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West Virginia Income Maintenance Manual Chapter 13

West Virginia Income Maintenance Manual Page 17 Chapter 13 Determining Disability, Incapacity, and Blindness

Used to obtain the Psychiatrist’s/Psychologist’s recommendation to the MRT. When this form is used it must have the DFA-RT-15 attached. 13.7.1.A.4 General Instructions for Completion Forms are to be completed as follows: • Each form is prepared in duplicate. One copy is filed in the case record. • The date, name, and address of the medical provider to whom the authorization is issued must be entered. • The Worker must also include the address of the county office. • Refer below for the number to enter as the case number. 13.7.1.A.5 Numbers Used on Medical Request Forms The forms used for requesting medical examinations and reports are self-explanatory. For auditing and federal reimbursement reasons, the Medicaid Identification (MAID) number or the Pending Medicaid Number must be used for any medical information requested. The following explains the numbers and when each is used. ➢ Pending Medicaid Number The number is 80 followed by seven zeros and the county number. For example, the Pending Medicaid Number for Kanawha County is 80-0000000.20. This number is used for an individual who is not a Medicaid recipient at the time the information is requested. This includes individuals who previously received Medicaid but are not current recipients. ➢ MAID Number This is the number assigned by the eligibility system for Medicaid billing. This number is used when medical information is requested for a current Medicaid recipient only. The local office must keep a log of all requests issued. The log must contain the following information: • MAID number or Pending Medicaid Number and the county number;