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of doing tape matches with one or more insurers in the State to verify that children are not covered by private health insurance.

The State will perform periodic random reviews and post- eligibility audits of the applications to assure compliance with CoverKids eligibility and enrollment policies. These reviews will include examination of applications and any additional information or documentation to assure that: a proper determination of eligibility was made, all the required information is obtained, the system contains needed edits, and referrals to Medicaid are made when indicated. The reviews will also audit applications for a sample of children to verify that the information provided by self-declaration during the application process is accurate. Families will be notified of the audit by letter and asked to provide documentation to verify information given. If an audit shows that a child or children in the family were not, in fact, eligible for CoverKids, the TPA will contact the family to give them the opportunity to provide information establishing eligibility within 10 days. Families who do not provide information that establishes eligibility will be notified by letter of termination eligibility, subject to the appeal rights described in section 12 of the State plan. Timeframes for disenrollment will be consistent with timeframes for disenrollment at redetermination, i.e., the last day of the month in which a final determination of ineligibility is made.

In addition, part of the quality assurance methodology will be planned reports on the following: • lists of CoverKids enrollees by county (this will be compared to the Medicaid population to assure the enrollee is not receiving both Medicaid and CoverKids services) • number of applications received • number of denials of applications with the reasons for denial • number of pregnant women and newborns who were determined to be CoverKids eligible, using presumptive eligibility, who were subsequently determined not eligible by the TPA • number of disenrollments with the reasons for disenrollment • number of hearings requested and their disposition • number of annual redeterminations • enrollee survey results

Application reviews will include assurance that any required verifications have been used, time frames have been met, and appropriate referrals have been made.

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