section .0200 – application processing, monitoring and
corrective action
10A NCAC 23C .0201 APPLICATION PROCESSING STANDARDS
(a) The county department of social services shall comply
with the following standards in processing applications:
(1) A decision on an individual's eligibility
for Medicaid shall be made within 45 calendar days from the date of application
for Medicaid except for applications in which a disability determination has
already been made or is needed. For those applications, a decision on an
individual's eligibility shall be made within 90 days from the date of
application. These timeframes shall apply in accordance with 42 CFR 435.911.
(2) Only require information or verification
necessary to establish eligibility for assistance;
(3) Make at least two requests for all
necessary information from the applicant or third party;
(4) Allow at least 12 calendar days between the
initial request and a follow-up request and at least 12 calendar days between
the follow-up request and denial of the application;
(5) Inform the client in writing, and verbally
when possible, of the right to request help in obtaining information requested
from the client. The county department of social services shall not discourage
any client from requesting such help;
(6) An application may pend up to six months
for verification that the deductible has been met or disability established.
(7) When a hearing decision reverses the
decision of the County Department of Social Services on an application, the
application shall be reopened within five working days from the date the final
appeal decision is received by the County Department of Social Services. If no
additional information is needed, the application must be processed within five
additional working days. If additional information is needed pursuant to the
final decision, the county shall make such requests in accordance with rules
for all applications. The first request for the additional information shall
be made within five working days of receipt of the final appeal decision. The
application shall be processed within five workdays of receipt of the last
piece of required information.
(b) The county department of social services shall obtain
verification other than the applicant's statement for the following:
(1) Any element requiring medical
verification. This includes verification of disability, pregnancy, incapacity,
emergency dates for aliens referenced in 10A NCAC 23E .0102(c), incompetence,
and approval of institutional care;
(2) Proof a deductible has been met;
(3) Legal alien status;
(4) Proof of the rebuttal value for resources
and of the rebuttal of intent to transfer resources to become eligible for
Medicaid. When an applicant or recipient disagrees with the determination of
the county department of social services on the value of an asset, then the
applicant/recipient must provide proof of what the value of the asset is;
(5) Proof of designation of liquid assets for
burial;
(6) Proof of legally binding agreement limiting
resource availability;
(7) Proof of valid social security number or
application for a social security number;
(8) Proof of reserve reduction when resources
exceed the allowable reserve limit for Medicaid;
(9) Proof of earned and unearned income,
including deductions, exclusions, and operational expenses when the applicant
or Income Maintenance Caseworker has or can obtain the verification; and
(10) Any other information for which the
applicant does not know or cannot give an estimate.
(c) The county department of social services shall verify
or obtain an item of information when:
(1) A fee must be paid to obtain the
verification;
(2) It is available within the agency;
(3) The county department of social services is
required by federal law to assist or to use interagency or intra-agency
verification aids;
(4) The applicant requests assistance; or
(5) The applicant is physically, mentally, or
otherwise incapable of obtaining the information, or is unable to speak English
or read and write, or is housebound, hospitalized, or institutionalized, and a
representative does not accept responsibility for obtaining the information.
History Note: Authority G.S. 108A-54; 42 C.F.R.
435.911; Alexander v. Flaherty, V.S.D.C., W.D.N.C., File No. C-C-74-183,
Consent Order Filed 15 December 1989; Alexander v. Flaherty Consent Order filed
February 14, 1992; Alexander v. Bruton Consent Order dismissed Effective
February 1, 2002;
Eff. September 1, 1984;
Amended Eff. April 1, 1993; August 1, 1990;
Temporary Amendment Eff. March 1, 2003;
Amended Eff. August 1, 2004;
Transferred from 10A NCAC 21B .0203 Eff. May 1, 2012.