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Division of Welfare and Supportive Services H-145 Medical Assistance Manual PRESUMPTIVE ELIGIBILITY 23 Oct 01 MTL 04/23 CASE DOCUMENTATION The PE certified staff completing the eligibility determination is required to sign and issue the PE Notice of Decision (Form 2991).

H-150 PRESUMPTIVE ELIGIBILITY STANDARDS

All qualified providers and hospitals must maintain the following eligibility standards in order to remain a certified PE facility provider.

1. Ninety-four percent (94%) of all PE decisions must be correctly determined based on the State’s PE policies and must be entered into the PE system correctly from the information gathered at application.

2. Ninety percent (90%) of individuals determined presumptively eligible by a hospital must submit a full health insurance application to DWSS prior to the end of the presumptive eligibility period.

3. Qualified providers processing Prenatal pregnancy PE are encouraged to stress the importance of applying for full health insurance from DWSS to continue to receive Medicaid services beyond the PE period.

When entering information into the PE system, PE certified staff must ensure the accuracy of the information being entered. The use of slang or nicknames is not permitted. Individual names, dates of birth, and social security numbers must be accurate upon entry into the PE system to ensure a proper data match can occur and identity confirmed.

H-151 DWSS PROGRAM, REVIEW, AND EVALUATION (PRE) AUDIT

DWSS Program, Review, and Evaluation (PRE) staff will monitor monthly reports as well as conduct audits to ensure policy, procedures and standards are being met. All qualified providers and hospitals are required to cooperate with PRE by providing case records and any supporting documentation as requested to complete a PRE audit.

When a qualified provider or hospital is determined to have fallen below standards based on the PRE audit review period, a corrective action plan (CAP) will be developed for the qualified provider or hospital by the DWSS PRE staff. If PRE staff determine, after implementation of the CAP, the qualified provider or hospital remains below the standards, the hospital will:

o be disqualified by DWSS; and

o no longer be authorized to conduct PE determinations; and

o be required to serve a 1 year sit out period from making PE determinations.

Note: Non-cooperation with a PRE audit request without good cause (as determined by PRE) may result in the immediate assessment of the qualified provider or hospital being placed in a CAP.