Course: Eligibility Appeals Process Course Code: M&L c006 Version: 24/02/2018

Transcription

1 Course: Eligibility Appeals Process Course Code: M&L c006 Version: 24/02/2018

2 Before Getting Started Disclaimer The scenarios contained within this document and the data in the training environment are fictitious in nature and are intended for the purposes of training only. Steps are documented based on the scenarios Note, that not all page clusters and fields are documented within this guide. Only mandatory fields and fields that are important to the specific scenarios are included. Detailed text information is included in some fields as an example of the type of information that may be required in the production environment; however, in the interest of time, you only need to enter the first part of the information provided for the purposes of this learning session. Caution! To ensure the protection of sensitive data, participants must not enter any real client data into the DSCIS training environment at any time. Information Notes: Information notes are provided throughout the participant guide to highlight key points. Activities: A Hands on activities are key to successful learning. The participant guide has guided activities for each topic to help the participant learn. These activities are completed together with other learners in your training session. ACTIVITY TITLE Self-Study: Self-study activities are included at the end of the participant guide. Use these activities to practice what you have learned throughout the module. 1

3 Operational Business Process Context: Ineligibility Review Process The technical DSCIS functionality instructions included within this module relate to the adult developmental services business process where an individual is confirmed ineligible for Ministry-funded adult developmental services under SIPDDA, and where the individual requests a review of that decision (in accordance with the Application Entity Policy Directive 3.0: Review Process for Decisions on Eligibility). Where an individual is deemed ineligible by the DSO, the individual, and/or representative of their choice, has 25 business days from the date of the letter informing them of their ineligibility to provide the DSO with a written request for a review of that decision. Note: The DSO may exercise discretion in extending the timeframe in instances where an individual, and/or representative of their choice, is unable to submit the written request as required. The review process for decisions on eligibility includes 3 successive stages: Stage 1 The first stage of the review process is conducted by the DSO staff member who made the initial eligibility decision and the staff supervisor. The DSO staff member and supervisor will review the individual s documentation, and any additional information or supporting documentation provided by the individual, to confirm whether or not the individual meets the eligibility criteria in accordance with the Act and Regulation. If requested, the DSO and supervisor will meet with the individual and/or representative to discuss the individual s file and supporting document and to explain the eligibility criteria and how the criteria apply to their case. Within 15 business days, a new eligibility decision will be made and the individual and/or representative will be notified in writing of the outcome of the Stage 1 review. If the individual and/or representative disagrees with the outcome of their Stage 1 eligibility review decision, they then have 10 business days to provide a written request for a Stage 2 review. Stage 2 The second stage of the review process is conducted by the DSO Executive Director (or delegate). 2

4 The Executive Director will determine whether the Stage 1 review process was conducted appropriately, and will then review the individual s documentation, including any additional information or supporting documentation provided by the individual, to confirm whether or not the individual meets the eligibility criteria. Within 15 business days, a new eligibility decision will be made and the individual and/or representative of their choice will be notified in writing of the outcome of the Stage 2 review. If the individual and/or representative disagrees with the outcome of their Stage 2 eligibility review decision, they then have 10 business days to provide a written request for a Stage 3 review. Stage 3 The third stage of the review process is conducted by the Executive Director (or delegate) of an alternate DSO (with the selection of the other DSO to be determined by the individual, or if they have no preference, by the DSO). The DSO that made the initial decision of ineligibility and which completed the first two stages of the review process does not participate in Stage 3. The Executive Director of the alternate DSO will determine whether the Stage 2 review process was conducted appropriately, and will then review the individual s documentation, including any additional information or supporting documentation provided by the individual, to confirm whether or not the individual meets the eligibility criteria. Within 15 business days, a new eligibility decision will be made and the individual and/or representative of their choice will be notified in writing of the outcome of the Stage 3 review. The decision made from the Stage 3 review is final. An Issues Case is created in DSCIS when the DSO Agency deems the person as ineligible for Developmental Services and the individual has provided the information required to request a review of the decision. 3

5 Table of Contents Before Getting Started... 1 Disclaimer... 1 Steps are documented based on the scenarios... 1 Information Notes:... 1 Activities:... 1 Introduction... 5 Module Introduction... 6 Module Objectives... 6 Module Audience... 7 Communicating an Eligibility Decision:... 7 Topic 1: Create an Issues Case (Stage 1)... 9 Activity 1: Create an Issues Case Notes: Activity 2: Add a note to the Issues Case Activity 3: Add an attachment to the Issues Case Topic 2: Editing Details on an Issues Case Activity 1: Edit details on an existing Issues Case Topic 3: Adding a Resolution & Closing an Issues Case Activity 1: Adding a resolution to an Issues Case Activity 2: Submitting the Resolution for Approval Activity 3: Closing an Issues Case Activity 4: Changing the Closure details on an Issues Case Self Study Self-Study Activity 1: Add Resolution to Issues Case Self-Study Activity 2: Add a note to an Issues Case Self-Study Activity 3: Add a resolution to John FrinkXYZ Issue Case Release Notes

6 Introduction This training manual provides technical DSCIS functionality process steps. For more information regarding the ineligibility review process, refer to the Application Entity Policy Directive 3.0: Review Process for Decisions on Eligibility. DSCIS follows an applicant through the process of applying for and receiving developmental services and supports. There are five major business processes: initial contact determine eligibility perform assessment create outcome plan match and link individual to service DSCIS v6 features include a number of enhancements to further promote a clientcentric approach to service delivery in the DS sector. The enhancement of DSCIS builds on existing operational procedures connecting individuals to available resources and creating provincially consistent processes within the sector. For DSOs, an enhancement to DSCIS provides better data quality, more up-to-date information on individual service needs and available service resources. Assumption: it is assumed that the reader is familiar with the policy required to make decisions regarding eligibility requirements. Users should be logged in as a DSO Case Support user role to complete the tasks associated with this training module. DSCIS v6 training is broken down into 9 modules. Each module aligns with a specific task in the system. As such, not every staff will be required to take each module. 5

7 DSO Core Training: Code Module Name Code Module Name e-learning DSCIS 6.0 Look and Feel c004 Resource Management e-learning End-to-End DSCIS v6 c005 Case Maintenance c001 Intake & Eligibility c006 Eligibility Appeals Process c002 Individual Consolidated Evidence & PSL c007 Supervisor Workspace c003 Service Connections Module Introduction This module covers key concepts and functions related to creating and managing the Issues Case functionality within the upgraded Developmental Services Consolidated Information System (DSCIS). Module Objectives: This module covers steps associated with the appeals process when an individual (or their representative) requests a review of the ineligibility decision from the DSO. Not all steps and processes will be covered. Information may be pre-populated into the training environment to assist completing steps that require a system process not available in the training environment. initial contact determine eligibility perform assessment create Outcome Plan match and link individual to service Eligibility Appeals 6

8 After completing this module, you will be able to: Create an Issue Case Edit details Add / Approve / Edit the Resolution Close an Issue Case Module Audience: This module is intended for: 1. Intake Workers 2. Service Navigator 3. Other Communicating an Eligibility Decision: As part of the Intake and Eligibility process, the DSO shall advise the individual, or representative of their choice, in writing whether the individual is eligible for Ministryfunded adult developmental services and supports in accordance with the Act and Regulation, within 20 business days or receipt of all documentation, including receipt of any documentation review or the results of a (re)assessment by a psychologist or psychological associate required to confirm eligibility for developmental services and supports. Where an individual is deemed ineligible by the DSO, and they request a review of their eligibility decision, an Issues Case is created in DSCIS. The review process has three goals: 1. To encourage review and resolution of decisions on eligible at the local level; 2. To provide timely resolution of disputes; and 3. To provide a fair, unbiased and user-friendly review in process. At no stage of the review process is the accuracy or validity of the individual s clinical diagnosis to be assessed or evaluated by the Application Entity. If an individual, and/or representative of their choice, believes that the diagnosis provided by a psychologist or psychological associate does not accurately reflect their level of cognitive and adaptive functioning, they must seek resolution of this issue with the psychologist or psychological associate who completed the psychological assessment/psychological report. Alternatively, the individual or 7

9 person acting on their behalf may seek the second opinion of a psychologist or psychological associate registered with the College of Psychologists of Ontario and undergo additional diagnostic testing and/or assessment. Eligibility Review Process: DSOs use a three-stage approach to review a decision on eligible that is under dispute. Stage 1: Stage 2: Stage 3: Written request for review within 25 business days to DSO staff who made decision, with Stage 1 review decision to be made within 15 days. Written request for further review within 10 business days to Executive Director of the DSO, with Stage 2 review decision to be made within 15 days. Written request for final review within 10 business days to be completed by an Executive Director of an alternate DSO, with Stage 3 review decision to be made within 15 days. 8

10 Topic 1: Create an Issues Case (Stage 1) An Issues Case is created when the DSO Agency deems the person as ineligible for Developmental Services and the individual has provided the information required to appeal the decision. Stage 1: An individual requesting Ministry-funded adult developmental services and supports who is deemed ineligible in accordance with the Act may request a review of that decision. The individual, and/or representative of their choice, has 25 business days from the date of the letter informing them of their ineligibility to provide the DSO with a written request for a review of that decision. The DSO may exercise discretion in extending the timeframe in instances where an individual, and/or representative of their choice, is unable to submit the written request as required. Stage 1 of the review process will be conducted by the DSO staff member who made the initial eligibility decision, as well as the staff supervisor. The DSO must complete this stage within 15 business days. The DSO staff member and supervisor will review the individual s documentation, and any additional information or supporting documentation provided, to confirm whether or not the individual meets the eligibility criteria in accordance with the Act and Regulation. If requested, the DSO and supervisor will meet with the individual and/or representative to discuss the individual s file and supporting document and to explain the eligibility criteria and how the criteria apply to their case. Within 15 business days, a new eligibility decision will be made and the individual and/or representative will be notified in writing of the outcome of the Stage 1 review. If the individual and/or representative disagrees with the outcome of their Stage 1 eligibility decision review by the DSO staff and supervisor, or believes that they were treated unfairly in the process, the individual may request a Stage 2 review. If the individual and/or representative disagrees with the outcome of Stage 2 review, they may request a Stage 3 review. Stage 3 reviews are completed by the Executive Director (or delegate) and are the final stage of review. Creating an Issues Case in DSCIS allows the DSO and supervisor to track the process, record decisions and document information. 9

11 A Activity 1: Create an Issues Case Scenario: Rod FlandersXYZ has been deemed ineligible for Developmental Services and he wishes to appeal the decision. ISSUES CASE The Issues Case is located on the DSS (Integrated Case) in DSCIS v6. As such, an individual must have a DSS (Integrated Case) in order to create an Issues Case. Steps: 1. From the Clients and Cases tab, select to expand the shortcuts panel 2. Select the Search tab 3. Select Person The Person Search tab opens 4. In the First Name field, type Rod 5. In the Last Name field, type FlandersXYZ, where XYZ is your unique learner code 6. Select The Shortcuts panel can be collapsed at any time by clicking 7. Select the hyperlink associated with the Reference Number, known as the 300 number for your Rod FlandersXYZ to open the Person Page 10

12 8. From the Person Page, navigate to the Cases tab and select the DSS (Integrated Case), marked as Open The DSS Case opens in a new tab. 9. In the DSS Case, select the Issues tab 10. Select to create a new Issues Case A New Issue Case wizard opens. 11. Select Developmental Disability from the Evidence Type drop down menu 12. Confirm Eligibility Stage 1 is listed in the Issue Type drop down menu 13. Confirm Rod FlandersXYZ is listed in the Member drop down menu 14. Select to move to the Details tab 15. In the Details tab, type in today s date in the Start Date or access the and select today s date The date should reflect the date the appeal letter has been received. 16. Select the next Rod FlandersXYZ in the Select Evidence section 17. Select The Issues Case, labelled as ES 1 (R.FlandersXYZ) ### opens in a new tab. Outcome: You have successfully created an Issues Case This activity is now complete 11

13 Notes: Notes are an important part of case maintenance in DSCIS. Most notes will be maintained on the DSS (Integrated Case) except when no DSS (Integrated Case) exists. Notes related to an Issue Case must be documented in the DSS (Integrated Case and follow the provincially consistent process outlined in the M&L c005: Case Maintenance module. A ADDING A NOTE Activity 2: Add a note to the Issues Case Scenario: As part of case maintenance, a note is required to be added to the Issues Case. Let s add a note to Rod FlandersXYZ s DSS Case. Continuing from the DSS Case opened in Topic 1, Activity 1: Steps: 1. Navigate to the DSS Case for Rod Flanders 2. Navigate to the Communications tab 3. Select Notes from the side navigation panel 4. Select The New Note window opens 5. In the Subject text box, type Eligibility Stage 1 6. In the New Note area, add details regarding Rod s Issues Case 7. Select Outcome: You have successfully added a note to the Issues Case This activity is now complete 12

14 A ADDING AN ATTACHMENT Activity 3: Add an attachment to the Issues Case Scenario: To support the appeals process an attachment can be added to the Issues Case. Let s add an attachment to Rod FlandersXYZ s Issues Case. Navigating back to the open Issues Case, labelled as ES 1 (R.FlandersXYZ) ### in Topic 1, Activity 1. Steps: 1. Navigate to the Communications tab 2. Select Attachments from the side navigation panel 3. Select The New Attachment window opens 4. Choose an appropriate file by selecting the Choose File icon 5. Add appropriate details in the Files Detail section 6. Add a description in the Attachment Description box 7. Select Additional documents can be added to the file by selecting the DSS Case, as required or in Outcome: You have successfully added an attachment to Rod FlandersXYZ Issues Case This activity is now complete 13

15 Topic 2: Editing Details on an Issues Case The details, such as the start / end date, priority or comments can be edited after the Issues Case has been saved. In this topic we will explore the steps required to edit details on an Issues Case A Activity 1: Edit details on an existing Issues Case Scenario: Nelson Muntz XYZ has incorrect information in the Issues Case and it needs to be corrected. Let s edit the information. EDIT AN ISSUES CASE Search for and open the Issues Case, labelled as ES 2 (N.MuntzXYZ) ###: Steps: 1. Select the button and choose Edit from the menu The Edit Issue window opens 2. In the Start Date field, change the date to be yesterday by typing the date in DD/MM/YYYY format or selecting the date using the icon 3. A comment can be added in the Comments box 4. Select Outcome: You have successfully edited the Start Date in Nelson MuntzXYZ Issues Case This activity is now complete 14

16 Topic 3: Adding a Resolution & Closing an Issues Case At each stage of an Issues Case, the DSO must render a decision and notify the individual and/or representative of their choice, in writing of the decision within 15 business days. The individual and/or representative of their choice have the ability to request a further, subsequent review of the decision three times, in accordance with the three stages of the ineligibility review process. The decision of the Stage 3 review is considered final. The use of the DSCIS functionality remains the same throughout each of the stages. The outcome decision of each stage of the eligibility review process is tracked in DSCIS as a resolution within the Issues Case. A ADDING A RESOLUTION Activity 1: Adding a resolution to an Issues Case Scenario: The decision to uphold Rod FlandersXYZ determination of ineligible has been made and needs to be added to the Issues Case. Let s record the decision in DSCIS. Navigate back to Rod FlandersXYZ from open Issues Case, labelled as ES 1 (R. FlandersXYZ) ### created in Topic 1: Steps: 1. From the Home tab in the Issues Case, select the List Action Icon 2. Select Add Resolution The Add Resolution window opens. 3. Select Decision Upheld from the Resolution drop down menu 4. Select Outcome: You have successfully added a Resolution to Rod FlandersXYZ Issues Case This activity is now complete 15

17 An Issues Case resolution does not require supervisor approval; however it must be submitted for approval in DSCIS. DSCIS will change the Resolution status to Approved once it has been submitted. The Issues Case will automatically close after a set period of time. A Activity 2: Submitting the Resolution for Approval. Scenario: DSCIS requires the Issues Case to be submitted for approval. Let s submit the resolution for approval using Rod FlandersXYZ case. ADDING A RESOLUTION Continuing from open Issues Case, labelled as ES 1 (R. FlandersXYZ) ### in Topic 3, Activity 1: Steps: 1. From the Home tab in the Issues Case, select the List Action Icon 2. Select Submit Resolution for Approval The Submit Resolution for Approval window opens 3. Add a comment, if necessary 4. Select The Resolution status will show as Approved on the Issues Case home tab. Outcome: You have successfully submitted the Resolution for Approval for Rod FlandersXYZ Issues Case This activity is now complete 16

18 DSOs have the flexibility to determine whether or not they will close Issues Cases in DSCIS. Activity 3 outlines the steps for closing an Issues Case. Please refer to your local business practice to confirm if this is a required step in your DSO. A Activity 3 Closing an Issues Case. Scenario: The Resolution has been added to Nelson MuntzXYZ case and the Issues Case can now be closed. CLOSING AN ISSUES CASE Continuing from open Issues Case, labelled as ES 2 (N. MuntzXYZ) ### in Topic 2, Activity 1: Steps: 1. From the Home tab in the Issues Case, select the List Action Icon 2. Select Close The Close Case window opens 3. Select the reason Application Withdrawn from the Reason drop down menu 4. Select 5. A comment can be added if required The Issues Case is now closed Outcome: You have successfully closed the Issues Case for Rod FlandersXYZ This activity is now complete 17

19 A Activity 4 Changing the Closure details on an Issues Case. Scenario: The closure reason was recorded incorrectly for Nelson MuntzXYZ Issues Case. Let s change the Closure Reason. CHANGE THE CLOSURE REASON Continuing from open Issues Case, labelled as ES 2 (N. MuntzXYZ) ### in Topic 3, Activity 2: Steps: 1. From the Home tab in the Issues Case, select the List Action Icon 2. Select Change Closure Details The Change Closure Details window opens 3. Select an alternative reason from the Reason drop down menu 4. Select 5. A new comment can be added if required The closure details have been changed. Outcome: You have successfully changed the closure reason for the Rod FlandersXYZ s Issues Case This activity is now complete 18

20 Self Study Use this section of the participant guide to practice what you have learned throughout this module. You can refer to the sections above to assist with the steps, if required. Self-Study Activity 1: Add Resolution to Issues Case Scenario: Elizabeth HooverXYZ has requested a review of the ineligibility decision from Stage 1 and Stage 2. Add a decision to her Stage 3 Issues Case HINT: 1. You can search for Elizabeth HooverXYZ from the Quick Links on the Home Page 2. The Issues Case resides on the DSS (Integrated Case) 3. Adding a Resolution to an Issues Case is completed through the List Action Menu Self-Study Activity 2: Add a note to a DSS Case Scenario: Add a note to Elizabeth HooverXYZ s DSS Case HINT: 1. Notes are located on the Communications tab within the DSS Case Self-Study Activity 3: Add a resolution to John FrinkXYZ Issue Case Scenario: John FrinkXYZ has submitted a request for review of their ineligibility decision to the DSO. Add a resolution to his Issues Case HINT: 1. Search for John FrinkXYZ using the Quick Links from the Home Page or by accessing the Shortcuts Menu 2. The Issues Case can be found on the DSS (Integrated Case) tab 3. Add a resolution by using the List Action Menu 19

21 Release Notes Version 05/12/2016 SUG Training DRAFT Version 17/01/2017 Edited version Version 18/01/2017 Edited to add close case reason Version 19/01/2017 Changed activity for Add Resolution to use Rod FlandersXYZ Removed DRAFT watermark in advance of training Version 20/01/2017 Sent to print Version 27/01/2017 Added comment re: date in Topic 1, Activity 1 Changed location of adding notes based on IMSC decision January 13 Version 24/02/2018 Minor edits for DSCIS 6.1 release 20