Free Agency Response to the State Quality Assurance (QA) Medicaid Finding, HCF 10172 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10172 (07/08)

STATE OF WISCONSIN

AGENCY RESPONSE TO THE STATE QUALITY ASSURANCE (QA) MEDICAID FINDING
As described in Section XX of Appendix AL of the State and County Contract Covering Social Services and Community Programs, failure to take corrective action may result in liquidated damages. Complete, sign and return this form with documentation of corrective action to the following address: Wisconsin Department of Health Services Bureau of Enrollment Management / Room 1050 Attn: Medicaid Quality Assurance Program Supervisor P.O. Box 309 Madison, WI 53701-0309 CARES Case Number Case Name

We agree with the error finding. If necessary, correct the case and submit documentation of your corrective action within 30 days. Corrective action can include termination of current and future benefits, the calculation of overpayment amounts and claims establishment, or restoration of benefits that were incorrectly under-issued, denied or terminated for all months affected by the error. If an overpayment occurred due to client error, establish a claim to initiate benefit recovery. To assist with error reduction initiatives, indicate what information from the client, agency or state would have helped prevent this error: Please respond within 30 days of receipt of the QA error finding. Additional Comments

We disagree with the error finding. Provide additional information and/or documentation to explain why you consider the eligibility determination to be correct. Please respond within 10 days of receipt of the QA error finding. Additional Comments

If client error, was this case referred to fraud for further investigation?

Yes

No

SIGNATURE ­ Agency Representative SIGNATURE ­ Agency Supervisor Agency Name

Date Signed Date Signed