Medicaid Policy                                                                 

113-1 Restricted Medical Information

No Previous Policy

 

At times, when a provider completes a medical report for an applicant or recipient, the provider may not want the person to view the report.  Because applicants and recipients are entitled by law to view information used to determine their eligibility, use the following procedures when an applicant or recipient requests to see medical reports contained in the case record.

 

Determine if the Medical Report is Restricted.

1. If the report specifies not to show it to the applicant or recipient, go to item 2, below.

   1. If a report is marked "Confidential," it may not necessarily mean the provider does not want the applicant or recipient to see it.  Ask the provider if the report may be shown to the applicant or recipient and document the provider's response.  If the provider says it may be shown to the person, it is not restricted.  If the provider states that it cannot be shown to the member, go to item 2, below.

   2. If the medical report does not state the provider wants to restrict it from the applicant's or recipient's view and it is not marked "Confidential," but it seems to contain information that could have an adverse impact on the person, follow the procedures below to determine if the information can be released directly to the applicant or recipient.

(1)  Call the provider who completed the report to determine if the information can be released directly to the applicant or recipient.  Document the provider's response.  If the provider states it can be released directly, the report is not restricted.  If the provider states that it cannot be released directly, go to item 2, below.

OR

(2)  Have an eligibility supervisor review the report and determine if the information can be released directly to the applicant or recipient.  The supervisor may choose to discuss the report with the Disability Review Coordinator at the Dept. of Health.  If the supervisor states it can be released directly, the report is not restricted.  If it cannot be released directly, follow the procedure under item 2 to designate an authorized representative.

2. Designate an Authorized Representative.

When the provider indicates the report is not to be shown to the applicant or recipient, discuss with the provider that applicants and recipients must have access to medical records used to determine their eligibility.  If the provider feels the information may have an adverse impact on the person, tell the provider that we can ask the person to designate an authorized representative to receive the information.

A.   If the provider refuses to allow the information to be released to an authorized representative, go to item 3, below.

B.   If the provider agrees that the information may be released to an authorized representative, ask the applicant or recipient to designate one.  The designation must be done in writing.  Because medical reports may be technical, the applicant or recipient may want to chose a physician, social worker, or other professional to receive the information.

(1)  Before releasing medical records to an authorized representative, send a notice to the representative explaining the release and responsibility a representative assumes.

(2)  After the medical records are released to the authorized representative, send a notice to the applicant or recipient stating the records were sent to the representative.

If the applicant or recipient refuses to designate an authorized representative, ask the provider if the report can be redone so the information may be released directly to the applicant or recipient.  If the report cannot be redone, explain to the applicant or recipient that eligibility cannot be determined without the use of the medical information, and that unless the person has access to the information through an authorized representative, we cannot use the information.  If the person still refuses to designate a representative, deny or close the case for failure to provide information.

3. Redo the Report.

If the provider refuses to allow the release of medical information to an authorized representative, ask the provider if the report can be redone so that it could be released to the applicant or recipient, or the person's representative.  If the report cannot be redone, go to item 4, below.

4. Effect of Not Being Able to Use the Medical Report.

If the report cannot be redone AND an authorized representative cannot receive the information, do not use the information for eligibility determinations.  Unless the person can obtain a medical report from another provider, this may result in the case being denied or closed for failure to provide information.