BASIC (04-08)

DI 81030.125 Retrieving Certified Electronic Folders (CEF) from the Medical Consultant (MC) Staff

A. Background

When the quality reviewer completes the form SSA-448, (Request for Medical Advice), chooses one or more internal MC staff locations and selects the “Refer” button, an internal movement posts to the first referral location. Work Unit (WU) status changes to MC staff referral. This action makes the case available to the MC staff users. Occasionally, after a case is referred to the MC staff, it is determined that:

  • The case was sent to the MC staff prematurely or erroneously, or

  • Case facts have changed which make MC staff review unnecessary, or

  • MC staff completed its review but failed to clear its action, or

  • MC staff review resulted in a fully favorable determination, but the case was referred to a subsequent MC staff user.

When any of the previous situations occur, only the MC staff user can take appropriate action to clear the case referral from the MC staff.

B. Policy

When DQB needs a case cleared from MC staff referral, the DQB user works with an MC staff user to clear the referral. Refer to DI 81030.125D. for the procedure to clear a case referral from the MC staff.

C. Procedure – Determining Case Status

To determine the case status:

  • Select “Reports” on the Disability Case Adjudication and Review System (DICARS) menu bar and select “Query,” or select “Query” on the toolbar. The DICARS “Query” screen appears.

  • Key in the social security number (SSN).

  • Select the “Ref Status” button.

  • The “MCS (Medical Consultant System) Coding Status” screen appears. The MC staff coding status indicates each referral made by a specific 448 and the action taken by the MC staff. MC staff coding status codes are:

    - Pending

    - In Review

    - Cleared

    NOTE: All MC staff referrals in the case must be “Cleared” before a DQB user can take an action on a case.

Or

  • Select “Reports” on the menu bar, highlight “MCS Reports,” then select “Browse MCS Assignments,” or select “View MCS” on the tool bar.

  • This option produces a read-only version of the “MCS All Referrals” pick list, which shows all referrals for the applicable case and the status code of each referral. Status codes are:

    - Available (the equivalent of “Pending” referral status)

    - In Review

    - Cleared

D. Procedure - DQB User Action

When the DQB user determines that a case must be cleared from the MC staff, the DQB user first determines the MC staff status (refer to DI 81030.125C.) and takes the appropriate following action.

1. If the Referral is in Review Status and the MC Staff User is Available

Request that the MC staff user

  • Take the applicable action to clear the referral from the MC staff.

  • Clear any additional available/pending referrals on the case, if there are any such referrals.

2. If the Referral is in Review Status and the MC Staff User is not Available

  • Remove the referral from the MC staff user's My Pick List and move it to the MC staff user's All Referrals (refer to DI 81030.125E.).

    NOTE: This action requires the user to have the security profile item “Manage MCS Referrals,” which is available in both the DQB and the MC staff user profiles. The DQB Director decides who is assigned the appropriate security profile in each DQB.

  • Request an MC staff user to add the referral to his/her pick list (My Pick List) and take the applicable action to clear the referral from the MC staff.

  • Request the MC staff user to clear any additional available/pending referrals on the case, if there are any such referrals.

3. If the Referral(s) is in Available/pending Status or Available/pending and Cleared Status

  • Request an MC staff user to add the available/pending referral to his/her pick list (My Pick List) and take the appropriate action to clear the referral from the MC staff.

  • Request the MC staff user to clear any additional available/pending referrals on the case, if there are any such referrals.

E.</