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West Virginia Income Maintenance Manual Chapter 1

West Virginia Income Maintenance Manual Page 126 Chapter 1 Application/Redetermination Process

The Medicaid client may be eligible to receive direct reimbursement for out-of-pocket medical expenses if the Department has not acted on the application within a reasonable period of time and the delay is not due to factors beyond the control of the Department. See Chapter 10. 1.6.6.A Documenting Reason for Delay To document the reason for any delay in processing a Medicaid application, the Worker must record in comments: • All actions taken in processing the application; and, • The results of required case reviews. The instructions for these procedures are found below. A rebuttable presumption that the application was not acted on within a reasonable period of time exists when conditions such as, but not limited to, are met: • Proper documentation, as shown below, which establishes that delay is due exclusively to factors beyond the control of the Department, is not in the case record. • Documentation for the required case review is not in the case record. This presumption may be rebutted only by clear and convincing evidence that all necessary actions by the Department for processing the application were undertaken in a timely fashion. This presumption may not be rebutted solely by the testimony of a Worker who failed to meet the documentation requirements. 1.6.6.A.1 Instructions for Documentation for Pending Medicaid Applications For all Medicaid applications, the documentation in the eligibility system must include, but is not limited to, the following: • Date of application. • Date the verification checklist or DFA-6 and 6A were mailed or given to the client. NOTE: For Medicaid AGs, when the last case action was a denial due solely to failure to meet spenddown within the application processing time limit, the period of consideration (POC) and/or period of eligibility (POE) is backdated, if appropriate, based on the date the client requests reconsideration of his application.