Policy Directive                                                                          Issuance Number: MS 07-11

Medical Services Policy Manual                           Issuance Date: July 18, 2007

From: Joni Jones, Director                                       Expiration Date: Until Superseded

Subj:  Medical Review Team (MRT) Denials and Closures Explanation of Adverse Action        

Arkansas Act 2227 of 2005 requires that a Medicaid applicant or recipient be provided specific information when an adverse action is taken based on a medical or other clinical determination.  This requirement applies to application denials or case closures due to a Medical Review Team decision.  The Act requires that the individual be notified of the specific medical records that were used in making the determination and the criteria that was not met.   

To implement this provision, a new notice system and process has been developed to be used when MRT determines an individual does not meet the disability criteria and therefore the Medicaid application must be denied or the case closed.  This will require that the county send a manual notice of action with a notice generated from MRT.  The purpose of this directive is to describe the process that will be followed by MRT and the county offices.  

I.  Applications Taken and Case Reviews Due on or after May 1, 2007                  

    A. MRT Process  

MRT has established procedures to gather information to provide to the applicant or recipient  regarding what information was used in determining if a disability exists and the reason for denial or case closure.  Information provided will be similar to the explanation SSA provides upon denial of an application based on disability.  When the MRT case manager is screening an initial application or re-examination application, the client’s work history, age, education and medical records reviewed is entered into a database.  When a denial or case closure decision is made by MRT due to not meeting the disability criteria, form DCO-700A (Explanation of MRT Findings) will be printed by MRT.  A copy of the DCO-700A is attached.  The notice, DCO-700A, explains what medical records were used by the physician in making the  MRT determination and the criteria not met.  MRT will scan and email the DCO-700A along with the DCO-109 to the County Administrator (CA) and the Economic Services Supervisor (ESS).  The email will come from the “DHS MRT Unit”.  The address for an Outstationed Worker will be DHS.MRT.Unit@arkansas.gov.  Please do not reply to this email address.  If you have any questions, contact Carolyn Duncan or Becky Williams in the MRT Unit.

B. County Office Process  

Upon receipt of the DCO-109 and DCO-700A, the caseworker will manually send the Explanation of MRT Findings (DCO-700A) along with the appropriate preprinted DCO-700 to the applicant or recipient (copies attached).  The DCO-700 will state the reason for the denial or case closure.  Specific notice text has been developed for each MRT denial code or case closure.  A screen message will be issued providing the preprinted DCO-700s for the manual notices.  The caseworker should save the notices on the computer to use as a template.  They will not be available on DHS Gold.  System generated notices will not be used for these denials or closures.  

II.  Applications Taken and Case Reviews Due Prior to May 1, 2007  

A system-generated notice will be sent for adverse action taken on an application or case review dated prior to May 1, 2007.  The DCO-109 will indicate when a manual notice is not required.  A DCO-700A will not be generated for a denial or closure for applications or case reviews taken or due prior to May 1, 2007.  

If you have any questions, please contact your Program Support Specialist.  

Inquiries to:    Judy Key, 501-682-8259

                        Carmen Banks, 501-682-8258

                        Carla Droughn , 501-682-8254

                        Dona Young, 501-682-1562

                        Isabel Hebert , 501-682-8896