Assess whether a retailer should be disqualified (104f9a)

Situation

A thousand UI claims from one IP block put disability CDR medical-evidence pack 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 retailer should be disqualified from disability CDR medical-evidence pack, 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 disability CDR medical-evidence pack after a thousand UI claims from one IP block.

Hypotheses to test

• Disability CDR medical-evidence pack reads as Pay or continue once a thousand UI claims from one IP block is lined up to the same Public Benefits population.
• Disability CDR medical-evidence pack is closer to Recoup after a thousand UI claims from one IP block; Pay or continue would over-claim this Compliance and Integrity Operations extract.
• Deny is still live in disability CDR medical-evidence pack for Medicaid eligibility integrity analyst in a Medicaid agency with a surge in MAGI mismatches.
• Disability CDR medical-evidence pack is missing the fact Medicaid eligibility integrity analyst needs after a thousand UI claims from one IP block; stop this Public Benefits close.

Analysis required

• Quantify overpayment if a retailer should be disqualified is wrong.
• Separate a case-level error from a program-design failure in a Medicaid agency with a surge in MAGI mismatches.
• Match household facts in disability CDR medical-evidence pack to the rule that pays the benefit.
• For this Public Benefits Compliance and Integrity Operations file, read disability CDR medical-evidence pack against a thousand UI claims from one IP block and write the one fact that would move a retailer should be disqualified for Medicaid eligibility integrity analyst.

Recommendation

Choose Pay or continue / Recoup / Deny / Hold on this Public Benefits / Compliance and Integrity Operations packet (disability CDR medical-evidence pack after a thousand UI claims from one IP block). 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.