section .0200 – application processing, monitoring and corrective action

Published: 2015

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section .0200 – application processing, monitoring and

corrective action



(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


(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


(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.