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Medical Enforcement and Passing Audit

Note: Medical is a CFR requirement, not a performance measure.

Medical Enforcement – Per CFR Title 45 §303.30 and §303.31 – 75% Compliance level

Medical enforcement is an ongoing process. The State must petition the court to order health insurance coverage for the child(ren). If ordered, the State must attempt to secure insurance information or compel the specified person (can be NCP, CP or both) to obtain health care coverage for the child(ren). Once the information is secured, the State must pass the information on to either third party liability or the custodial parent.

Health care coverage includes:

  • Fee for service (such as cash medical)
  • Health Maintenance Organization (HMO)
  • Preferred provider organization (PPO)
  • Private health insurance policies
  • Government medical assistance program or health plan (Medicaid)
  • Indian Health Services (IHS)

The most common medical error received is for not obtaining or attempting to obtain medical support information. The NCP, CP or both may be ordered to provide health care coverage for the child(ren) or a third party such as, the NCP’s or CP’s spouse may be an alternative provider for the child(ren). Information regarding medical support coverage or availability of coverage can be obtained by generating the appropriate medical form to the appropriate person.

  • M01* sent to NCP to inquire if insurance is available
    • Sent to the NCP if NCP’s spouse is the alternative provider
  • M04* sent to CP to inquire if insurance is available
    • Sent to the CP if the CP’s spouse is the alternative provide
  • M05 (M05C) sent to NCP’s or CP’s employer to inquire if medical support is available
  • M06 sent to inquire about the availability of Indian Health Services
  • MED5** (MED5C) sent to NCP’s or CP’s employer and used to force enroll children in health care coverage

We may know that the person who was ordered to provide health care coverage does not have it available due to incarceration or receiving SSA/SSI. These circumstances do not exclude an office from inquiring about the availability of medical support information as CSS must obtain or attempt to obtain information regarding the availability of health care coverage annually.

The easiest way to correct this error is by simply checking to see if the M01, M04, M05, M06 or MED5 has been generated during the audit period. If the appropriate document(s) haven’t been generated, then manually generate the appropriate document(s). This information must be obtained or attempted to be obtained annually.

The second most common error is for not modifying an order with an inadequate or non-existent medical support provision. Any cases coded as B, N, O or X in the OBL MED ORD field requires a modification.

See Medical Support Cheat Sheet for more information.

* The M01 and M04 will only auto generate under limited circumstances. Once all criteria is met, these forms will initially auto generate. It will only auto generate again if an action has taken place to trigger the criteria to be looked at, such as, an obligation change to the medical order or a change submitted through OHCA for a medical order. After the initial generation, these notices will need to be manually generated.

** The MED5 (MED5C) will not automatically generate if the obligation screen indicates that Medicaid is the active coverage (M in the MED ORD field).

For additional medical information, help and tools, click on the following links.

CSS Medical page

Self-Assessment: Audit Methodology and Code of Federal Regulations

CSQuest Medical Enforcement articles and CSQuest Medical Establishment articles