B-9000, Denials

Revision 19-3; Effective September 1, 2019

 

Before a person is denied for any reason during redetermination, eligibility for QMB/SLMB must also be tested.

If the redetermination is denied in error, protect the date of receipt of redetermination no matter how old the redetermination.

 

B-9100 Administrative Denials

Revision 19-1; Effective March 1, 2019
 

The automated system provides a DG-0001 report, which indicates all pending and overdue reviews. Each region uses this as a tracking tool to ensure all reviews are completed by their due date. If a redetermination packet, other than a Form H1200-SR, has been mailed and the recipient or authorized representative (AR) has not responded, the eligibility staff may contact the recipient or AR to determine why the packet was not returned prior to denial, however, this is not a requirement. If no response is received and it has been 13 calendar days after the form was mailed:

  • send Form TF0001, Notice of Case Action, informing the recipient of the denial and the right to request a hearing; and
  • dispose the case action, denying the recipient without further contact.

Note: Eligibility staff can reinstate Community Attendant Services (CAS) or Home and Community-Based waiver services (HCBS) without a new Form H1746-A, MEPD Referral Cover Sheet, if:

  • the packet is received before the effective date of the denial;
  • the LTSS summary reflects ongoing coverage; and
  • CCSE or waiver staff verify the recipient continued to receive CAS or HCBS.

Related Policy

Reference for Notification Forms, Appendix XI
Application for Waiver Programs, O-1100
Medical Effective Date, R-1200

 

B-9200 Medical Necessity/Level of Care Determination at Redetermination

Revision 09-4; Effective December 1, 2009
 

When reviewing an MEPD case, verify medical necessity/level of care determination if:

  • the recipient's medical necessity or level of care determination has been denied, or
  • the recipient has relocated to a different facility and no medical necessity/level of care determination has been received.

If the medical necessity/level of care determination has been denied, do not sustain the review.

Reference: See Section B-7431, Denial of Level of Care/Medical Necessity Determination, for procedures when medical necessity/level of care is denied.

 

B-9300 Date of Death Denials and Verification Sources

Revision 19-3; Effective September 1, 2019

Date of Death Matches

HHSC matches recipients on active TIERS Eligibility Determination Groups (EDGs) with records from the Social Security Administration (SSA), Texas Bureau of Vital Statistics (BVS), the Centers for Medicaid and Medicare Services (CMS), and DADS Webservices to identify deceased persons and automatically remove them from active EDGs. If unable to process the death data automatically, TIERS creates tasks for staff to perform more research to determine the validity of the computer match. TIERS will attempt to update the Date of Death (DOD) information for all active and inactive person(s).

Death Verification Sources

Take action to clear any discrepancies when DOD data is received on an active or inactive person within TIERS and the system is unable to automatically dispose the case. When the system cannot dispose the case, a series of alerts are created for staff to explore and request additional verification of the death data.

Primary source of verification of death is the Bureau of Vital Statistics (BVS).

If BVS is not available, verify the date of death using two of the following sources:

  • Social Security Administration (SSA);
  • statement from guardian or other authorized representative;
  • copy of death certificate;
  • statement from a doctor;
  • newspaper death notice (obituary);
  • statement from a relative or household member;
  • statement from funeral director; or
  • records from hospital or other institution where the person died.

Note: If BVS is received but the date of death does not match previously reported information, accept BVS as verification and dispose the case. No additional verification is needed because BVS is considered the primary verification source.

Example: DOD data received from an SSA interface shows a DOD of 01/15/2019 but, the same person had a DOD of 01/13/2019 listed in TIERS. Alert 812, Verify Discrepancy in Date of Death for Individual is created for additional action. Staff verify the DOD by contacting the nursing home where the person was residing prior to death and also locate the person's obituary online. Staff enter the DOD based on the additional information and clear the alert

For detailed processing instructions, staff may review the Eligibility Services State Processes document and the Change and Alert Guide.

Related Policy

Social Security Administration Deceased Individual Report, R-4110