Article 8 Section 02 Erroneous Certification

 

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Required Worker Actions

08.02.01A

 

 

08.02.01 Erroneous Certification

 

08.02.01A
Required Worker
Actions

Upon the discovery of an error resulting in erroneous certification of CMS, the worker must immediately contact their Supervisor.  Depending on when the error is discovered, the worker will immediately take action as instructed below.  The erroneous certification details must be recorded in the case comments.

 

Note:  This process will remain the same until CMS IT system is upgraded.

 

If the error was discovered...

Then the worker shall...

within 30 calendar days of the erroneous action, and based on worker clearance of IDX, no claims have been received,

rescind the certification back to the original application date by taking the following actions:

1

Issue NOA CMS-34R to the applicant informing them of the error and the rescission.

2

Send a CMS-4 to the ASO at MS 0557B noting the change in eligibility status and the reason for the error.

 

more than 30 calendar days after the erroneous action or within 30 calendar days but worker clearance of IDX reflects claims submitted for dates of service within the erroneous certification period,

discontinue CMS eligibility by taking the following actions:

1

Issue NOA CMS-34R to the applicant informing them of the error and date of discontinuance.

2

Discontinue CMS benefits effective immediately.

3

Send a CMS-4 to the ASO at MS 0557B noting the change in eligibility status and the reason for the error.

4

Inform the CMS Third Party Liability (TPL) Program Specialist (PS) for overpayment assessment and collections, as applicable.

 

 

Note:  The TPL PS shall determine if additional actions are required, on a case by case basis, and as directed by the CMS Program Manager.  In some cases, the provider may be liable for repayment of claims paid erroneously.