0815.020.15 Medical Recertifications (Utilization Reviews) – DSS Manuals
IM-33 March 29, 2012
Medical recertifications for NF, MHC and IMR level of care are not completed by Eligibility Specialists. These recertifications are done by the Utilization Review Committees, as established through the Department of Health and Senior Services, Division of Senior and Disability Services.
When a change in level of care needs to be made as a result of a utilization review, the Division of Senior and Disability Services will notify the Eligibility Specialist of the change.
As a result of a utilization review, if COMRU sends a DA-125 to the Eligibility Specialist indicating that the participant is no longer eligible for the level of care s/he is receiving, follow the procedures in 0815.070.00 Claimant Leaves the Vendor Facility to determine eligibility for non-vendor MHABD.
Update the entry on the Facility and Placement Information Details screen (FACPLACE or FMJ4) in the DA-124A/B Level of Care field.
Enter a comment from the Facility and Placement Information Details screen (FACPLACE or FMJ4) noting the date the DA-125 was received and describing the verification of the change.
Enter a comment from the Eligibility Unit Member Role (EUMEMROL or FM3Z) screen describing the adjustment.
Complete the eligibility determination ( EDRES ) in FAMIS and authorize the adverse action to change the level of care or close the case. NOTE: Always review the Budget Summary screen prior to authorizing a case action in FAMIS. From the MHABD Action Authorization screen (FMD9) use F16= MHABD to view the MHABD Assistance Group Summary screen. Select the coverage type and use F16= AGBUDSUMM to view the Adult MO HealthNet Budget Summary screen press F17=INCSUM to view the Income Summary Detail screen and F18=EXPSUM to view the Expense Summary Detail screen to ensure all countable income and expenses are included in the budget.