How to Decide What Medical Evidence Is Needed
- Request existing medical records before authorizing new evaluations or services
Use DSHS 14-150, Medical Evidence Request (Physical) and DSHS 14-150A, Medical Evidence Request (Psychological) to communicate to the provider exactly what medical information you want and medical procedures you are authorizing.
When authorizing examinations or other diagnostic services, include specific details known about the client’s condition, and follow the guidelines in this category for requesting specific tests.
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Initial decision: Current medical evidence for initial incapacity decisions is a report containing objective findings based on an examination within 90 days of the date of application. Only request new medical evidence when available evidence is either older than 90 days or insufficient for an incapacity decision.
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Document your reason for obtaining new medical evidence.
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Medical evidence more than 90 days old is acceptable when it is:
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Intelligence testing scores from a WAIS-III (Weschler Adult Intelligence Scale) administered after age 18;
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Medical evidence used by DDDS to approve a NGMA (non-grant medical assistance) decision that is still in effect, where the medical information was obtained no longer than 12 months ago; or
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For a client more than 50 years old, objective findings of a chronic, deteriorating condition based on an exam within the last 12 months.
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Review decision: Current medical evidence for review decisions is a report containing objective findings obtained within the past 45days.
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If the client has seen his medical provider within the past 45 days, do not authorize a new evaluation. Obtain a report from records and authorize payment using the "report from records" service.
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Explain reasons for obtaining any new testing or evaluations at review in the ICMS (Inclusive Case Management System) case notes.
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Medical Evaluations / Procedures
The medical evidence fee is payment to the medical provider for specific services. Standards for incapacity and expedited Medicaid evaluations are in the Provider Handbook, which must be given to every provider. Review incapacity evaluations for the following information before you process the payment.
- General physical evaluation: A general physical evaluation should contain all of the following information:
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Chief complaint or reason for the visit;
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Medical history including date the condition began, response to treatment, and any hospitalizations;
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Physical examination findings including vital signs, description and explanation of abnormal findings, and range of motion (if done);
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Results of diagnostic testing (lab work, x-rays, etc.);
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Assessment/diagnosis with the severity of the diagnosed condition. The provider should not include any diagnosis based only on the person’s complaints without supporting objective findings;
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History of drug and / or alcohol use;
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Rating of how the medical condition affects the client’s overall ability to perform basic work-related activities. Basic work-related activities are sitting, standing, walking, lifting, handling, carrying, seeing, hearing, communicating, and understanding/following directions;
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Prognosis and estimate of how long the person will be limited to the listed severity and functional rating;
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Medications, equipment, and/or supplies prescribed or provided;
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Recommendations for additional testing or consultation;
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Recommended treatment;
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Name, title and signature of the person performing the service;
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Date of service; and
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Copies of chart notes from the last six months, hospital summaries, medical records or lab results attached to DSHS 13-021, Physical Evaluation form or a narrative report.
- Comprehensive physical evaluation (e.g. orthopedic or neurological): A comprehensive physical evaluation contains all of the information listed under the general physical evaluation section above, in addition to:
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Progression of symptoms such as motor loss, sensory loss or mental restrictions;
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Description of any restrictions on personal care or daily activities caused by the condition; and
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Copies of clinic records.
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Mental health evaluation completed by an MHP (mental health professional):
The written report should include an MSE (mental status exam) and copies of the client’s records. The evaluator must include information indicating they are a qualified MHP. If the evaluator does not indicate this, contact the evaluator to verify their status. If the person is not an MHP, do not authorize paymentfor the service.
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Psychological and psychiatric evaluation:
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The Psychological evaluation is a diagnostic interview including an MSE and an assessment of daily living skills, conducted by a licensed psychologist.
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The Psychiatric evaluation is a diagnostic interview conducted by a licensed psychiatrist, or an Advanced Registered Nurse Practitioner when certified in psychiatric nursing.
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Both evaluation types result in a written report that must include:
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Chief complaint; |
Diagnosis
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History of past & present illness |
Prognosis
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Mental status |
Capability to manage funds
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Functional information |
Medical source statement, indicating what the client can do despite the impairment
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- Psychological diagnostic testing is limited to the following:
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For a general claim of mental disorder:
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For a claim of cognitive disorder:
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WAIS-III: Weschler Adult Intelligence Scale
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WMS-III: Weschler Memory Scale
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Rey: This is a 15-item visual memory test, often used to determine malingering
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Trailmaking: Used to determine cognitive damage
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For a claim of depression:
After interviewing the client, determine what tests are necessary and request them with the psychological evaluation.
Request subtest scores, statistical scores, and the narrative summary of all tests that you request. The narrative summary of the testing may help prevent the purchase of another exam/testing when the person applies for SSI. Division of Disability Determination Services (DDDS) calls this the “analysis of the information”.
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Special report for SSI administrative hearing purposes:
This is medical evidence given by a medical provider, to be used at an administrative hearing when a client is involved in the Social Security disability appeals process. These reports are a supplement to medical evidence already obtained by us and the consulting exams obtained by DDDS. This service must be pre-approved by the social services worker. Use this service description to pay for the provider’s time when either:
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The medical provider provides verbal information to the attorney, followed by a written report; or
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The medical provider appears at an administrative hearing to offer testimony in person.
In either case, the medical provider must send you a detailed billing listing the service provided and the amount of time spent providing the service. See Medical Evidence Fee Schedule for payment details.
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Medical evidence at the SSI administrative hearing level:
Historically, when a case reached the SSI administrative hearing level and it was determined that the medical evidence in the record was not adequate to support the disability claim, additional medical was obtained at that point.
We no longer routinely authorize and reimburse for evaluations when a client reaches the SSI hearing level. We must get clear, objective medical evidence early in the client's eligibility period, at the initial decision and at reviews. In doing so, you should not need further evaluation when the client reaches the SSI hearing level. For situations when further evaluation is necessary, follow these procedures:
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If there is new condition, conduct an incapacity review and authorize payment with SSPS code 6220.
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If this is not a new condition, complete the DSHS 17-118. Request for Expenditure Approval. You must state the reason you need the medical evaluation and the cost. The 17-118 is then sent to headquarters staff. If approved, payment would be authorized with SSPS code 96224.
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Payment for Medical Evidence
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You must have an itemized bill with the provider’s usual and customary fees before authorizing payment. The bill must be kept in the client’s case file for audit purposes.
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Physician Services for Diagnostic procedures: Diagnostic procedures include, for example, lab work (e.g., urinalysis, blood tests), radiology, strength testing and a wide variety of other procedures. For diagnostic procedures, pay the provider’s usual and customary fee or the allowable maximum, whichever is less. The allowable maximums are found in the "Physician-Related Services Billing Instructions", issued by MAA (Medical Assistance Administration).
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When the allowable maximum is listed as "BR" (by report), pay 65% of the provider’s billed fee.
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Pay no more than $450 total for all diagnostic procedures per client per initial evaluation.
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Hospital Services for Diagnostic Procedures: For outpatient diagnostic procedures done in a hospital setting, pay the usual and customary fee or the allowable maximum for the relevant CPT code, whichever is less.
Use the Outpatient Hospital Fee Schedule
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Medical evidence other than diagnostic procedures: Payments for these services are made according to the Medical Evidence Fee Schedule. Pay the provider’s usual and customary fee or the amount shown in the fee schedule, whichever is less.
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When you decide a client is eligible for GAU either initially or at review, complete the DSHS 14-332 (Disability Assessment) before paying for medical evidence. If a GAX / SSIF referral is appropriate per the 14-332, use service code 6220 to pay for the medical evidence. If a referral is not appropriate, use code 6020.
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