Assess whether a provider's attendance is fabricated (1c9aa2)

Situation

A CDR where treating-source evidence conflicts with a CE put housing overlapping-address and income file in front of Medicaid eligibility integrity analyst in a Medicaid agency with a surge in MAGI mismatches. This Public Benefits / Compliance and Integrity Operations close is a provider's attendance is from housing overlapping-address and income file, and the live options are Pay or continue, Recoup, Deny.

Decision

Medicaid eligibility integrity analyst in a Medicaid agency with a surge in MAGI mismatches must choose Pay or continue / Recoup / Deny / Hold using housing overlapping-address and income file after a CDR where treating-source evidence conflicts with a CE.

Hypotheses to test

• Authorize Pay or continue now; housing overlapping-address and income file already has the discriminator after a CDR where treating-source evidence conflicts with a CE.
• Keep Recoup in force until housing overlapping-address and income file is completed after a CDR where treating-source evidence conflicts with a CE for Medicaid eligibility integrity analyst.
• Treat housing overlapping-address and income file as Deny because both readings appear after a CDR where treating-source evidence conflicts with a CE.
• Refuse a Public Benefits close: Medicaid eligibility integrity analyst does not have the page a provider's attendance is turns on in housing overlapping-address and income file.

Analysis required

• Separate a case-level error from a program-design failure in a Medicaid agency with a surge in MAGI mismatches.
• Match household facts in housing overlapping-address and income file to the rule that pays the benefit.
• Trace the notice and appeal path Medicaid eligibility integrity analyst must preserve.
• For this Public Benefits Compliance and Integrity Operations file, read housing overlapping-address and income file against a CDR where treating-source evidence conflicts with a CE and write the one fact that would move a provider's attendance is for Medicaid eligibility integrity analyst.

Recommendation

Choose Pay or continue / Recoup / Deny / Hold on this Public Benefits / Compliance and Integrity Operations packet (housing overlapping-address and income file after a CDR where treating-source evidence conflicts with a CE). The follow-on Compliance and Integrity Operations action is what Medicaid eligibility integrity analyst does next: implement the option, assign an owner, and log the missing fact.