P1304 Processing Applications for SMI A and SMI B Customers

Program	Manual Section
SSI-MAO	MA1304

The chart below shows how to identify the SMI category and what medical documentation is needed from the Tribal/RBHA or integrated health plan:

Category

Functioning Level

Medical Documentation Needed

SMI A

Meets the functional criteria for:

At Initial Application:

SMI Determination Summary and/or Molina supplemental form “SMI Eligibility Outcome”

At Renewal

SMI Determination (PM form 3.10.1) from the Tribal/RBHA that gives the current functional limitation.

For SMI A Sample Review:

The AHCCCS Medical Benefit Disability Report (DE-121) form; and
Medical records and progress notes dated within the last year that identifies the current functioning level. When the medical records are more than 3 months old, updated progress notes dated within the last 3 months are needed.

SMI B

Does not meet the criteria for SMI A, but does meet the criteria for dysfunction in role performance or risk of deterioration

At Initial Application:

SMI Determination PM form 3.10.1 or Molina supplemental form “SMI Eligibility Outcome”;
Medical records within the last year that support and validate the SMI Determination Summary and current functioning level;
When the medical records are more than 3 months old, updated progress notes dated within the last 3 months are needed; and
Either of the following:
- AHCCCS Medical Benefit Disability Report (DE-121) form; or
- SSA Disability Report (SSA-3368-BK form) completed within the past year.

At Renewal:

SMI Determination (PM form 3.10.1) form from the Tribal/RBHA verifying the current functional limitation with supporting medical documentation; and
Either of the following:
- A new AHCCCS Medical Benefit Disability Report (DE-121) form; or
- SSA Disability Report (SSA-3368-BK form) completed within the past year.

Follow the steps below to determine initial eligibility:

Step	Action
1	Is the customer at least age 65 or already disabled per the SOLQI? If YES, STOP. Process the application. A DDSA referral is not required. If NO, continue to step 2.
2	Do you have all of the information needed to process the case? If YES, continue to step 3. If NO, STOP. Request additional information. See section 3 below.
3	Does the customer meet all other eligibility requirements? If YES, continue to step 4. If NO, STOP. Process the application using the appropriate denial reason.
4	Did the Tribal/RBHA provide the required medical documentation? If YES: Approve presumptive eligibility; For SMI B, forward the DE-121 form and medical documentation to DDSA for a medical determination. See How to Complete a DDSA Referral for more details; and Follow-up on the DDSA decision per instructions in SMI DDSA Process below. If NO, request additional information. See section 3 below.

When the Tribal/RBHA does not provide the financial or medical documentation needed to make a decision, follow the steps below.

Step	Action
1	Send a Request for Information (RFI) to the customer.
2	Was the requested information received? If YES, continue to Step 3. If NO, STOP. Deny the application for the appropriate reason.
3	Is the customer SMI A? If YES, process the case. If NO, process the case and forward the medical documentation to DDSA. See How to Complete a DDSA Referral for more details.

Follow the steps below when you receive the DDSA decision.

Step	Action
1	Document the DDSA decision in case notes.
2	Does the DDSA report show that the customer is disabled? If YES, enter the Diary Date on the “Disability” screen. Verify the Disability verification factor. Continue to step 3. If NO, do not verify the Disability verification factor. Enter the DDSA denial information on the “Disability” screen. Continue to step 3.
3	Process the application.

For reporting requirements, AHCCCS must complete the DDSA referral process on a sample of customers that meet the definition of SMI A.

Follow the steps below to complete an SMI A Sample Review:

Step	Action
1	Send an RFI to the customer to complete the DDSA packet.
2	Was all the completed DDSA received? If NO, STOP. Discontinue eligibility for failure to complete a DDSA. If YES, complete a DDSA referral (see How to Complete a DDSA Referral for more details). Continue to step 3.
3	When a DDSA decision is received, follow the steps in Section 4 above.