Revision 13-2; Effective June 1, 2013

 

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 13-2; Effective June 1, 2013
 

The automated system provides a DG0001 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 individual/authorized representative (AR) has not responded, the eligibility worker may contact the individual/AR or DADS 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 and the case record indicates the recipient or AR is capable of completing the redetermination form:

  • 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: The MES can re-instate DADS coverage without Form H1746-A, MEPD Referral Cover Sheet, if:

  • the packet was received from disposal date to the effective date of the denial,
  • the LTSS summary reflects ongoing coverage, and
  • DADS staff/liaison to Star Plus staff verify the client continued to receive services.

Example: Case due Feb. 10, 2013. Denial disposed Feb. 11, 2013. Denial is effective March 31, 2013.

The review packet was received on or before March 31, 2013. No new Form H1746-A is required, if the additional requirements listed above are met.

See Appendix XI, Reference for Client Notification Forms.

 

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.