Long Term Care (LTC): How to Deny LTC Medical and Section K LTC Authorizations

The Appendix U, Reasons for Negative Benefit Actions, Section IV, list the codes that can be used for denials for the LTC medical benefit and Section K LTC authorizations. As with every program, there are codes for the denial that are proper for us to use, and those we do not want to use.

Refer to article IMS: IMS Codes for LTC Authorization Actions or to the table shown here for codes that are proper to use for denial actions. On denials and closures, the worker enters the Action type (K12), Reason (K16), and the Ending Date (K47) fields in the Auth. LT Care tab. Choose the appropriate reason from the table shown here. Codes 11 through 16 are only used for Advantage Waiver.

All 69 closure/denial actions require a hand generated ABCDM-37-C-Notice to Client Regarding Long Term Care Medical Care.

CODE REASON Computer-generated message
1 – Death of Client No-computer-generated message

 

2 – Client’s request You have withdrawn your request for Personal Care, Advantage Waiver, Nursing Home, or Assisted Living.

 

3 – Change in level of care A change in level of care.

 

4 – Change in providers A change in providers.

 

6 – Change in case number A change in the OKDHS case number for authorization.

 

7 – Ineligible Provider The provider is no longer eligible.

 

10 – Financial eligibility not met You do not meet the financial eligibility for Personal Care, Advantage Waiver, Nursing Home, or Assisted Living.

 

21 – Transfer of resources Due to transfer of resources you are ineligible for nursing home level of care.
22 – Moved out of state You moved out of state.

 

23 – Unable to locate We have been unable to locate you.

 

44 – Failed or refused to cooperate in determining eligibility You failed or refused to help OKDHS determine your eligibility to receive benefits. This could include failing to complete an interview, answer questions, or not signing the application or review as requested. Rules regarding this action can be found at OAC ___.

 

45 – Failed or refused to provide necessary verification within the time allowance. OKDHS asked you to provide documents to prove you are eligible to receive benefits and you did not provide one or more of the required documents. Rules regarding this action can be found at OAC___.

 

49 – Entered nursing facility (for closure only) You entered a nursing care facility.

 

69 – Other No notice generated. An ABCDM-37-C must be sent to client for reason 69.

The table shown here lists the codes that are improper to use. These codes should NOT be utilized by AFS LTC staff.

Code Reason Computer-generated message

 

9 – Non-cooperation You have not cooperated in the delivery of services.

 

11 – Not in targeted group for the Advantage Waiver (AW) You are not in a targeted group for the Advantage Waiver

 

14 – Cost of services exceed allowable capitalization The cost of services exceeds the allowable capitalization.

 

15 – No open Advantage Waiver slot. There is no open Advantage Waiver slot.

 

16 – Needs cannot be met through AW You needs cannot be met through Advantage Waiver services.

 

17 – Harm to self or others Harm to self or others.

 

18  – Another person threatens harm to others A household member or frequent guest threatens harm to others.

 

20 – Medical eligibility not met You do not meet the medical eligibility for Personal Care, Advantage Waiver, Nursing Home, or Assisted Living.

 

Example 1:

Michael applied for ADV/SPPC on 6/9/2022 and telephone interview completed on the following day. An ADM-92 was provided to Michael 6/10/2022 requesting life insurance policy and cash value, 5 years bank statements, and 2021 1099 for minerals. No verification submitted within 10 days.

Deny Medical on reason 45-Failure to provide verification within time allowed.

Deny ADV and SPPC authorizations on reason 45-failure to provide verification within time allowed.

Example 2:

Robert has applied for ADV/SSPC on 8/2/22. He does not categorically relate and has not applied for Social Security Disability. During the interview, Robert states that he is unwilling to apply for disability benefits.

Deny Medical on reason 18A – Incapacity, disability, or blindness not determined based on client’s statement.

Deny ADV and SPPC on reason 69-Other. Mail hand generated ABCDM-37-C notice for denial reason – Does not meet categorical relationship. Do not deny on reason on reason 18 as this is a medical denial code – A household member or frequent guest threatens harm to others.

Example 3:

Angie applied for ADV/SPPC 08/2/22. Angie does not categorically relate. SDX indicates SSI application 4/16/22 was denied on reason 32-Nonpay-capacity for substantial gainful activity. She has appealed the denial 3/23/33.

Deny Medical on reason-18-Incapacity, disability, or blindness not established based on SSA level of care determination/LOCEU.

Deny ADV and SPPC on reason on 69-Other. Mail hand generated ABCDM-37-C notice for denial reason – Does not meet categorical relationship.

Denial A SPPC 4.

Example 4:

Ruth is a single applicant who has applied for ADV/SPPC 6/15/22. She has $15,000 in her checking account and a whole life policy with a cash value of $5,000.

Deny Medical on reason 15-Exceeds resource standard.

Deny ADV/SPPC authorization on reason 10-Financial eligibility not met. Do not deny on medical denial code 15 – there is no open Advantage Waiver slot.

 

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