2
ND
PARTY REVIEW WORKSHEET
(Effective 4/1/2017)
Caseworker Name
ADD or IA/IS #
Supervisor
D
(mm/dd/yy)
Application
I
(mm/dd/vv)
DOA:
I
0 MAGI O TRADITIONAL
0 HEALTH CHOICE
CH/Primarv Person
Disposition Date
Prooram/Class
Certification Period:
Type
Date of Review
Authorization Period:
D
I
(mm/dd/yy)
Denial/Withdrawals
D
Renewals
I
A. AGENCY RECORD:
D
Terminations
Case set up with correct IA/IS # (Income aoolication/Income Suooort)
y
N N/A
1.
Appropriate case narrative/notes/documentation in NC Fast
y
N N/A
1.
Case processed within required timeframe
y N N/A
1.
2.
3.
4.
Notice
Notice
Notice
Notice
y
y
y
y
1.
1.
2.
3.
4.
5.
B. DOCUMENTATION:
C. TIMELINESS:
D. NOTICES:
sent
sent
sent
sent
upon approval
upon denial/termination/withdrawal
but was not timely
but did not contain correct information
E. NON-INCOME ELIGIBILTIY:
N
N
N
N
N/A
N/A
N/A
N/A
N
N
N
N
N
N
N
y N
y N
y N
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N
N
N
N
N/A
N/A
N/A
N/A
Correct Date of Birth entered into NCFast
Correct Gender entered into NCFast
Correct SSN entered into NCFast
Citizenship/alien status verification provided and verification meets policy requirements
Failed to assist aoolicant with obtainino verification of citizenship if needed
6. Reasonable oooortunity policy applied appropriately (citizenship/alien)
7. Identity verified aooropriately
8. Residency verified aooropriately
9. Correct household composition
10. Manaqed Care or Exempt Code entered into NCFast appropriately
y
y
y
y
y
y
y
1.
y
y
y
y
y
y
y
y
y
y
y
y
y
y
y
2.
3.
4.
5.
6.
7.
8.
9.
1.
F. INCOME/BUDGETING:
Earned income verified appropriately
a. Available electronic verification of income used (if aooropriate)
b. Waoes verified appropriately with employer/source
c. Self-employment verified aooropriately
Earned income entered in NCF correctly
Unearned income verified appropriately
a. Available electronic verification of income used (if aooropriate)
Unearned income entered into NCF correctly
Reasonable compatibility policy appropriately applied
Income deductions applied appropriately
Determinations shows correct Income counted
NCHC fee notice sent prior to authorization (12 calendar)
a. Fee paid prior to authorization
b. Ineligible for NCHC due to comprehensive health insurance
HCWD premiums calculated correctly
G. DISABILITY:
Disability established
a. APPiied for Social Security (post eliqibility)
b. Verified by DDS
C.
Assessment compteted in NCFAST
y
y
y
y
.N