*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016. Please refer to the EPM for current health care program policy information. ***
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Effective: June 1, 2011 |
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09.05.05 - Inconsistent Information |
Archived: June 1, 2016 (Previous Versions) |
This section explains when to verify information that is inconsistent with other information or documentation on file.
Verification requirements:
1. Request verification if information or documentation provided by a MinnesotaCare applicant or enrollee is inconsistent with:
n other information the agency has; or
n the applicant’s or enrollee’s own statements; or
n information collected in other ways, including but not limited to information or documentation collected for purposes of a case review, audit, fraud investigation or overpayment analysis.
2. Pend MinnesotaCare eligibility (P30 or C48) for applicants and enrollees while awaiting information and verification to resolve an inconsistency.
MMIS will automatically deny or close eligibility in 60 days for applicants or at the end of the renewal period for enrollees renewing coverage.
3. Request that enrollees provide information and verification within 10 days when inconsistent information is received or discovered between renewals.
Cancel MinnesotaCare with 10-day notice for enrollees who fail to resolve inconsistent information within 10 days. Use cancellation code 66 ”Requested Information Not Received” to cancel coverage in MMIS.
Fraud referrals: See Fraud.
l County agencies.
Refer MinnesotaCare cases to county agency fraud investigators if there is reason to suspect an applicant or enrollee is withholding, concealing or misrepresenting information.
l MinnesotaCare Operations.
Refer cases to the HCEA MinnesotaCare Fraud Investigation Team.
Example:
Elliot is a self-employed small business owner enrolled in MinnesotaCare. Elliot’s MinnesotaCare case is selected for review in an audit, and the auditor finds unreported income for Elliot’s business. The information collected by the auditor shows that Elliot had more gross receipts for his business in the previous year than are indicated on the tax forms he submitted for MinnesotaCare eligibility. The auditor sends copies of Elliot’s bank statements and other business records to MinnesotaCare.
Action:
Send a Request for Information (DHS-3271) to Elliot. Provide a description of the information that is inconsistent with the tax forms Elliot submitted. Request an explanation of the inconsistent information and verification to support the explanation. Verification may include a signed statement from the enrollee asserting the reason for the inconsistent information.
Elliot admits that he had additional income that he did not report on the verification he originally provided.
Action:
Redetermine MinnesotaCare eligibility including the income as verified by the auditor’s documents in the new income calculation. Assess an overpayment if Elliot received MinnesotaCare coverage while he was ineligible, received a greater benefit than he was eligible for, or paid a lesser premium than he should have been assessed. See Overpayments. Refer the case to the agency’s fraud investigators if Elliot fails to respond to the request for information or does not provide a reasonable explanation of the inconsistent information, since it appears he may have misrepresented his income.
Verify information that is inconsistent with documentation or information on file, even when it is not mandatory, if all of the following conditions exist:
l The information is necessary to determine at least one of the following:
n Eligibility.
n Premium Amount.
n Spenddown.
l The information is inconsistent with at least one of the following:
n Other information the agency has.
n A client's own statements.
l The client cannot satisfactorily explain an inconsistency.
Document the following information in the case record:
l A description of the inconsistency.
l An explanation of why verification was necessary.
l A description of the verification.
See No Income Reported for more information if a client reports no income.