GIS 12 MA/027: Medical Evidence Gathering for Disability Determinations – Adult Cases

To: Local District Commissioners, Medicaid Directors

From: Judith Arnold, Director, Division of Health Reform and Health Insurance Exchange Integration

Subject: Medical Evidence Gathering for Disability Determinations – Adult Cases

Effective Date: Immediately

Contact Person: Local District Support Unit - Upstate (518)474-8887, NYC (212)417-4500

The purpose of this GIS message is to inform local departments of social services (LDSS) of a revision in the process to be followed to gather medical information for adult disability determinations for submission to any Disability Review Team (DRT), whether it be the State or a local DRT. This message clarifies the necessary medical and non-medical documentation to be gathered and provides for a uniform medical information gathering and submission process statewide.

Information from an applicant/recipient's (A/R) treating medical providers is considered the optimal medical evidence to use when performing a disability determination. Historically, the NYS Medicaid Disability Manual gave districts the option to ask medical providers to complete pages 1 and 2 and all applicable body system sections of the twenty-five page "Medical Report for Determination of Disability" (LDSS-486T) or to complete pages 1 and 2 of that form and submit copies of the individual's medical records for the most recent 12 months or for the desired disability determination timeframe.

The LDSS-486T form, as currently submitted by providers, often does not supply a disability reviewer with sufficient medical information to complete a disability determination. The forms are frequently incomplete and/or contain insufficient documentation to make a determination of disability. In many instances, providers are refusing to complete the form. For this reason, disability reviews are frequently returned with a decision of "No Action" for more medical information. This results in the delayed processing of the A/R's Medicaid eligibility while more medical evidence, such as office notes, laboratory results, medical imaging evidence and treatment records are obtained. In addition, insufficient medical documentation on the LDSS-486T form frequently results in unnecessary consultative exams (CE). This practice is costly, supplies a mere "snapshot" of the A/R's condition and should be used only if a treating provider is unwilling or unable to provide necessary medical evidence or the A/R does not have a treating provider. For these reasons, the LDSS-486T form and the procedure for gathering medical information have been revised. The body system sections have been eliminated and only a brief functional capacity assessment remains (see attachment I).

Effective immediately, for all adult disability determinations, districts are instructed to begin using the revised LDSS-486T form and to follow the process of information gathering described in this message. There is no change to information gathering for a child case as the forms used in those cases have proven to gather sufficient information.

For adult cases, the following documentation must be obtained prior to submission of the case for disability review.

  • "Disability Interview" form (LDSS-1151) – This form has been revised and re-named the "Disability Questionnaire" (see attachment II) since disability interviews have been eliminated and it is now often mailed to a recipient. This form may be completed by the A/R, the A/R's representative, or a local district worker, if the worker assists the A/R via the telephone or in person. If the form is completed by the A/R or A/R's representative, a district worker must ensure that all required information is documented on the form, including the A/R's SSI/SSDI history, with date of application (month/year), decision date (month/year), reason for a denial, and appeal date, if applicable. The completion of the education and work history portions of the form are also extremely important because these vocational factors are necessary when determining disability based on an A/R's residual functional capacity. The work history portion must include documentation of the job title, type of business, dates worked (month/year), hours worked per week, and rate of pay. In addition, the kind and amount of physical activity involved in each job must be documented. The revised form is intended to be user-friendly while gathering all the appropriate information needed for a disability determination.
  • "Medical Report for Determination of Disability" form (LDSS-486T) and provider medical records - The revised LDSS-486T form must be sent to each of the A/R's treating providers. In addition, the A/R's medical records, e.g., progress notes, testing reports, etc., for the most recent 12 months, or for the desired disability determination timeframe, must be requested. If the treating providers refuse to complete the LDSS-486T one-page form but send the medical records, submit the medical records to the SDRT or DRT for disability review. If a disability determination cannot be made based on all of the available medical records and a functional capacity assessment is needed, a consultative examination must be arranged by the district.
  • Hospital/Treatment facility records – In general, admission and discharge summaries from hospitalizations occurring during the desired disability determination time period, in addition to medical records from other treatment facilities, e.g., mental health facilities, nursing homes, etc., must be obtained and submitted.

All requests for medical evidence must be accompanied by a cover letter (see sample letter, attachment III) which clearly documents the medical evidence needed for the time period requested. If a district currently sends the LDSS- 486T form and a cover letter for the provider to the A/R instead of directly to providers and hospitals/treatment facilities, that process may continue provided the newly revised form is utilized and the provider cover letter contains all the information in the sample letter attached to this GIS message.

Districts are reminded that when submitting a disability package to the SDRT, a completed "Transmittal Sheet - Disability Determination Request" (LDSS-654) must accompany each submission. This form has also been revised, to provide clarity regarding case types (see attachment IV). In filling out the transmittal form, districts are reminded to check all applicable boxes at the top of the form and enter the A/R's name and case number, case type (New or CDR), the district's name and address, and the date submitted. The name, title, and phone number of the district contact person must also be documented at the bottom of the form.

The revised information gathering process will help ensure that a complete disability packet is gathered and eliminate the need for time-consuming "No Action" decisions and costly CEs. It will also create a uniform process for information gathering statewide, which will become increasingly important as state takeover of Medicaid functions proceeds. The NYS Medicaid Disability Manual has been revised to reflect this new process. All revised LDSS forms may be found on CentraPort.