Assess whether a provider's attendance is fabricated (edd6a5)

Situation

The Recoupment and Policy desk packet is issuance file-control totals that will not balance after a CDR where treating-source evidence conflicts with a CE. Medicaid eligibility integrity analyst in a benefits issuance vendor after a file-control break must name Pay or continue or Recoup for this Public Benefits file. Medicaid eligibility integrity analyst in a benefits issuance vendor after a file-control break has to name Pay or continue or Recoup for this Public Benefits Recoupment and Policy file.

Decision

Medicaid eligibility integrity analyst in a benefits issuance vendor after a file-control break must choose Pay or continue / Recoup / Deny / Hold using issuance file-control totals that will not balance after a CDR where treating-source evidence conflicts with a CE.

Hypotheses to test

• A CDR where treating-source evidence conflicts with a CE is noise around an already-controlled Recoupment and Policy process in a benefits issuance vendor after a file-control break, given issuance file-control totals that will not balance.
• A CDR where treating-source evidence conflicts with a CE is the event in issuance file-control totals that will not balance that forces Pay or continue for Medicaid eligibility integrity analyst under Public Benefits.
• Issuance file-control totals that will not balance shows a one-file miss after a CDR where treating-source evidence conflicts with a CE, not a Recoupment and Policy program failure.
• Issuance file-control totals that will not balance cannot decide a provider's attendance is yet after a CDR where treating-source evidence conflicts with a CE; hold is the only Public Benefits close a benefits issuance vendor after a file-control break can defend.

Analysis required

• Trace the notice and appeal path Medicaid eligibility integrity analyst must preserve.
• Test eligibility, recoupment, and improper-payment facts in issuance file-control totals that will not balance after a CDR where treating-source evidence conflicts with a CE.
• Quantify overpayment if a provider's attendance is is wrong.
• For this Public Benefits Recoupment and Policy file, read issuance file-control totals that will not balance 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.