Scoring when medical records are not available or conflict with reported function

Follow the steps below when the information provided by the customer, caregiver, or representative during the PAS conflicts with the medical records, or medical records are not available:

Step Action 1 Were medical records provided for the customer? If YES, continue to step 2. If NO, STOP. Score based on what the caregiver or representative reported, noting any differences between what was and what you observed. 2 Do the medical records support the customer’s responses? If YES, STOP. Score based on the customer’s responses. If NO, contact the caregiver to discuss and clarify the differences. Continue to step 3. 3 Does the caregiver have a valid reason explaining why the medical records contradict what is being reported? If YES, score based on the caregiver’s report and add comments to each section that has a discrepancy describing the reason the reported information was used instead of the medical records. If NO, score based on the most relevant records and add comments to each section that has a discrepancy explaining why the reported information was not used. Contact your Benefits and Eligibility Manager (BEM) requesting review. The BEM determines if the PAS scores are accurate, if able. When the BEM is unable to determine the accuracy of the scores, a M.A.R.S. Inquiry is sent to PAS Policy.