10A NCAC 23G .0204      RESPONSIBILITY FOR ERRORS

(a)  The Division shall be financially responsible for costs resulting from the erroneous issuance of benefits and Medicaid claims payments when:

(1)           Policy guidance given by the Division or its agents is erroneous and the Division determines that is the sole cause of any erroneous benefits or payments;

(2)           A systems failure at the State computer center occurs on the last cutoff date of the month preventing the county DSS from data entering case terminations or adverse actions; or

(3)           Any other failure or error the Division determines is attributable solely to the State occurs.

(b)  The county department of social services shall be financially responsible for costs resulting from the erroneous issuance of benefits and Medicaid claims payments when it:

(1)           Authorizes retroactive eligibility outside the dates permitted by federal regulations or Rule .0203 of this Section;

(2)           Fails to send required notices of patient liability or deductible balance to medical providers;

(3)           Fails to end-date special coverage indicators such as Community Alternatives Program (CAP) in the State eligibility information system;

(4)           Enters an authorization date in the eligibility system that is earlier than the effective date of eligibility;

(5)           Fails to determine the availability of or fails to enter data on third-party resource information in the State eligibility information system;

(6)           Terminates a case or individual after the Medicaid ID card has been issued;

(7)           Fails to initiate application for Medicare Part B coverage for recipients who are eligible, but refuse or are unable to apply for themselves; or

(8)           Takes any other action that requires payment of Medicaid claims for an ineligible individual, for ineligible dates, or for an amount that includes a recipient's liability and for which the State cannot claim federal participation.

(c)  The amounts to be charged back shall be determined pursuant to G. S. 108A-25.1A(c).

History Note:        Authority G.S. 108A-25.1A; 108A-54; 108A-54.1B; 42 C.F.R. 433.32; 42 C.F.R. 435.903;

Eff. June 1, 1990;

Amended Eff. May 1, 1992;

Transferred from 10A NCAC 21A .0604 Eff. May 1, 2012;

Readopted Eff. June 1, 2019.