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VII. Requests for Re-Determination

In situations where the Primary Service Provider initiates the re-determination process, it will notify the EEU of consumers/clients enrolled in the DSAMH LTC system who are judged to no longer need long term behavioral health services due to improvement in their behavioral health status and their success in recovery. The primary service provider must submit a Request for Re-Determination and notify the consumer of this request; the Request for Re-Determination will include a certification that the consumer has been notified and wants to return to the basic benefit. The Request for Re- Determination will also describe why the client no longer needs LTC, as well as a summary of treatment plans (including recommendations for current treatment) and a description of the client’s ongoing self-care and relapse prevention plan. When the EEU receives this request, it will notify the enrollee of their right to dispute this recommendation and provide them with the procedures for doing so. If the consumer disputes the provider’s recommendation, the EEU will take this into consideration during its review. When the consumer is requesting a re-determination, the DSAMH Office of Consumer Affairs will assist the consumer in submitting the Consumer Request for Re-Determination.

The EEU will review the Request for Re-Determination and make a determination within five (5) working days as to whether the consumer will be disenrolled from the LTC System. The EEU will notify the Primary Service Provider and the consumer of the results of this determination within two (2) working days of the review’s completion. When the provider has requested disenrollment and the EEU determines that the consumer should continue to be enrolled, this decision is made with the concurrence of the EEU physician. The EEU will send the Eligibility Determination Summary to the Primary Service Provider.