Revision 19-1; Effective March 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.