two business days after case entry.

H-135 “PRUDENT PERSON” PRINCIPLE

The policies included in the manual are rules for determining eligibility. It is impossible to foresee and give examples for all situations; therefore, the qualified provider and hospital staff certified to make PE determinations are encouraged to use reason and apply good judgment in making eligibility decisions when rare and unusual situations are encountered.

Reasonable decisions made by PE certified staff based on the best information available, using good judgment, program knowledge, experience and expertise in a particular situation is referred to as the Prudent Person Principle. The “Prudent Person Principle” may be applied when rare and unusual situations are encountered, and guidance is not clearly stated in this Medicaid Assistance Manual (MAM). Any decision made that is determined to be incompatible with current DWSS or DHCFP policy will be cited in accordance with the established DWSS PRE PE Review Guide.

H-140 WITHDRAWAL OF APPLICATION

An individual may voluntarily withdraw an application any time before PE determination is made. The qualified provider or hospital must allow the request to be made electronically, telephonically recorded, or handwritten.

H-145 CASE DOCUMENTATION

All PE decisions are reviewed by the DWSS Program, Review, and Evaluation (PRE) unit. The PE certified staff must include in an individual’s case record any facts used to support the decision on the application. A case narrative is required, and documentation must be clear and concise to allow the DWSS PRE unit reviewing the case to determine the reason, logic and accuracy of the PE certified staff’s decision and actions.

Any decision made that is determined to be incompatible with current DWSS or DHCFP policy will be cited in accordance with the established DWSS PRE PE Review Guide.

Supporting documentation, voluntarily provided by the individual, must be maintained in the case record.

The PE application must be complete and signed by the individual or the individual’s authorized representative.