| TO: | ALL COUNTY OFFICES |
| FROM: | JANEL R. LUCK, DIRECTOR |
| SUBJECT: | CLARIFICATION OF PROCEDURES FOR SUBMITTING MEDICAL INFORMATION TO THE MEDICAL REVIEW TEAM |
DISCUSSION:
The procedures for submitting information to the Medical Review Team (MRT) are revised and clarified. The Income Maintenance policy manual sections 1060.005.05, 1060.005.10, and 1060.005.15 are updated to reflect the following changes:
- An examination with a specialist can be scheduled by the FSD county office when it is determined that information that could be obtained from the specialist is necessary for MRT to make a decision. Do not wait for approval from MRT to schedule these examinations.
- Submission of medical records to MRT along with the Social Information Summary (IM-61) is not required if the claimant earns over the Substantial Gainful Activity (SGA) limit and the claimant is not claiming any impairment-related work expenses necessary to enable him or her to work. The income must be verified and recorded on the IM-61 prior to submission to MRT.
- Medical records are required in addition to the IM-61 if the claimant earns over the SGA limit and the claimant incurs impairment-related work expenses (IRWE). Impairment-related work expenses are defined as expenses related to the claimant's disabilities that are necessary to enable him/her to work. The income and expenses must be verified and recorded on the IM-61 prior to submission to MRT.
- When submitting information on cases previously reviewed by MRT, medical reports from the past five years are not required unless available in the case record or it is believed that earlier medical reports are pertinent to the claimant's current condition(s).
- If the claimant's only existing medical records are chiropractic records, a medical examination must be scheduled by the FSD county office.
Obtaining Medical Evidence for the Medical Review Team
The medical records submitted to MRT must include information related to the medical condition(s) being claimed by the applicant or recipient. The eligibility specialist can authorize an examination with a physician skilled in the treatment and diagnosis of the condition(s) claimed when:
- medical information regarding the condition(s) claimed is not available;
- the claimant's only existing medical records are chiropractic records; or
- s/he feels the information that could be obtained from the specialist is necessary for MRT to make a determination.
Submission of Records to MRT for Individuals Engaged in Substantial Gainful Activity
The Substantial Gainful Activity (SGA) limit is defined by the Social Security Administration and is updated annually. Appendix D regarding SGA limits is added to the manual. The SGA limit for 2006 is $860 per month. The SGA limit effective January 1, 2007 is $900.00. When a claimant's income exceeds the SGA income limit and the claimant incurs impairment-related work expenses necessary to enable him or her to work, the IM-61 must record both the claimant's income and impairment-related work expenses. This information must be submitted to MRT along with the claimant's medical records. Impairment-related work expenses may include, but are not limited to, cost of:
- attendant care services;
- transportation;
- medical devices such as wheelchairs and braces;
- the cost of drugs and medical services that are directly related to the individual's impairment. Examples include but are not limited to: anticonvulsant drugs to control epilepsy; antidepressant medication for mental disorders; medication used to allay the side effects of certain treatments; radiation treatment or chemotherapy for cancer patients; immunosuppressive medications that kidney transplant patients regularly take to protect against graft rejection; anticonvulsant blood level monitoring; corrective surgery for spinal disorders; electroencephalograms and brain scans related to a disabling epileptic condition; and tests to determine the efficacy of medication on a diabetic condition;
- prosthetic devices; and
- work-related equipment and assistive devices such as one-handed typewriters, vision aids, helper animals, and sensory aids.
When sending the information to MRT, record the amount of monthly income and impairment-related work expenses incurred by the claimant on the IM-61. Monthly income and impairment-related work expenses recorded on the IM-61 must be verified. Submit the IM-61 along with all medical records to MRT.
EXAMPLE: Ms. Jones' pay stubs show she works 40 hours per week at a rate of pay of $7.00 per hour. 40 hours x $7.00 = $280.00 per week x 4.333 = $1213.24. Ms. Jones claims work-related equipment and assistive devices totaling $590.00. The monthly income and expenses are verified by the eligibility specialist. The eligibility specialist records the amount earned, $1213.24, and the impairment-related work expense amount, $590.00, on the IM-61. The IM-61 is submitted to MRT along with all medical records.
If the claimant is engaged in Substantial Gainful Activity and does not claim impairment-related work expenses needed to enable him/her to work, medical information is not required. Record the claimant's statement of gross monthly income on the IM-61. Verify and record the gross monthly income on the IM-61 and submit the form to MRT. Ensure that income figures recorded on the IM-61 have been converted to monthly amounts.EXAMPLE: Mr. Smith's pay stubs show he works 40 hours per week at a rate of pay of $7.00 per hour. 40 hours x $7.00 = $280.00 per week x 4.333= $1213.24. Mr. Smith does not claim impairment-related work expenses. $1213.24 is recorded on the IM-61. Medical records do not need to be submitted to MRT.
Submitting Information On Cases Previously Reviewed By MRT
The following information is required for all cases previously reviewed by MRT in which the claimant does not currently receive disability-based SSI or Social Security Disability Insurance (SSDI):
- A new Social Information Summary (IM-61);
- A new medical report, unless otherwise specified by MRT;
- The most recent Social Information Summary or Medical Consultant's Recommendation processed by MRT;
- Medical reports for the last five years if available in the case record. The eligibility specialist may submit earlier reports, when available, if they are pertinent to the claimant's current medical condition(s). This includes reports from State Mental Hospitals, Tuberculosis Sanatoriums, Cancer Hospitals, Veterans Administration Hospitals, Vocational Rehabilitation, and private hospitals, as well as other pertinent information;
- If the claimant is engaged in Substantial Gainful Activity and is claiming impairment-related work expenses needed to enable him/her to work, record the claimant's statement and verified amount of monthly gross income and expenses on the IM-61; and
- All correspondence with MRT. Other correspondence, such as copies of referral letters to psychiatrists, orthopedists, etc. related to determining disability and rehabilitation should also be forwarded for review.
NECESSARY ACTION:
- Review this memorandum with appropriate staff.