Medicaid Quality Check Guidelines | Medicaid

Was the case authorized within SOP? If not, was the reason documented in Gateway? Was the reason accurate? E.g. client delay should NOT be documented when verification is NOT requested timely to be returned before the case reaches SOP; rather, that is worker delay; other agency should NOT be used when a case is on a vacant caseload and just assigned to a case worker; rather, that is agency delay.

Was the correct COA processed in the case (ABD and/or FM)? Was the case potentially PCT eligible? Was the reason for PCT ineligibility correct? For ABD, was the case potentially FBR?

If the verification for citizenship was NOT a US Passport (not limited passports), a Certificate of Naturalization (N-550 or N-570), or a Certificate of Citizenship (N-560 or N-561), was identity verified using acceptable verification as listed in Section 2215 - Citizenship/Immigration/Identity or on Form 218 - Citizenship/Identity Verification Checklist? Was the Declaration of Citizenship in the case record? Was it used for ID for any children under 16? Are there children in the case 16 or over? Was proper ID requested for them? Form 216 – Declaration of Citizenship is good as ID only for those under 16. If Other Acceptable Verification (OAV) was used (e.g. use of FDSH/SOLQ/SDX/BENDEX), was it documented appropriately?

Was income, earned or unearned, entered correctly? Is there appropriate verification in the case record? Was Representative Pay determined correctly? Was income documented correctly? Were all income interfaces accessed, reviewed and addressed properly (e.g. DOL, Income Verification (IV) and Employer Income Verification System (EIVS)) and were discrepancies explored and documented? Were SOLQ, SDX and BENDEX pulled and addressed, if appropriate?

For ABD, PGW & Family Medically Needy cases, were resources appropriately addressed and documented? Is there appropriate verification in the case record? Did Lexis Nexis show property or a vehicle? If so, was it addressed? Did AVS interface provide any liquid resource information after authorization? If so, was the information followed up on? Does SOLQ, SDX or BENDEX show direct deposit? If so, was a bank account explored? For ABD, was the Burial Exclusion applied appropriately? Were life insurance policies coded correctly to count when the CSV is a countable resource?

Rev 08/25