Medicaid Quality Check Guidelines | Medicaid

Was case submitted within SOP? If not, was the reason coded on MISC and documented on REMA? Was the reason accurate? E.g. client delay should NOT be used when verification is NOT requested in time to be returned before the case hits SOP – that is worker delay; other agency should NOT be used when a case is on a vacant caseload and just assigned to a worker – that is agency delay.

Was the correct COA assigned to the case (ABD or FM)? Was the case potentially LIM eligible? Was LIM ineligibility documented? Was reason for LIM ineligibility correct? For ABD, was 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 also verified using acceptable verification as listed on Form 218? 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? (See Form 218 – Declaration of Citizenship good as ID only for those under 16.) Was SUCCESS documented appropriately?

Was income, earned or unearned, entered correctly in SUCCESS? Is there appropriate verification in the case record? Was Representative Pay determined correctly? Was SUCCESS documented correctly? Was DOL addressed and were any discrepancies explored and documented? Was Data Broker pulled and was any information found, explored with the customer and documented? Were SDX and BENDEX pulled and addressed, if appropriate?

Any deceased spouse or parent? Was RSDI explored? Any military service? Were VA benefits explored? Did anyone recently lose a job (including quitting) or does DOL show potential for UCB? Was the A/R required to apply for UCB? Was SUCCESS documented with client’s statement as to intent to apply (was an alert created to follow up in three months) or why client not required to apply? If not required due to disability, was this verified and documented?

For MN and LIM cases, were resources addressed and documented? Is there appropriate verification in the case record? Did Data Broker show property or a vehicle? If so, was it addressed? Did the credit report provide any resource leads? If so, were they followed up on? Does 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 in order to count in SUCCESS when the CSV is a countable resource?