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If a discrepancy results from an applicant or recipient's identity information and one or more of the databases or information tools authorized under Sections 43-12-5 through 43-12-17, the department shall review the respective applicant or recipient's case using the following procedures:
If the information discovered does not result in the department finding a discrepancy or change in an applicant's or recipient's circumstances that may affect eligibility, the department shall take no further action.
If the information discovered under Sections 43-12-5 through 43-12-17 results in the department finding a discrepancy or change in a recipient's circumstances that may affect eligibility, the department shall promptly redetermine eligibility after receiving such information within ten (10) business days, or the minimum required by federal law.
If the information discovered under Sections 43-12-5 through 43-12-17 results in the department finding a discrepancy or change in an applicant's or recipient's circumstances that may affect eligibility, the applicant or recipient shall be given an opportunity to explain the discrepancy; however, self-declarations by applicants or recipients shall not be accepted as verification of categorical and financial eligibility during eligibility evaluations, reviews, and redeterminations.
Unless prohibited by federal law, the department shall provide written notice, within ten (10) business days, or the minimum required by federal law to the applicant or recipient, which shall describe in sufficient detail the circumstances of the discrepancy or change, the manner in which the applicant or recipient may respond, and the consequences of failing to take action. The applicant or recipient shall have ten (10) business days, or the minimum required by federal law, to respond in an attempt to resolve the discrepancy or change. The explanation provided by the recipient or applicant shall be given in writing. After receiving the explanation, the department may request additional documentation if it determines that there is risk of fraud, misrepresentation, or inadequate documentation.
Unless prohibited by federal laws, if the applicant or recipient does not respond to the notice, the department shall, within ten (10) business days, or the minimum required by federal law deny or discontinue assistance for failure to cooperate, in which case the department shall provide notice of intent to deny or discontinue assistance. Eligibility for assistance shall not be established or reestablished until the discrepancy or change has been resolved.
If an applicant or recipient responds to the notice and disagrees with the findings of the match between his or her identity information and one or more databases or information tools authorized under Sections 43-12-5 through 43-12-17, the department shall review the matter. If the department finds that there has been an error, the department shall take immediate action to correct it and no further action shall be taken. If, after a review, the department determines that there is no error, the department shall determine the effect on the applicant's or recipient's case and take appropriate action. Written notice of the respective department's action shall be given to the applicant or recipient.
If the applicant or recipient agrees with the findings of the match between the applicant's or recipient's identity information and one or more databases or information tools authorized under Sections 43-12-5 through 43-12-17, the department shall determine the effect on the applicant or recipient's case and take appropriate action. Written notice of the department's action shall be given to the applicant or recipient. In no case shall the department discontinue assistance upon finding a discrepancy or change in circumstances between an individual's identity information and one or more databases or information tools authorized under Sections 43-12-5 through 43-12-17 until the applicant or recipient has been given notice of the discrepancy and the opportunity to respond as required under this section.
The executive director of the department, or his or her designee, at his or her discretion may review the agency conference record of a hearing to determine that the local or state decision was correct. The executive director, or his or her designee, shall prepare a decision summarizing the issue and the basis for the decision. In cases in which the executive director, or his or her designee, finds that the facts in the record are inadequate or that incorrect policy has been applied, he or she will direct the county to get the facts or use correct policy and change the decision, reinstate the payment, or correct the amount of payment retroactively to the date of erroneous action.
The department shall promulgate rules and regulations necessary for the purposes of carrying out this section.
Wherever applicable and cost-effective, the Division of Medicaid and the Department of Human Services shall share data, data sources, and verification processes aimed at reducing fraud and waste.