Eligibility, Enrollment, and Payment Verification
Provisional domain 2: Eligibility, Enrollment, and Payment Verification. This provisional section focuses on the rules that decide whether a recipient or provider may be paid. Expect questions that require you to choose the strongest verification source and to spot when an approval has gone stale.
Core rules
- Eligibility is a point-in-time determination, not a permanent status. Recheck at renewal, reported income or status change, death, exclusion, and ownership change.
- Use a verification hierarchy: primary source first, independent secondary source next, self-attestation last. Self-attestation is usable only when corroborated or explicitly allowed by rule.
- Enrollment screening commonly covers identity, licensure, exclusion lists, and disclosed ownership or affiliations. Approval to enroll is not approval of every later claim.
- Payment conditions: eligible recipient, covered service or item, documented necessity, allowable amount, and no duplicate payment.
Worked example
An applicant self-reports an active professional license. The registry shows the license expired last month. Do not approve enrollment pending primary-source verification. Reasoning: self-report is the weakest tier; expiration is disqualifying until renewed; the reviewer must record the registry checked, the date, the result, and the exception. If enrollment is provisional under local rules, claims still need a separate payment-condition check.
Traps
Treating enrollment approval as perpetual; relying on self-attestation alone; checking exclusions only at onboarding and never before payment; missing ownership affiliations; and failing to document the exact source and date of verification.