State of Wisconsin Department of Health Services

Release 24-01 April 03, 2024

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9.10 Questionable Items

Information is questionable for BadgerCare Plus when:

1. There are inconsistencies in the group’s oral or written statements.
2. There are inconsistencies between the group’s claims and collateral contacts, documents, or prior records.
3. The member or their representative is unsure of the accuracy of their own statements.
4. The member has been convicted of Medicaid or BadgerCare Plus fraud or has legally acknowledged their guilt of member fraud.
5. The member is a minor who reports that they are living alone. This does not apply to minors applying solely for Family Planning Services.
6. The information provided is unclear or vague.
7. CWWCARES Worker Web. The web-based pages used in the CARES operations. determines the case meets an automated EPPError Prone Profile.

9.10.1 Front End Verification

Front End Verification (FEVfront-end verification) is intensive verification of a case by a special unit or worker. A group should be referred for FEV only when its characteristics meet a designated profile (see Process Help, Section 31.3.5.1 FEV/Fraud Referral vs. Claim Referral).

9.10.2 Error Prone Profile

The EPP functionality in CWW (see Process Help, Chapter 70 Error Prone Profile) identifies error prone cases at application and renewal and tracks the resolution of identified potential errors. Once an EPP has been detected, affected programs cannot be confirmed until the EPP is resolved or deferred.

EPP identifies three types of potential errors:

• Questionable Income and/or Expenses
• Unresolved Discrepancies
• IPVIntentional Program Violation/Overpayment History

9.10.2.1 Questionable Income and/or Expenses

Cases may be identified and tracked by EPP as having questionable income or expenses based on either of the following conditions:

• Expenses exceed income.
• Total income has remained the same for an extended period of time.

9.10.2.2 Unresolved Discrepancies

Cases may be identified and tracked by EPP as having unresolved discrepancies if they have inaccurate or unreported income based on the presence of unresolved SWICAState Wage Information Collection Agency, UIBUnemployment Insurance Benefits, SOLQ-IState Online Query Internet, or Prisoner Match discrepancies.

9.10.2.3 Intentional Program Violation or Overpayment History

Cases may be identified and tracked by EPP if they include members who have a history of IPVs or overpayments.

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The information concerning the BadgerCare Plus program provided in this handbook release is published in accordance with: Titles XI, XIX and XXI of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapter 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10171