Table of Contents

Section 10 / Part 1

Effective Date: January 24, 2006

Disability Determination Services

Disability Determination Services (DDS) requires extensive medical information in order to process claims for Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) in accordance with federal rules and regulations. Therefore, the service specifications and rates listed in this section apply exclusively to DDS and are not available for other Rehabilitation Services

programs.

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Medical and Hospital Records

DDS requires extensive medical records including the patient's history as well as current

information

¡ DS pays the following fees for copies of existing medical records from doctors, hospitals and other acceptable medical sources: $16.29 plus 54 cents per page, up to a maximum

of $37.

¡ DDS also requests reports summarizing existing medical evidence of record (MER). DDS pays $15 for brief MER reports and $25 for comprehensive MER reports.

Government agencies such as state hospitals or the Veterans Administration provide records without charge. Schools provide records without charge except those records deemed to be medical evidence by Social Security standards. Medical evidence provided by schools may be paid at the rates listed above for medical records.

DDS will also pay search fee for medical records of $1 per quarter hour (or portion thereof).

DDS does not pay for records in advance of receipt of the requested records.

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Mileage

Claimant, medical provider, vendor and any other service provider (such as sign language interpreter) travel must be pre-authorized by DDS. Travel is to be paid at the mileage rate for vendors established by Rehabilitation Services, which is currently no more than 25 cents per

mile.

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Interpreter Services

DDS will pay for foreign language interpreting services and sign language interpreting services when needed as a reasonable accommodation to allow claimants to participate in medical exams and the DDS process.

¡ In accordance with Rehabilitation Services policy, fees for foreign language interpretation are paid at the usual and customary local rate.

¡ In accordance with Rehabilitation Services policy, fees for sign language interpretation are based on the certification level of the interpreter. The current fee schedule is: $20 an

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hour for Level I, II or III certification; $25 an hour for Level IV certification; and $30 an hour for Level V certification.

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Office of Hearings and Appeals (OHA)

DDS will pay medical providers up to $55 an hour for a review of medical records for OHA cases. This is available exclusively for OHA cases.

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Medical Services

Because of the comprehensive medical information required for the disability claims process, DDS has established the following fee schedule. This fee schedule is authorized only for use by DDS and may not be used by other units of Rehabilitation Services or the Department of Social and Rehabilitation Services.

1. Disability Determination Consultative Examination (DDCE)

¡ Payment up to a maximum of $85.

¡ This examination includes a review of a comprehensive medical history and physical

examination with decision making of exceptional complexity. Specifically this includes:

- Documentation of the claimant's major or chief alleged impairments.

- A detailed description, within the area of specialty, of history of impairments.

- Description, and disposition, of pertinent “positive” and “negative” detailed findings based on history, examination, and laboratory tests and any other abnormalities or lack thereof reported or found during examination or tests.

- Diagnosis and prognosis for the claimant's impairments.

- Statements about what the claimant can still do despite his/her impairment.

- Consulting opinion about the claimant's ability, despite impairment to do work-related activities such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling.

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6. Goldman Evaluation (GOLDM)

¡ Payment up to a maximum of $100.

¡ The Comprehensive Report(DDCR) fee is not available for this evaluation service.

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Psychological Services

1. Disability Determinations Consultative Examination - Psychological (DDCE-P)

¡ Payment up to a maximum of $70.

¡ The DDCE-P exam includes a comprehensive history and psychological examination with

decision making of exceptional (legally defensible) complexity. Specifically this includes documentation of:

- The claimant's major or chief alleged impairments.

- A detailed description, within the area of specialty, of history of impairments.

- Description, and disposition, of pertinent “positive” and “negative” detailed findings based on history, examination, and laboratory tests and any other abnormalities or lack thereof reported or found during examination or tests.

- Diagnosis and prognosis for the claimant's impairments.

- Statements about what the claimant can still do despite his/her impairment.

- Consulting opinion about the claimant's ability, despite impairment to do work-related activities such as the claimant's ability to understand, to carry out and remember instructions and to respond appropriately to supervision, coworkers, and work pressures in a work setting.

¡ See Comprehensive Report (DDCR) description for report requirements.

¡ Examinations may be provided by any contracting medically acceptable source as defined

by the Social Security Administration.

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Psychological Testing

The most current version of psychological testing instruments must be used. The Comprehensive Report (DDCR) fee is not available for these psychological testing services.

1. Intelligence testing - up to a maximum of 2.5 hours @ $52.50 per hour

¡ This includes the Weschler Adult Intelligence Scale and the Stanford-Binet. Intellectual testing should be ordered only if there is a reason to suspect an intellectual deficit or

learning disability.

2. Standardized Achievement Testing - up to a maximum of 2.5 hours @ $52.50 per hour.

¡ In cases where a learning disability is suspected, the Woodcock-Johnson Achievement
Battery may be ordered. When achievement deficits are believed to result from academic underachievement or lack of education, the Wide Range Achievement Test may be sufficient (maximum of 1 hour).

3. Personality Assessment - up to a maximum of 2 hours @ $52.50 per hour.

¡ In situations where there is reason to suspect that a psychiatric impairment will interfere with work function or completion of a training or academic program, personality

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assessment such as the MMPI and/or projective testing such as the Rorschach or TAT may be appropriate, particularly if there is a minimum of existing information.

4. Neuropsychological assessment - up to a maximum of 8 hours

(code M0601 or 90830).

¡ Neuropsychological evaluation (such as the Halstead Reitan and Luria Nebraska) should be done very sparingly but may be appropriate in complex cases of head injury or learning disability. The District or State Psychological Consultant must approve referrals for a complete neuropsychological battery. The hourly rate is procedure code M0601 or 90830. This is not a specialist exam.

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Comprehensive Report

1. Disability Determination Comprehensive Report (DDCR)

¡ Payment up to a maximum of $40 for reports generated by the medical provider.

Payment up to a maximum of $25 for reports generated with the DDS telerecorder

system.

¡ DDS requires timely, comprehensive reports to be submitted in accordance with the medical and psychological examinations. The report fee is available only in conjunction with exams, not in conjunction with psychological testing, speech/language evaluation, ancillary or laboratory testing or studies. The DDCR fee may be paid in addition to the examination fees.

2. DDCR requirements for medical exams

¡ A comprehensive report is to be provided in a timely manner after the examination, to

include:

- Discussion of pertinent history with source of history and an estimate of the

reliability of the history.

- History of present illness, including reason for not working when appropriate for

adults.

- Factors which increase problems/impairments.

- Factors which may provide relief.

- Claimant's (or child's) description of how the impairment limits the ability to

function.

- When appropriate for a child's exam, documentation related to growth and development history, developmental milestones including speech and language, and school performance.

¡ Information must be in narrative rather than questionnaire or check-off form. Current medication should be listed by name of drug and dose. Social history and family history if pertinent shall be documented. Review of systems should describe other impairments and symptoms the claimant has experienced relative to specific organ systems. Pertinent negative findings, which would be considered in making a differential diagnosis of the current illness or in evaluating the severity of the impairments, shall be documented. The report should also include:

- Blood pressure.

- Pulse rate.

- Respiratory rate.

- Height/weight without shoes.

- Head circumference if the child is under age 3.

- Tanner stage as appropriate.

- Description of claimant's general appearance and pertinent behavior during the

examination.

- Any other pertinent information specific to the specialty of the provider.

3. DDCR requirements for psychological exams

¡ A comprehensive report is to be provided in a timely manner after the examination, to

include:

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- Discussion of pertinent history with source of history and an estimate of the

reliability of the history.

- History of present illness including reason for not working.

- Factors which increase problems/impairments.

- Factors which may provide relief.

- Claimant's description of how the impairment limits the ability to function.

¡ Information must be in narrative rather than questionnaire or check-off form. Current medication should be listed by name of drug and dose. Social history and family history if pertinent shall be documented. Pertinent negative findings, which would be considered in making a differential diagnosis of the current illness or in evaluating the severity of the impairments, shall be documented.

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Ancillary/Laboratory Studies

Unless otherwise specified, ancillary/laboratory studies shall be purchased using the Medicaid

fee schedule.

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Negotiates Fees

With the approval of the RS Director, the DDS Director has the authority to negotiate fees with hospitals, volume providers and providers in critically underserved areas in order to provide timely service. The prudent person concept will be used with maximum fees not to exceed usual and customary rates or rates allowed by the Social Security Administration.

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