Procedures for Urgent Case Requests

The EW must follow these procedures when an urgent case request is received:

  1. EW:
    1. Has applicant or his/her authorized representative complete the application and DDSD packet.
    2. Screens case for presumptive disability criteria and clears all other aspects of eligibility, including property and income.
    3. Asks doctor/medical facility for faxed medical reports to verify the severity of medical condition (i.e., hospital admission, outpatient progress reports, X-ray reports, pathology reports, laboratory studies, etc.).
    4. Enters in Item 10 of the MC 221:
      1. “Urgent Case Request - Please Evaluate for Presumptive Disability”, and “Attention: Operations Support Supervisor”.
      2. Note: “PD approved” box in Item 10 of the MC 221 must NOT be checked.
    5. Enters EW’s Fax number in Item 11 of the MC 221.
    6. Gives the completed packet (full packet) to appointed District Office DDSD screener to review for completeness.
  2. District Office DDSD Liaison:    
    1. Sends the urgent case DDSD packet to the Medi-Cal Program Coordinator.
  3. EW:
    1. Mails the original DDSD packet, including the medical reports to the DDSD office in Los Angeles.
  4. MC Coordinator:
    1. Faxes the DDSD packet and medical reports to the DDSD office.
    2. Phones  DDSD to tell them an Urgent Case Request was faxed.
  5. DDSD:    
    1. Requests additional information (if necessary) from medical source by fax or phone.
    2. Reviews case to ensure the applicant/recipient has not been previously denied by Social Security.
    3. Evaluates the case to determine if disability can be approved presumptively. Notifies the Medi-Cal Program Coordinator of the PD decision within 2 working days and will continue to process the case quickly to make a formal decision. If PD was approved and disability is not established when a formal decision is made, DDSD will indicate on the decision “Previous PD decision not supported by additional evidence.”
  6. MC Coordinator:    
    1. Immediately passes on information to appointed DDSD Liaison at the District Office.

Note: EW must not delay sending a DDSD packet if medical reports have not been received. Medical reports can be faxed to DDSD later with an MC 222 LA as soon as they are received. Indicate in Item 10 of MC 222 LA “Urgent Case Request. Medical reports attached. Packet sent on (date).”

Examples of Situations Requiring Urgent Case Request

Example 1Example 1A client suffered massive head and internal injuries, is comatose, and needs an immediate Medi-Cal decision for transfer to a facility which specializes in head trauma. While the client is expected to survive, he/she is expected to be dependent on a wheelchair for the rest of his/her life.    

Example 2 Example 2 A client has lung cancer which has spread to the spine and vital organs. The doctor states he/she is expected to live 6 to 12 months, even with treatment, and needs aggressive therapy immediately.   

Example 3 Example 3 Client has irreversible kidney failure caused by uncontrolled high blood pressure and is now on renal dialysis. Hospital records and the doctor’s outpatient notes include lab studies which confirm that the kidney function has decreased over the past year and dialysis is required for the client to survive. An immediate MC decision is necessary to transfer the client to an outpatient renal dialysis clinic.   

Example 4 Example 4 A client has severe diabetes. The doctor states a below the knee amputation must be performed because of gangrene caused by poor circulation of both legs. The doctor sends reports from earlier hospitalizations, lab studies, progress notes, and a letter specifying the immediate need for a disability decision so that the client can be hospitalized for surgery.   

Follow-Up/Expediting Decisions

Even though eligibility has been granted, a full DDSD referral must be completed when an applicant is presumptively determined to be disabled.

Whenever immediate medical care is indicated:

  • Note that the case needs to be expedited on the MC 221 in the Comments Section.
  • Submit medical records with the DDSD packet if they are available. Do not hold up the referral pending receipt of medical records.

Verification Requirement

The applicant/recipient must provide the EW with a medical statement from his/her physician verifying one of the Presumptive Disability Conditions. The medical statement must be:

  • Signed and dated by a doctor and include his/her title, and
  • Included with the DDSD packet.

Note: If there is a delay in obtaining verification from the applicant or medical source and the EW cannot grant PD, do not hold the DDSD referral packet. The EW must forward the referral packet to DDSD, as DDSD can also grant PD.

Blindness and Disability Determination

When Required

  • Prior to approval.
  • Whenever there is a change.
  • Disability must be re-verified at each annual RD.

Documentation Required

Acceptable verification includes:

  • Proof of Social Security (Title II) benefits based on disability or blindness
  • Proof of Supplemental Security Income/State Supplemental Payment (SSI/SSP) benefits based on disability or blindness.
  • Proof of Railroad Retirement Benefits (RRB)

Receipt of one of the above types of disability benefits can be adopted for a MC disability determination and a referral to State Programs-Disability Determination Service Division (SP-DDSD) is not needed. However, if the applicant is not in receipt of one of the above disability benefits, then a disability packet must be completed and sent to SP-DDSD for a disability determination.

Presumptive disability (PD) may be established by obtaining a letter from a physician verifying that one of the PD conditions exist.

By following procedures established by DDSD. A full DDSD packet must be sent to Los Angeles no later than 10 days after receipt of the completed MC 223, except when the delay is due to circumstances beyond control of the County. If medical records are available, they may be submitted with the packet. However, in no case should submission of the packet be delayed to obtain those records.

Presumptive Disability (PD) Checklist

Use the Presumptive Disability (PD) checklist below to help ensure accurate PD determinations and referrals.

  • Does the client’s impairment exactly match an impairment on the PD condition list? If so, does the MC 221 - Item 10 have the following information:
    • “PD approved” box checked, and
    • The specific medical condition used to grant PD.
  • Has there been a prior SSA/SSI denial within the past 12 months? If yes, PD can only be approved if the client alleges a new medical condition that exactly matches a PD condition which SSA did not previously consider.
  • Is there a signed and dated verification of the disability/impairment from the applicant’s physician/medical source? Is a copy included with the DDSD packet?
  • Is the client otherwise eligible for MC? If no, a disability referral is not necessary since other MC requirements are not met.
  • Is the client performing SGA? If yes, PD cannot be granted and a disability referral is not appropriate.
  • Submit the DDSD packet immediately. Do not delay sending the packet if medical verification is lacking or delayed. DDSD can initiate a PD determination if the medical evidence supports it.
  • Is the PD effective date the month in which the MC 221 is completed and the medical verification obtained?
    • The EW must never grant PD for any past month.
    • Do not grant PD from the month of application, unless the required MC verification and the MC 221 are completed in the month of application.

Related Topics

MAGI MC and DDSD

DDSD - Presumptive Disability (PD)