533 D         CASE PROCESSING

1. Initial Applications

An initial application can come in the following forms:

• MED 4 application or referral from denied MAGI Medicaid application. If a MED 4 application is submitted or a referral from a denied MAGI Medicaid case is received, send notice M320, Information Needed - TEFRA.

• Referral from MAGI Medicaid when there is no MAGI Medicaid eligibility and the application includes a disabled child.

If the TEFRA process starts from a denied or closed MAGI case, send notice M322, PEND TEFRA Disabled Child Denied DKC. The family is allowed 15 days to:

• Contact Comagine Health to be connected with a care coordinator for TEFRA and begin the LOC assessment process,

• Return the MED 1, MED 2, and any accompanying medical information for a disability determination, and 

• Complete an interview.

The caseworker must follow procedure outlined in MS 533(C)(4).

2. Actions for NF-LOC and IPH-LOC

After receiving a referral from DPA by the receipt of the GEN 140B, Comagine Health will send the child's parent or guardian a welcome letter and ask the parent to contact Comagine Health within 30 days for care coordinator referrals. This letter also instructs the parent to contact DPA if needed.

If the parent contacts a care coordinator and begins the TEFRA assessment process, Comagine Health will:

• Receive ICF/IDD-LOC applications and make appropriate referrals to DSDS (refer to step below for further ICF/IDD processing) and track the process to ensure the care coordinator provides a completed assessment for ICF/IDD-LOC, completed COC, and completed Support Plan within required time frames. The care coordinator's failure to provide these documents will result in denial.

• Track the process to ensure the care coordinator provides a completed assessment for NF-LOC and IPH-LOC, completed COC, and completed Support Plan within required time frames. The care coordinator's failure to provide these documents will result in denial. 

If the care coordinator follows through and provides all documentation in the required time frames, Comagine Health will make a LOC decision and notify DPA of approval or denial.

If LOC is denied, Comagine Health notifies the DPA TEFRA Specialized Medicaid PAA with the following information:

• Name of child,

• The child's care coordinator, and

• Rationale for denial.

The DPA TEFRA Specialized Medicaid PAA issues the denial letter and sends a copy to the LTC unit. The LTC unit completes all actions in EIS.

3. Actions for ICF/IDD-LOC

If an application for ICF/IDD-LOC is received, Comagine Health will make a referral and provide the following information to DSDS for all new applications and ICF/IDD renewals:

• Child's name, date of birth, and SDS ID number,

• Date required for LOC determination to meet DPA time frames, and

• Care coordination agency and main contact person.

After the initial referral, the following steps occur:

Step 1:

DSDS sends the care coordinator an email requesting the ICF/IDD LOC packet be forwarded to DSDS.

Step 2:

The care coordinator has 30 days to send the ICAP packet to DSDS.

• If the packet is not completed and a level of care determination cannot be made within 90 days, Comagine Health will issue a denial due to not completing the ICF/IDD LOC packet.

• If DSDS receives all documentation and determines the child does not meet LOC, DDS notifies Comagine Health that LOC is denied and provides the reason(s) for the denial. Comainge Health notifies the DPA TEFRA Specialized Medicaid PAA who then issues the denial letter to the parent and notifies the LTC unit of the denial. The LTC unit must close or deny the TEFRA Medicaid case in EIS.

Step 3:

The care coordinator will contact DSDS if there is difficulty completing the ICF/IDD LOC packet within the 30-day period and explain any problems being encountered. If an extension is needed, DSDS will refer the care coordinator to Comagine Health. Comagine Health will work with the DPA TEFRA Specialized Medicaid PAA to provide guidance in completing the ICF/IDD LOC packet.

Step 4:

DSDS will notify Comagine Health with the results of the ICF/IDD LOC determination. If the LOC determination results in an approval, Comagine Health will notify the care coordinator, DPA TEFRA Specialized Medicaid PAA, and the LTC unit of the approval.

If the ICF/IDD LOC determination results in a denial, the DPA TEFRA Specialized Medicaid PAA will:

• Send a letter to the parents with copies to the care coordinator, Department of Law, and DSDS notifying them ofthe LOC denial, and

• Notify the LTC unit of the LOC denial to either close or deny the TEFRA Medicaid.

4. Getting Adequate Documentation for ICF/IDD LOC Processing

The ICF/IDD LOC determination may require information that is not readily available such as a current IQ test or psychological evaluation.

The care coordinator will assist new applicants in scheduling an appointment with a Medicaid provider. After the appointment is scheduled, the parent must contact the LTC unit and request a disability exam coupon (DE 25) for the month the appointment is scheduled.

The care coordinator will assist current TEFRA recipients in scheduling an appointment with a Medicaid provider. The evaluation or testing will be billed to Medicaid.