CFR

431.804—Definitions.

As used in this subpart—

Active case means an individual or family determined to be currently authorized as eligible for Medicaid by the agency.

Administrative period means the period of time recognized by the MEQC program for State agencies to reflect changes in case circumstances, i.e., a change in a common program area, during which no case error based on the circumstance change would be cited. This period consists of the review month and the month prior to the review month.

Claims processing error means FFP has been claimed for a Medicaid payment that was made—

(1) For a service not authorized under the State plan;

(2) To a provider not certified for participation in the Medicaid program;

(3) For a service already paid for by Medicaid; or

(4) In an amount above the allowable reimbursement level for that service.

Eligibility error means that Medicaid coverage has been authorized or payment has been made for a recipient or family under review who—

(1) Was ineligible when authorized or when he received services; or

(2) Was eligible for Medicaid but was ineligible for certain services he received; or

(3) Had not met recipient liability requirements when authorized eligible for Medicaid; that is, he had not incurred medical expenses equal to the amount of his excess income over the State's financial eligibility level or he had incurred medical expenses that exceeded the amount of excess income over the State's financial eligibility level, or was making an incorrect amount of payment toward the cost of services.

Negative case action means an action that was taken to deny or otherwise dispose of a Medicaid application without a determination of eligibility (for instance, because the application was withdrawn or abandoned) or an action to deny, suspend, or terminate an individual or family.

State agency means either the State Medicaid agency or a State agency that is responsible for determining eligibility for Medicaid.

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