Is It Really an Administrative Denial?
The Member was not eligible on the PAR receipt date.
Everything else in the request is complete.
Is this an Administrative Denial?
Yes.
Member eligibility on the PAR receipt date is an administrative requirement.
No amount of supporting documentation can overcome an unmet administrative requirement.
Next Step: Issue the appropriate Administrative Denial and clearly document the eligibility finding.
Member not eligible.
Administrative Denial.
A provider submits a Housing Transition Supports request.
You verify: Required documentation is complete, Requested service is within HSS scope, Housing Support Plan supports the request, and No active RFI.
During your review, you discover the Member's Medicaid coverage ended before the PAR was received.
What is the administrative reason this request cannot move forward?
Member was not eligible on the PAR receipt date.
Don't simply say, "The Member isn't eligible."
Identify which administrative requirement wasn't met and tie it to the evidence.
Next Step: Document the eligibility finding, complete the Administrative Denial pathway, and issue the appropriate notice.
Review note: Denied.
Good enough?
No.
Document what was requested, what administrative requirement wasn't met, and why.
Deny because one document is missing.
Not necessarily.
Consider whether an RFI is appropriate first.
The Housing Support Plan is missing.
Administrative Denial?
This is a missing-information issue.
The next step is an RFI if allowed under the workflow.
Don't deny when the provider still has an opportunity to provide required information.
Required documentation missing.
RFI.
The Member meets all HSS requirements.
The documentation is complete.
The Housing Support Plan supports the request.
During review you discover the provider submitting the PAR is not enrolled or approved to provide the requested HSS service.
What is the administrative reason?
The provider does not meet the administrative requirement to submit or provide the requested HSS service.
Administrative requirements apply to both the Member and the provider.
The denial is not because the Member doesn't qualify.
It is because the request cannot move forward under program requirements.
Next Step: Document the provider eligibility issue and complete the Administrative Denial process. Work on connecting Member to approved CBO.
Review note: Member ineligible.
What's missing?
The supporting evidence.
For example: "Member was not eligible on the PAR receipt date."
Deny because the documentation conflicts.
Not yet.
Clarify the conflict first.
A provider submits a PAR requesting payment for hotel lodging through Housing-Related Deposit.
Administrative Denial?
The requested service is outside HSS program scope.
Administrative Denials apply when the requested item or service cannot be covered under HSS.
Housing Support Plan and PAR conflict.
Clarify the conflict before determining the pathway.
The PAR requests Housing Transition Supports.
The Housing Support Plan clearly states the Member has been successfully housed for one year and only needs ongoing tenancy support.
Everything else is complete.
Is the administrative reason:
A. Wrong service requested
B. Outside HSS scope
C. Administrative Denial
None of the above.
This is not yet an Administrative Denial.
The documentation and requested service conflict.
The next step is to resolve the conflict according to the workflow before determining the correct pathway.
Next Step: Clarify the request (likely through RFI if appropriate under your SOP), then continue the review.
Review note: Outside scope.
What's missing?
Identify what was requested and explain why it falls outside HSS scope.
A denial should answer:
Deny because you're unsure.
Never.
Review, clarify, or escalate before making a determination.
The reviewer discovers another approved authorization for the same Member, same service, and same dates.
What should you consider?
Review the duplicate according to the SOP. If confirmed to be a duplicate that cannot move forward, the appropriate pathway may be an Administrative Denial.
Don't assume every second request is automatically denied. Verify the facts first.
The provider never responded to the RFI within the required timeframe.
Follow the SOP. If policy allows, the next step may be an Administrative Denial for failure to provide the requested information.
The denial is based on the unresolved administrative requirement, not because the reviewer assumed the answer.
While reviewing a Housing-Related Deposit request, you discover another authorization that:
The provider submitted a second PAR because they forgot the first one had already been approved.
What is the administrative reason?
The request is a duplicate of an existing approved authorization.
Don't deny because "it looks like a duplicate."
Verify that it is a duplicate and document how you confirmed it.
Next Step: Follow duplicate request procedures and complete the appropriate Administrative Denial if the duplicate cannot move forward.
Your review note says: "Denied. Member not eligible."
What important information is missing?
The documentation should tell the complete story:
A denial should answer why, not just what.
Deny because the provider says they'll send it later.
Follow the workflow.
Do not approve or deny based on promises. Follow the RFI process and required timeframes.
Everything about the Member meets HSS requirements.
However, the provider is not eligible or approved to submit the request.
Can the request move forward?
No.
This is an administrative requirement.
Administrative requirements apply to providers as well as Members.
You're unsure whether the request meets administrative requirements.
Don't guess.
Pause, review the SOP, and escalate if required.
Good reviewers know when to stop.
The review is complete.
The documentation supports the requested service.
The Member is eligible.
The provider is eligible.
The reviewer notices the Member has already reached the program's allowable utilization limit for this benefit.
What is the administrative reason?
The allowable utilization or lifetime limit has already been met.
This is not a documentation issue.
It is an administrative program limitation.
Next Step: Document the utilization finding, identify the supporting evidence, and complete the Administrative Denial pathway or ask for an Exception in rare cases.
You processed an Administrative Denial three months ago.
Today:
She opens TruCare and reads only this: "Outside scope. Denied."
What information should Heather have been able to find in your documentation?
Your documentation should clearly explain:
Write every review as if someone else will have to defend it.
Because one day, they probably will.
A Housing Transition Supports request includes: Member eligible, Provider eligible, Correct service, Required documents, No RFI, and Service sequencing met.
However, the documentation clearly supports Housing Sustainment Services instead.
Administrative Denial?
Not yet.
The reviewer should resolve the documentation conflict before deciding the pathway.
One of the biggest reviewer mistakes is choosing a pathway before understanding the problem.
The right answer isn't always "approve" or "deny."
Sometimes the right answer is: "I don't have enough information to make a defensible decision yet."