WAC 388-448-0035 How we assign severity ratings to your incapacity
"Severity rating" means a rating of the extent of your incapacity, and how severely it impacts your ability to perform the basic work activities. Severity ratings are assigned in Steps II through IV of the PEP. The following chart provides a description of levels of limitations on work activities and the severity ratings that would be assigned to each.
Effect on work activities
Severity rating
There is no effect on your performance of basic work-related activities.
1
There is no significant effect on your performance of basic work-related activities.
2
There are significant limits on your performance of at least one basic work-related activity.
3
There are very significant limits on your performance of at least one basic work-related activity.
4
You are unable to perform at least one basic work-related activity.
5
We use the severity rating given by the medical evidence provider:
If the rating is supported by and consistent with the medical evidence;
If the provider’s assessment of your limitations is consistent with our definition of the rating; and
If the rating is consistent with other medical evidence provided to us.
If the medical evidence provider assigns a severity rating that is not consistent with the objective evidence and your symptoms from your impairment as described in the medical evidence, we take the following action:
If your limitations are more severe than the rating given, we raise your severity rating; or
If your limitations are less severe than the rating given, we lower your severity rating; and
We give clear and convincing reasons for adjusting the rating.
Use the following conversion scale to convert the degree of impairment to a numerical value for use in the PEP.
Degree of Impairment
Numerical Value
None
1
Mild
2
Moderate
3
Marked
4
Severe
5
When the provider does not give a severity rating:
Contact the provider and ask them to assign a severity rating or explain why they chose not to assign one;
When the provider chooses not to assign a severity rating, review the medical evidence. Use reference sources, facts present in the medical evidence, and your professional judgment to assign a severity rating that is consistent with the objective medical evidence and severity definitions in WAC 388-448-0035; and/or
Refer the case to a Medical Consultant for assistance with interpreting the medical information.
When the severity rating given by the provider is supported by the objective findings, accept the rating.
You may adjust the provider's ratings if you have clear and convincing reasons why the rating should be adjusted (e.g. rating is not consistent with the objective medical evidence). If the adjusted rating results in the person having only one impairment with a severity rating less than three, deny incapacity at Step 1 (see below).
WAC 388-448-0040
WAC 388-448-0040
Effective September 1, 2000
WAC 388-448-0040 PEP Step I - Review of medical evidence required for eligibility determination
When we receive your medical evidence, we review it to see if it is complete and to decide whether your circumstances match GAU program requirements.
We require a written medical report to determine incapacity. The report must:
Contain sufficient information as described under WAC 388-448-0030;
Be written by an authorized medical professional;
Document the existence of a potentially incapacitating condition; and
Indicate an impairment is expected to last ninety days or more from the application date.
If the information received is not clear, we may require more information before we decide your ability to be gainfully employed. As examples, we may require you to get more medical tests or be examined by a medical specialist.
We deny incapacity when:
There is only one impairment with a severity rating less than three;
A reported impairment is not expected to last ninety days (twelve weeks) or more from the date of application;
The practitioner is not able to determine that the physical or mental impairment would remain incapacitating after at least sixty days of abstinence from alcohol and drugs; or
We do not have clear and objective medical evidence to approve incapacity.
When it is clear that the effects on work activities are solely the result of alcohol or drug abuse/addiction, deny incapacity [WAC 388-448-0010 (4)]. When the available information is unclear that a physical or mental impairment will continue to be incapacitating after at least 60 days of abstinence from alcohol or drug use, take the following actions:
Request clarification from the provider. When additional clarification results in clear differentiation, proceed with the PEP,
When additional information from the provider does not differentiate the impairment from alcohol or drug use, deny incapacity, and
Refer the client for a chemical dependency assessment.
Duration:
If the provider’s estimate of the duration of the impairment is consistent with the medical evidence provided, accept it.
If the provider is unable to estimate duration, use reference sources and your professional judgment to assign duration.
When the provider identifies a condition as chronic, you may consider the condition to meet the 90-day duration requirement even when qualified as episodic or in remission if this determination is consistent with the objective medical evidence.
EXAMPLE
Dale is diagnosed with chronic rapid-cycling bi-polar disorder. The most significant impairment on work activities is due to psychotic symptoms, which-according to his psychiatrist-are episodic in nature. Although not currently psychotic, he has had 3 major psychotic episodes within the last 2 months. He has not yet been stabilized on medication. Accept this as meeting the 90-day duration requirement.
EXAMPLE
Kim is diagnosed with chronic Crohn's disease, which affects her digestive system. Currently, there is no inflammation or pain associated with this disorder. It is not clear when the disease will flare up again. Her last episode was 4 months ago. Do not accept this as meeting the 90-day duration requirement.
"By history" means that a condition is reported by the person and that medical records do not support the diagnosis and suggests that the diagnosis is not currently active. Request more information from the provider to determine if the impairment currently has an effect on work activities before accepting it as objective medical evidence.
If it is clear the impairment will last less than 90 days, deny assistance for lack of duration.
Follow the medical evidence procedures in Incapacity Determination Process. Deny incapacity if you are unable to obtain clear, current, objective medical evidence.
WAC 388-448-0050
WAC 388-448-0050
Effective September 1, 2000
WAC 388-448-0050 PEP Step II - How we determine the severity of mental impairments
If you are diagnosed with a mental impairment, we use information from the provider to determine if your impairment prevents you from being gainfully employed. We review the psychological evidence to determine the severity of your mental impairment.
The severity of your mental impairment is based on:
Psychosocial and treatment history;
Clinical findings;
Results of psychological tests; and
Symptoms observed by the examining practitioner that show impairment of your ability to perform basic work-related activities.
If you are diagnosed with mental retardation, the diagnosis must be based on the Wechsler Adult Intelligence Scale (WAIS). The following test results determine the severity rating:
Intelligence Quotient (IQ) Score
Severity Rating
85 or above
1
71 to 84
3
70 or lower
5
If you are diagnosed with a mental impairment with physical causes, we assign a severity rating based on the most severe of the following three areas of impairment:
Memory defect for recent events;
Impoverished, slowed, perseverative thinking, with confusion or disorientation; or
Labile, shallow, or coarse affect.
We base the severity of the functional psychotic or nonpsychotic disorder, excluding alcoholism or drug addiction, on:
Clinical assessment of these twelve symptoms: depressed mood, suicidal trends, verbal expression of anxiety or fear, expression of anger, social withdrawal, motor agitation, motor retardation, paranoid behavior, hallucinations, thought disorder, hyperactivity, preoccupation with physical complaints; and
Clinical assessment of the intensity and pervasiveness of your symptoms and their effect on work activities.
We base the severity rating for a functional mental impairment on accumulated severity ratings for the twelve symptoms in subsection (4)(a) of this section as follows.
Symptom Ratings or Condition
Severity Rating
The functional mental impairment is diagnosed with psychotic features;
You have had two or more hospitalizations for psychiatric reasons in the past two years;
You have had more than six months of continuous psychiatric hospital or residential treatment in the past two years;
The overall assessment of symptoms is rated three; or
At least three symptoms are rated three or higher.
3
The overall assessment of symptoms is rated four; or
At least three symptoms are rated four or five.
4
The overall assessment of symptoms is rated five; or
At least three symptoms are rated five.
5
If you have more than one type of mental impairment, we assign a severity rating as follows:
Condition
Severity Rating
Two or more disorders with ratings of three; or
One or more disorders rated three, and one rated four.
4
Two or more disorders rated four.
5
We deny incapacity when you do not have a significant physical impairment and your overall mental severity rating is one or two;
We approve incapacity when you have an overall mental severity rating of five, regardless of whether you have a physical impairment.
On the DSHS 13-021A, Psychological/Psychiatric Evaluation form:
In section D.2: When an organic mental syndrome condition is identified as deteriorating, add one adjustment point to the severity rating.
In section D.3: For a functional mental disorder, the global illness score (in D.3.m.) is the severity rating. If there are three or more boxes checked with a more severe rating than the global illness rating, raise the severity rating by one adjustment point.
NOTE:
In all cases, only one adjustment point per disorder type (organic or functional) is allowed.
EXAMPLE
In section D.3.m. of the Psychological/Psychiatric Evaluation form, Tom has a global illness rating of moderate, which is a "3" severity rating. In section D.3., the psychologist has rated Tom as having "marked" severity in two categories and "severe" in one category. Since there are three categories that have a higher rating than the global illness rating of "3," you would add one adjustment point, resulting in an adjusted severity rating of "4."
WAC 388-448-0060
WAC 388-448-0060
Effective September 1, 2000
WAC 388-448-0060 PEP Step III - How we determine the severity of physical impairments
We must decide if your physical impairment is serious enough to limit your ability to be gainfully employed. "Severity of a physical impairment" means the degree that an impairment restricts you from performing basic work-related activities (see WAC 388-448-0010). Severity ratings range from one to five, with five being the most severe. We will assign severity ratings according to the table in WAC 388-448-0035.
We assign to each physical impairment a severity rating that is supported by medical evidence.
If your physical impairment is rated two, and there is no mental impairment or a mental impairment that is rated one, we deny incapacity.
If your physical impairment is consistent with a severity rating of five, we approve incapacity.
Compare the severity rating given by the medical evidence provider with the objective evidence.
When it is consistent, accept it.
When it is not consistent, you may raise or lower the rating after consulting medical sources and references. You must have clear and convincing reasons for adjusting a provider's severity rating. Always fully explain your clear and convincing reasons for not accepting the provider's rating in your notes.
NOTE:
If you lower the severity rating given by the provider and the result is a denial of benefits, you must explain this on the DSHS 14-118 so that the client receives adequate notice in the denial letter. That is, you must state that you lowered the severity rating and the clear and convincing reasons for your decision.
WAC 388-448-0070
WAC 388-448-0070
Effective August 1, 2001
WAC 388-448-0070 PEP Step IV - How we determine the severity of multiple impairments
If you have more than one impairment we decide the overall severity rating by deciding if your impairments have a combined effect on your ability to be gainfully employed. Each diagnosis is grouped by affected organ or function into one of thirteen "body systems." The thirteen body systems consist of:
Musculo-skeletal,
Special senses and speech,
Respiratory,
Cardiovascular,
Digestive,
Genito-urinary,
Hemic and lymphatic,
Skin,
Endocrine and obesity,
Neurological,
Mental disorders,
Neoplastic, and
Immune systems.
We follow these rules when there are multiple impairments:
We group each diagnosis by body system.
When you have two or more diagnosed impairments that limit work activities, we assign an overall severity rating as follows:
Your Condition
Severity Rating
All impairments are in the same body system, are rated two and there is no cumulative effect on basic work activities.
2
All impairments are in the same body system, are rated two and there is a cumulative effect on basic work activities.
All impairments are in different body systems, are rated two and there is a cumulative effect on basic work activities.
3
Two or more impairments are in different body systems and are rated three.
Two or more impairments are in different body systems; one is rated three and one is rated four.
4
Two or more impairments in different body systems are rated four.
5
We deny incapacity when the overall severity rating is two.
We approve incapacity when the overall severity rating is five.
Document the cumulative effect (or lack of effect) that multiple impairments have on the basic work activities.
WAC 388-448-0080
WAC 388-448-0080
Effective September 1, 2000
WAC 388-448-0080 PEP Step V -- How we determine your ability to function in a work environment if you have a mental impairment.
If you have a mental impairment we evaluate your cognitive and social functioning in a work setting. Functioning means your ability to perform the tasks that would be required of you on the job and your ability to get along with your co-workers, supervisors and other people you would be in contact with while on the job.
We evaluate cognitive factors by assessing your ability to:
Understand, remember, and follow simple, one- or two-step instructions;
Understand, remember, and follow complex instructions, with three or more steps;
Learn new tasks;
Exercise judgment and make decisions; and
Perform routine tasks without undue supervision.
We approve incapacity when the practitioner’s evaluation shows you are:
At least moderately impaired in your ability to understand, remember, and follow simple instructions and at least moderately limited in your ability to:
Learn new tasks, exercise judgment, and make decisions; and
Perform routine tasks without undue supervision; or
Able to understand, remember, and follow simple instructions, but are:
At least moderately impaired in the ability to understand, remember, and follow instructions with three or more steps; and
Markedly impaired in the ability to learn new tasks, exercise judgment and make decisions, and perform routine tasks without undue supervision.
The practitioner’s evaluation reports your social factors after assessing your ability to:
Relate appropriately to coworkers and supervisors;
Relate appropriately in contacts with the public;
Tolerate the pressures of a work setting;
Perform self-care activities, including personal hygiene; and
Maintain appropriate behavior in a work setting.
We approve incapacity if you are rated at least two in one area of social functioning and at least three in all other areas of social functioning.
Ability to understand and follow simple instructions: This information is available from G.1.a. on DSHS 13-021A(X).
Ability to understand and follow complex instructions: This information is available from G.1.b. on DSHS 13-021A(X).
Composite cognitive score: This information is available from the sum of items G. 1. c., d., and e. on the DSHS 13-021A(X).
Person cannot understand simple instructions according to WAC 388-448-0080(2): The person must be rated at least moderate in G.1.a., and at least moderate in G. 1.c., d., and e.
Person can understand simple but cannot understand complex instructions according to WAC 388-448-0080(2)(b): The person must be rated at least moderate in G.1.b. and at least marked in G. 1. c., d., and e.
Social factors:
Composite social score: This information is available from the sum of social factors G.2. a. through e. on the DSHS 13-021A(x).
If the composite social score is 14 to 25, the person must meet the standards of WAC 388-448-0080(4). In G. 2. a. through e. the person must be rated at least mild in one area and at least moderate in all others.
Mental Status Examinations (MSE):
The purpose of a Mental Status Examination (MSE) is to assess the presence and extent of a person's mental impairment. The MSE may suggest specific areas for further testing or specific types of required tests. There are standardized and non-standardized Mental Status Examinations.
A standardized MSE includes a series of specific questions designed to assess memory, thought process and content, perception, attention and concentration, judgment, intelligence, insight, and orientation. A standardized MSE should usually be given where psychotic or cognitive problems are indicated in the psychological/psychiatric evaluation. While the Folstein is the most common, many standardized MSE's are available.
A non standardized MSE is not numerically rated and may be documented by indicating the degree to which a person is oriented (e.g. "O x 3" means a person is normal in the "three spheres" of time, place, and person - or fully oriented) along with more comprehensive observations including assessment of appearance, movement and behavior, affect, mood, speech, thought content and process, cognition, judgment, and insight.
The MSE should be conducted by an authorized provider and included within the psychological/psychiatric evaluation or attached as an addendum.
When used in conjunction with the evaluation, the MSE provides objective information, which should be consistent with the diagnoses and ratings contained in the psychological/psychiatric evaluation.
If the ratings on the psychological/psychiatric evaluation are inconsistent with the MSE, contact the provider for clarification before proceeding.
Some mental status exams use a numeric rating system. For example, a score of 24 or more on the Folstein Mini Mental Status Examination is considered normal.
EXAMPLE
The cognitive ratings on the DSHS 14-021A(X) are marked to indicate the client cannot follow simple one and two-step instructions. However, the client had no difficulty following instructions specifically developed to test this function - folding a piece of paper and placing it on the floor. Contact the provider and request clarification. The two pieces of information must be consistent to accurately reflect the status of the person being evaluated.
WORKER RESPONSIBILITIES
Ensure a MSE accompanies or is included with the psychological/psychiatric evaluation.
If the MSE is not consistent with the evaluation, get clarification from the provider. (See EXAMPLE above.)
WAC 388-448-0090
WAC 388-448-0090
Effective September 1, 2000
WAC 388-448-0090 PEP Step V - How we determine your ability to function in a work environment if you have a physical impairment
In Step V of the PEP we review the medical evidence you provide and make a determination of how your physical impairment prevents you from working. This determination is then used in Steps VI and VII of the PEP to determine your ability to perform either work you done in the past or other work.
"Exertion level" means the ability to lift, carry, stand and walk with the strength needed to fulfill job duties in the following work categories. For this section, "occasionally" means less than one-third of the time and "frequently" means one-third to two-thirds of the time. We only consider your strength, mobility, and flexibility. We review any work limits you have in the following areas, and then assign an exertion level and determine exertional limitations. The following table is used to determine your exertion level.
Included in this table is a strength factor, which is your ability to perform physical activities, as defined in Appendix C of the Dictionary of Occupational Titles (DOT), Revised Edition, published by the U.S. Department of Labor.
If You
Then We Assign This Exertion Level
Can not lift at least two pounds or stand and/or walk.
Severely limited
Can lift ten pounds maximum and frequently lift and/or carry lightweight articles. Walking and standing are only required for brief periods.
Sedentary
Can lift twenty pounds maximum and frequently lift and/or carry objects weighing up to ten pounds. Walk six out of eight hours per day or stand during a significant portion of the workday, with sitting and pushing/pulling arm or leg movements most of the day.
Light
Can lift fifty pounds maximum and frequently lift and/or carry up to twenty-five pounds.
Medium
Can lift one hundred pounds maximum and frequently lift and/or carry up to fifty pounds.
Heavy
"Exertionally-related limitation" means a restriction in mobility, agility or flexibility in the following twelve activities: balancing, bending, climbing, crawling, crouching, handling, kneeling, pulling, pushing, reaching, sitting, and stooping. If you have exertionally-related limitations, we consider them in determining your ability to work.
"Functional physical capacity" means the degree of strength, agility, flexibility, and mobility you can apply to work-related activities. We consider the effect of the physical impairment on the ability to perform work-related activities when the physical impairment is assigned an overall severity rating of three or four. We determine functional physical capacity based on your exertional, exertionally related and non-exertional limitations. All limitations must be substantiated by the medical evidence and directly related to the diagnosed impairment(s).
"Non-exertional physical limitation" means a restriction on work activities that does not affect strength, mobility, agility, or flexibility. Examples are: (a) Environmental restrictions which could include, among other things, your inability to work in an area where you would be exposed to chemicals; and (b) Workplace restrictions, such as impaired hearing or speech, which would limit the types of work environments you could work in.
Consideration of exertionally-related or non-exertional limitations may be crucial either in eliminating specific types of past work or in accurately assigning the level of work the person can currently perform. Non-exertional limitations may include:
Restrictions in seeing or hearing,
Allergies,
Restrictions in operating dangerous machinery or driving, and
Restrictions in working at heights due to dizziness.
WAC 388-448-0100
WAC 388-448-0100
Effective September 1, 2000
WAC 388-448-0100 PEP Step VI -- How we evaluation capacity to perform relevant past work
If your overall severity rating is three or four and we have reached this stage of the PEP and have not approved or denied your application, we decide if you can do the same or similar work as you have done in the past. We look at your current physical and/or mental limitations and vocational factors to make this decision. Vocational factors are education, relevant work history, and age.
We evaluate education in terms of formal schooling or other training that enables you to meet job requirements. We classify education as:
If You
Then Your Education Level Is
Can not read or write a simple communication, such as two sentences or a list of items.
Illiterate.
Have no formal schooling beyond the eleventh grade; or
Have participated in special education.
Limited education
Have received a high school diploma or general equivalency degree (GED); or
Have received skills training and were awarded a certificate, degree or license.
High school and above level of education.
We evaluate your work experience to determine if you have relevant past work. "Relevant past work" means work that:
Is normally done for pay or profit. We exclude work done in a sheltered workshop, a job where you were given special consideration, or activities you may have performed as a student or homemaker;
Has been performed in the past five years; and
You have done long enough for you to have acquired the knowledge and skills to continue performing the job. You must meet the specific vocational preparation level as defined in Appendix C of the Dictionary of Occupational Titles.
For each relevant past work situation you have had, we determine:
The exertional or skill requirements of the job; and
Current cognitive, social, or nonexertional factors that significantly limit your ability to perform past work.
After considering vocational factors, we approve or deny incapacity based on the following:
If You
Then We Take This Action on Incapacity
Have the physical or mental ability to perform past work and there is no significant cognitive, social or non-exertional limitation.
Deny
Have recently acquired specific work skills through completion of vocational training, enabling you to work within your current physical or mental capacities.
Deny
Are 55 years of age or older and have an impairment that is assigned an overall severity rating of at least three and do not have the physical or mental ability to perform past work or do not have work experience.
Enter each job from DSHS 14-050, Statement of Health, Education, and Employment that is considered relevant past work.
Use O*NET to get exertion and skill levels for the jobs the client has held. According to the Department of Labor, O*Net has replaced the Dictionary of Occupational Titles.
Compare the physical and mental requirements for each job with the person's current functional abilities, as identified in Step V. If mental or non-exertional physical limitations prevent an individual from performing a job they were formerly capable of doing, indicate that the person cannot do this job and document the specific reason.
EXAMPLE
A client is advised not to work in high places because of a seizure disorder. This would prevent the client from returning to past work as a roofer.
Deny incapacity when a person has recently completed vocational training or gained work skills that they can currently use to perform a job.
Deny incapacity when a person is able to do relevant past work.
Approve incapacity when a person is 55 years old or older and is unable to perform relevant past work, or has no relevant past work.
WAC 388-448-0110
WAC 388-448-0110
Effective September 1, 2000
WAC 388-448-0110 PEP Step VII -- How we evaluate your capacity to perform other work
If we decide you cannot do work that you’ve done before, we then decide if you can do any other work. In making this decision, we again consider vocational factors of age, education and limited English proficiency (LEP).
We approve incapacity if you have a physical impairment only and meet the vocational factors below:
Highest Work Level Assigned by the Practitioner
Your Age
Your Education Level
Other Vocational Factors
Sedentary
Any age
Any level
Does not apply
Light
50 and older
Any level
Does not apply
Light
35 and older
Illiterate or LEP
Does not apply
Light
18 and older
Limited Education
Does not have any past work
Medium
50 and older
Limited education
Does not have any past work
Medium
55 and older
Any level
Does not apply
Heavy
55 and older
Any level
Environmental restrictions apply
We approve incapacity when you have a mental disorder only and meet the age and social functioning limitations below:
Social Limitation
Age
Can not appropriately relate to coworkers and supervisors (rated three); and;
Can not tolerate the pressures of a work setting (rated four).
50 years and older
Can not tolerate the pressures of a work setting (rated five).
Can not appropriately relate to coworkers and supervisors (rated three); and
Can not tolerate the pressures of a work setting (rated four).
18-49
We approve incapacity when you have both mental and physical impairments and vocational factors interfere with working as follows:
Your Age
Your Education
Your Other Restrictions
Any age
Any level
Can not appropriately relate to coworkers and supervisors (rated three); and
Can not tolerate pressures of a work setting (rated four).
50 or older
Limited education
Restricted to medium work level or less.
18 to 49
Limited education
Restricted to light work level.
If we do not find that you are incapacitated by the end of Step VII of the PEP, an administrative review team (ART) makes the incapacity decision. The review team consists of two or more persons within the community service office (CSO) who are not in the position of providing direct eligibility or incapacity services to you. The ART reviews the medical evidence and your vocational factors.
Completion of high school by attendance in a special education curriculum is considered limited education.
High school education and above includes a non-English education if it otherwise meets the standards of a U.S. high school education.
If the person meets the criteria in the tables in WAC 388-448-0110
WAC 388-448-0110
Effective September 1, 2000
WAC 388-448-0110 PEP Step VII -- How we evaluate your capacity to perform other work
If we decide you cannot do work that you’ve done before, we then decide if you can do any other work. In making this decision, we again consider vocational factors of age, education and limited English proficiency (LEP).
We approve incapacity if you have a physical impairment only and meet the vocational factors below:
Highest Work Level Assigned by the Practitioner
Your Age
Your Education Level
Other Vocational Factors
Sedentary
Any age
Any level
Does not apply
Light
50 and older
Any level
Does not apply
Light
35 and older
Illiterate or LEP
Does not apply
Light
18 and older
Limited Education
Does not have any past work
Medium
50 and older
Limited education
Does not have any past work
Medium
55 and older
Any level
Does not apply
Heavy
55 and older
Any level
Environmental restrictions apply
We approve incapacity when you have a mental disorder only and meet the age and social functioning limitations below:
Social Limitation
Age
Can not appropriately relate to coworkers and supervisors (rated three); and;
Can not tolerate the pressures of a work setting (rated four).
50 years and older
Can not tolerate the pressures of a work setting (rated five).
Can not appropriately relate to coworkers and supervisors (rated three); and
Can not tolerate the pressures of a work setting (rated four).
18-49
We approve incapacity when you have both mental and physical impairments and vocational factors interfere with working as follows:
Your Age
Your Education
Your Other Restrictions
Any age
Any level
Can not appropriately relate to coworkers and supervisors (rated three); and
Can not tolerate pressures of a work setting (rated four).
50 or older
Limited education
Restricted to medium work level or less.
18 to 49
Limited education
Restricted to light work level.
If we do not find that you are incapacitated by the end of Step VII of the PEP, an administrative review team (ART) makes the incapacity decision. The review team consists of two or more persons within the community service office (CSO) who are not in the position of providing direct eligibility or incapacity services to you. The ART reviews the medical evidence and your vocational factors.
WAC 388-448-0120 How we decide how long you are incapacitated
We decide how long you are incapacitated, up to the maximum period set by WAC 388-448-0160, using medical evidence on the expected length of time needed to heal or recover from the incapacitating disorder(s).
If the provider gives a time range for the length of incapacity, i.e., 3 to 6 months, do not automatically approve for the minimum length of time. Each case should be assessed individually, taking into consideration the person's incapacitating condition, treatment plan, likelihood of improvement within a specific timeframe, etc. You should decide how much time is needed within the range given by the provider.
NOTE:
Do not choose the minimum length of time for incapacity in order to use it as a case management or treatment monitoring tool.
EXAMPLE
Joan has recently been diagnosed as having depression. She was prescribed her third medication trial two days ago. The provider indicates that the previous two trials on different medications have been unsuccessful, and it may take some time to find a successful medication or combination of medications. Given the information regarding the medication issues, your assessment may be to approve her incapacity for 6 months.
EXAMPLE
Paul has a tibia fracture. The medical provider stated that Paul's degree of limitation is expected to continue for 6 to 9 months. Paul is 20 years old, and is otherwise in excellent physical condition, having been a weight lifter up until his injury. Based on these factors, you assess that he may be employable within 6 months, and approve incapacity for 6 months.
For each incapacity approval, complete the DSHS 14-332, Disability Assessment. ICMS will prompt you to complete this as part of the PEP process (Step VIII in ICMS). Use this form to decide:
Whether the case should be referred for GAX and SSI facilitation services, and
Which SSPS payment code to use (6020 or 6220) to reimburse the provider for medical services that were provided to support an incapacity decision.
When completing the DSHS 14-118, Incapacity Decision, keep in mind:
The date of eligibility is the date complete medical documentation is received or the 45th day of application, whichever is earlier.
For denials and terminations, you need to include the specific reason on the 14-118 so that the client receives adequate notice.
Modification Date: October 28, 2007
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