Mississippi Administrative Code
Title 23 - Division of Medicaid
Part 101 - Coverage Groups and Processing Applications and Reviews Redetermination Processes
Chapter 9 - Authorizing a Nursing Facility Per-Diem Payment for a Beneficiary Eligible in a Non-Institutional Category
Rule 23-101-9.4 - Exparte Reviews

1. When to Complete an Exparte Determination. For an exparte determination to be made, the specialist must be in the process of making a decision on a current application, review or reported change. If the specialist is denying or closing for failure to return information or failure to complete the interview process, an exparte determination is not applicable.

2. Basis for the Exparte Review. The decision of whether the recipient is eligible under a different coverage group must be based on information contained in the case record. This may include income, household or personal information in the physical record which indicates the ineligible adult or child has potential eligibility in another coverage group. Information received through electronic matches with other state/federal agencies such as a disability onset date or prior receipt of benefits based on disability are also considered part of the case record.

3. Obtaining Information to Make the Determination. When potential eligibility under another coverage group is indicated, but the specialist does not have sufficient information to make an eligibility determination, the recipient must be allowed a reasonable opportunity to provide necessary information.

4. Eligibility Decision. If the individual is subsequently determined to be eligible in the new category, the approval must be coordinated with termination in the current program to ensure there is no lapse or duplication in coverage. However, if requested information is not provided or if the information clearly shows that the recipient is not eligible under another category, eligibility in the current program will be terminated with advance notice. During the advance notice period, the recipient is allowed time to provide all requested information to determine eligibility in the new program, provide information which alters the decision to terminate benefits in the current program or request a hearing with continued benefits.

5. Requested Information Provided After Closure. If the recipient subsequently provides all of the information needed to assess eligibility in the new program within two (2) months of termination, the case should be handled in accordance with the redetermination procedures.