health care professional's guide to medical reviews

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Ontario Disability Support Program

Health Care Professional’s Guide to Medical Reviews

ISBN 978-1-4868-0074-2 (Print) ISBN 978-1-4868-0075-9 (HTML) ISBN 978-1-4868-0076-6 (PDF)

CONTENTS

Introduction ................................................................................................................................... 5

Purpose of the guide .................................................................................................................5

Ontario Disability Support Program .........................................................................................6

What is the Ontario Disability Support Program? .................................................................6

Who is a person with a disability? ...........................................................................................7

What is a medical review?.........................................................................................................7

What is a health care professional’s role in a medical review? ............................................8

How much time does my patient have to complete their medical review package? ........8

Who completes the Medical Forms? .......................................................................................9

How do I receive payment for completing these forms? ....................................................10

Who do I contact if I have any questions? ............................................................................11

Contents of the Medical Review Package..............................................................................12

How to complete the Medical Forms ......................................................................................14

Medical Form Part A ................................................................................................................14

Medical Form Part B............................................................................................................... 21

Health Status Report ........................................................................................................ 21

Activities of Daily Living.................................................................................................... 27

Appendix A....................................................................................................................................29

Ministry of Community and Social Service’s Definitions ................................................... 29

Appendix B....................................................................................................................................30

Billing Guide for Additional Medical Information Requested by the Disability Adjudication Unit .................................................................................................................... 30

INTRODUCTION

As a licensed health care professional, you may be asked to provide medical information for a patient who is undergoing a medical review for the Ontario Disability Support Program.

The information you provide will help the Ministry of Community and Social Services assess whether your patient continues to be “a person with a disability,” as defined by the Ontario Disability Support Program Act, 1997.

It is important to note that the Ministry of Community and Social Services does not assess your patient in person.

Purpose of the guide This guide provides important information that will assist you in completing your portion of the Medical Review Package.

The purpose of the guide is to:

◼ provide an overview of the Ontario Disability Support Program including medical reviews

◼ explain your role in the Ontario Disability Support Program medical review process

◼ outline key information required by the Ministry of Community and Social Services to make an informed decision, and

◼ clarif y billing information.

Health Care Professional’s Guide to Medical Reviews 5

ONTARIO DISABILITY SUPPORT PROGRAM

What is the Ontario Disability Support Program?

The Ontario Disability Support Program is a provincial social assistance program that provides income support, health care benefits and employment supports to eligible Ontario residents who have disabilities.

To qualify for the Ontario Disability Support Program income support, a person must be:

◼ 18 years of age or older

◼ a resident of Ontario

◼ in financial need, and

◼ a person with a disability as defined by the Ontario Disability Support Program Act (unless a member of a prescribed class).

Most applicants must go through a disability determination process to determine if they meet the program’s definition of a person with a disability.

6 Health Care Professional’s Guide to Medical Reviews

Who is a person with a disability?

What is a medical review?

The program’s definition of a person with a disability is found in the Ontario Disability Support Program Act.

Meeting the definition means that:

◼ A person must have a substantial mental or physical impairment that is continuous or recurrent, and is expected to last one year or more.

◼ The impairment directly results in a substantial restriction in the person’s ability to attend to his or her personal care, function in the community or function in the workplace.

◼ The impairment, its duration and restrictions have been verified by an approved health care professional.

See Appendix A (page 29) for the Ministry of Community and Social Services’ definition of the above terms and phrases.

For more information about the Ontario Disability Support Program, please go to http://www.ontario.ca/socialassistance.

A medical review allows the Ontario Disability Support Program to make sure a person continues to meet the definition of a person with a disability under the Ontario Disability Support Program Act. When an applicant is found to be a person with disability under the Ontario Disability Support Program Act, a medical review date may be assigned. A medical review date is assigned only if there is a likelihood of improvement in the patient ’s impairments.


http://www.ontario.ca/socialassistance

A medical review is not a reapplication—it focuses on changes to your patient ’s original qualifying medical conditions and if necessary, any new medical issues that have emerged since the previous Ontario Disability Support Program disability decision. The medical review is an important part of maintaining the integrity of ODSP as a public program.

What is a health care professional’s role in a medical review?

The information you provide helps the ministry decide if your patient continues to qualify for ODSP income support. Specially trained staff who work in the ministry will review the information you provide to make a decision. Your role is to provide medical information about the person’s conditions, impairments and restrictions.

Approved health care professionals who are registered in Ontario complete the Medical Forms for their patients. Please return completed forms to your patient.

How much time does my patient have to complete their medical review package?

Your patient was given 90 days to complete and return their forms. The ministry is aware that medical appointments can take time to schedule, so the ministry will give more time if your


patient needs it. If your patient needs more time to complete the package, they can contact the Disability Adjudication Unit by phone, fax or mail for an extension (see page 11).

Who completes the Medical Forms?

Medical Form Part A may be completed by an Ontario registered:

◼ physician

◼ psychologist

◼ nurse practitioner

Medical Form Part B has two sections, the Health Status Report (HSR) and the Activities of Daily Living (ADL).

The HSR may be completed by an Ontario registered:

◼ physician

◼ psychologist

◼ nurse practitioner

The ADL may be completed by an Ontario registered:

◼ physician ◼ physiotherapist

◼ psychologist ◼ occupational therapist

◼ nurse practitioner ◼ registered nurse

◼ optometrist ◼ social worker

◼ psychological associate ◼ audiologist

◼ chiropractor ◼ speech language pathologist


◼ optometrist

◼ psychological associate

◼ registered nurse (new)

◼ optometrist

◼ psychological associate

◼ registered nurse (new)

How do I receive payment for completing these forms?

You will receive payment by billing OHIP or submitting an invoice to the ministry.

Here are the amounts and OHIP codes:

◼ Completion of Medical Form Part A ......................$35 ....... K057 ◼ Completion of Medical Form Part B

Both Health Status Report & Activities of Daily Living Index .........................$125 ....... K058

Only Health Status Report ...............................$100 ....... K059

Only Activities of Daily Living Index ..................$25 ....... K060

If you submit an invoice please:

1. Create an invoice on letter size paper that includes:

◼ your full name and profession, address and phone number

◼ your patient ’s full name, date of birth, and member ID (this is on each page of the form)

◼ the name of the form you completed (i.e., Part A, Part B Health Status Report and/or Part B Activities of Daily Living Index)

2. Mail your invoice to:

Ontario Disability Support Program Disability Adjudication Unit Box B18 Toronto, ON M7A 1R3


Who do I contact if I have any questions?

You can contact the Disability Adjudication Unit:

By phone

416-326-5079 (within Toronto) 416-326-3372 (TTY device in Toronto) 1-888-256-6758 (outside of Toronto) 1-866-780-6050 (TT Y device outside of Toronto)

By fax 416-326-3374


CONTENTS OF THE MEDICAL REVIEW PACK AGE

The Medical Review Package contains the ministry approved forms used for the purpose of collecting information to conduct a medical review.

The Disability Adjudication Unit notifies and sends the Medical Review Package to the Ontario Disability Support Program recipient whose medical review is due.

1. Medical Forms ◼ Collects current information about your patient ’s medical

conditions.

◼ There are two parts to the form:

Medical Form Part A is mandatory and collects current information about the medical conditions that were originally identified in the previous Ontario Disability Support Program disability decision.

Medical Form Part B identifies medical conditions that are not listed in Part A. It is only completed if necessary, based on the answers to the questions asked at the end of Part A.

◼ Based on your answers to the questions in Part A, you may need to proceed to Part B. In that case, both the Health Status Report and the Activities of Daily Living must be completed.


2. Summary of Disability Decision ◼ The summary provides the reasons your patient was

originally found to be a person with a disability and may assist you in completing the Medical Forms.

3. Information for Health Care Professional ◼ Provides you with information about medical reviews.

4. Consent to the Release of Medical Information ◼ This is an authorization form which allows for the exchange

of information between health care professionals and the Disability Adjudication Unit.

◼ A signature is required from the patient or legally authorized representative.

5. Self Report ◼ The self report is designed for your patient or a designate

(e.g. family member, friend, trustee, caseworker) to describe how his or her disability affects their life.

◼ It is an optional form for your patient to complete.

6. Instruction Sheet and an envelope addressed to the Disability Adjudication Unit


HOW TO COMPLETE THE MEDICAL FORMS

Please fill out each section as completely and as legibly as possible. This will assist the Ministry of Community and Social Services in determining your patient’s ongoing eligibility for the Ontario Disability Support Program support in a timely manner. If anything is missing, the ministry will need to follow up with you. This can cause a delay with your patient’s medical review.

Patient’s Identification

Your patient ’s personal identification will be prepopulated on the first page of the Medical Form.

Medical Form Part A

Section 1: Status of previously identified medical conditions, impairments and restrictions

Medical Form Part A focuses on the status of previously identified medical conditions, impairments and restrictions. This information is pre-populated in Section 1.1 and it is based on the verified medical information provided by the patient ’s health care professional at the time of the previous Ontario Disability Support Program disability decision. The information you provide in Section 1 will help the ministry assess the patient ’s current status including any clinically significant change(s) in the identified impairments and restrictions.


Section 1.1

Pre-populated: Previous medical condition, and List of previous identified impairments

and restrictions.

Major Depressive Disorder

decreased energy decreased concentration decreased memory

decreased ability to exercise problem with learning does not like to socialize

2015/03/20

2015/03/20

The date refers to the date of the previous Ontario Disability Support Program disability decision

For each Previous Medical Condition (e.g., Major Depressive Disorder) pre-populated in Section 1.1 of Part A, please complete the following:


Prognosis

Major Depressive Disorder A

A. Indicate the current prognosis. This information will help you answer question #2 in Section 1.2.

Impairments

B decreased energy decreased concentration

2015/03/20

decreased memory D

C E

B. For each pre-populated previous impairment indicate if it is still present.

C. List any new impairments that your patient has currently.

D. In the space provided, describe any clinically significant change to the listed impairments since the date of the Ontario Disability Support Program disability decision. This information will help you answer question #1 in Section 1.2.

E. Indicate the duration of all impairments (previous ones that are still present and any new ones) and whether the impairments are recurrent/episodic or continuous.


Restrictions

F decreased ability to exercise

2015/03/20 problem with learning does not like to socialize

H

G

F. For each pre-populated previous restriction indicate if it is still present.

G. List any new restrictions that your patient has currently.

H. In the space provided, describe any clinically significant change to the listed restrictions since the date of the Ontario Disability Support Program disability decision. This information will help you answer question #1 in Section 1.2.


Section 1.2

To determine if you need to provide further information, you will need to answer two questions in Section 1.2.

If you answered Go to Section 3 NO Sign and date the form

to both questions Form is complete

If you answered YES Go to Section 2

to any question


Section 2: Available medical and other information related to Section 1 only

The indication of improvement in Section 1 does not automatically imply that your patient is no longer a person with a disability. The ministry will use the information you provide in Section 2 to assess if your patient still continues to be a person with a disability.

Section 2.1

◼ Provide available information only. You have a choice to either describe this information or to attach relevant report. You do not need to do both.

◼ You do not need to provide information on any other medical conditions here but those listed in Section 1.


Section 2.2

Answer the question in Section 2.2 to determine whether you need to complete Part B.

Go to Section 3 If you answered Sign and date the form NO Form is complete

Part B needs to be If you answered completed

YES Before you go to Part B you must complete Section 3

Section 3: Certificate of Approved Health Care Professional

By signing and dating Part A, you are confirming that the information provided is true, in your professional opinion.


Medical Form Part B Only complete Part B if: ◼ There is clinically significant improvement in your patient’s

impairments or restrictions or any medical condition is expected to improve or prognosis is unknown

AND ◼ Your patient has other medical conditions presenting

with impairments and restrictions that contribute to your patient ’s current status.

Health Status Report

Section 1: Medical conditions not listed in Part A that contribute to the patient’s current status

Section 1 of Part B asks about the presenting medical conditions and the related impairments and restrictions in the respective columns represented below. List only Medical Conditions not already listed in Part A. You will need to provide prognosis, impairments, duration and restrictions for each medical condition you list.


Medical Condition 1 Prognosis of condition is likely to

improve remain same deteriorate unknown

Impairments

Duration of Impairments

Expected to last ▼ And are ▼

less than 1 year recurrent/episodic 1 year or more continuous

Restrictions

A B

C D

E

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Ministry of Community and Social Services Ontario Disability Support Program

Medical Form Part B

Recipient Name

Member ID Referral ID Date of the decision

Health Status Report (HSR)

Section 1. Medical conditions not listed in Part A that contribute to the patient’s current status.

1.1. Please provide information below.Impairment Any loss or deviation in psychological, physiological or anatomical structure or function.

Duration Refers to how long the impairment, either continuous or recurrent, is expected to last from the date the medical review form is completed

Restriction A limitation in activities of daily living caused directly by the impairment.

Medical Condition 2 Prognosis of condition is likely to

improve remain same deteriorate unknown

Impairments

Duration of Impairments

Expected to last ▼

less than 1 year1 year or more

And are ▼

recurrent/episodic continuous

Restrictions


A. Medical Condition is the name of the disease or disease state, diagnosis, or syndrome.

B. Indicate the prognosis of the listed medical condition.

C. List the associated impairments.

D. Indicate the duration of the impairments and whether the impairments are recurrent/episodic or continuous.

E. List all restrictions that your patient has as a result of the impairments.

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Member IDReferral IDRecipient Name

Ontario Disability Support Program Medical Form Part B Health Status Report

► If you answered No, please go to Section 3.

► If you answered Yes to any of the above, please complete Sections 2.2 and 2.3.

2.2. Describe below available information including the history that might be useful in understanding the patient’s mentalimpairments or attach copies of available reports (e.g. psychology, psychiatry, educational assessment, individualeducation plan, neuropsychological assessment, other mental health consult).

A. Mental health condition

See Attached

B. Substance-related or addictive disorder (note any withdrawal symptoms, related risk taking behaviours, etc.)

See Attached

C. Neurodevelopmental disorder

See Attached

D. Other medical condition presenting with a mental impairment (e.g. head injury)

See Attached

Section 2

Section 2.1

In this section you will indicate if any of the medical conditions you reported in Section 1 of Part B is a mental health condition, a substance– related or addictive disorder, a neurodevelopmental disorder, or another medical condition presenting with a mental impairment.

Go to Section 3 If you answered

NO to all questions

Complete therest of the

Section 2.1 and Section 2.2

If you answered YES

to any of the questions

Section 2.

2.1. Are any of the medical conditions you reported in Section 1 of Part B listed below?

Mental health condition Yes No

Substance-related or addictive disorder Yes No

Neurodevelopmental disorder (e.g. intellectual disability) Yes No

Other medical condition presenting with a mental impairment (e.g. head injury) Yes No


Section 2.2

In Section 2.2 you may choose to attach or describe available information that might be useful in understanding the patient ’s mental impairments.

Section 2.3

Intellectual and Emotional Wellness Scale

The Intellectual and Emotional Wellness Scale is a 28-item scale that is used to gather information related to psychiatric, psychological, neurological or other conditions presenting with mental impairments. It is important to complete this scale where applicable. The rating scale addresses both the severity and frequency of each symptom. If the frequency of a symptom is episodic, use the open area to the right of the scale to comment on the fluctuations in the severity of the episodic symptom.

Section 3: Available medical and other information related to Section 1 of Part B

Section 3.1

Use this section to describe your examination findings related to your patient ’s current medical status, unless you have described it elsewhere on this form. Focus on medical conditions listed in Part B.


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Section 3. Available medical and other information related to Section 1 of Part B

► You do not have to repeat the information already provided in previous sections.

3.1. Please describe available information, if applicable.

A. Examination findings

B. For recurrent or episodic impairments, describe how fluctuations in the severity affect the patient

Section 3.2

Additionally, you may choose to describe or attach additional medical and other supporting information such as your clinical notes, hospital reports, or consult reports that support or clarify the information you have identified on the form. This will assist the Disability Adjudication Unit in making an informed and timely decision.

3.2. Have any consultations or assessments been completed by another health care professional? Yes No

If No, please comment (e.g. pending or waiting list, not available, etc.)

If Yes please select the type

Diagnostic tests or investigations (e.g. laboratory, biopsy, sleep study, ultrasound, imaging, stress test, etc.)

Specify

Specialist consults (e.g. cardiology, neurology, rheumatology, oncology, etc.)

Specify

Other assessments or reports

Specify

Please describe below relevant findings or attach copies of the available report

See Attached

Note: Do not send actual x-rays or an original report. The cost of photocopying has been included in the fee.


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A. If No, please comment below (e.g. pending, side effects, no definitive diagnosis, not available, etc.)

B. If Yes, please complete relevant fields below and comment on progress

Hospital Admission, ER visit, Surgery Date Duration Describe purpose or attach admission or discharge report

Pharmacotherapy Dosage Frequency Start date Conditions or Impairments Response to treatment

Interventions and Services Start Date End Date Describe response to treatment or attach report

Psychotherapy

Counselling

Addiction services

Vocational rehabilitation

Occupational therapy

Physiotherapy

Other rehabilitation

Chemotherapy

Radiation

Other

If you indicated on the Medical Form that additional documents are available, but these are not described or attached with the forms, the Disability Adjudication Unit may request this information before a decision is made. Describe or attach only reports pertinent to the presenting conditions and impairments listed in Part B.

Section 4: Visual

Only complete this section if your patient has a visual condition (e.g., glaucoma, diabetic retinopathy) or impairment (vision loss). Please attach the most recent visual assessment (e.g., visual fields test).

Section 5: Auditory

Only complete this section if your patient has an auditory condition or impairment (e.g., hearing loss). Please attach the most recent auditory assessment (e.g., audiogram).

Section 6: Intervention and Treatment

To begin this section, first indicate whether your patient is receiving any treatment or intervention for conditions and impairments listed in Par t B.

Section 6. Intervention and treatment

6.1 Is the patient receiving any interventions and treatments for conditions and impairments listed in Part B?

Yes No


Section 6.1

If you answered No, it is important to explain why your patient is not receiving any inter vention or treatment (e.g., for some conditions there may not be any treatment available for your patient). You will have a chance to describe past treatments and interventions on page eight.

If you answered Yes, use the appropriate sections to provide information on your patient’s intervention and treatment such as medications and other relevant adjunct interventions (e.g., physiotherapy, hospitalizations, surgery, psychotherapy).

Section 6.2 and 6.3

At the end of Section 6, you have an opportunity to describe past treatments and reasons for discontinuation. You may also provide any other information that in your opinion is useful in understanding your patient ’s current situation.

Activities of Daily Living

Section 8: Activities of Daily Living Index

Section 8.1

The Activities of Daily Living Index is a 25-item index made up of activities performed on a daily basis. The rating scale ranges from 0 (no limitation) to 3 (severe limitation). You may use the open area to the right of the index to describe the limitation.


Section 8.2 and 8.3

In these sections, you have an opportunity to describe any services and help your patient requires. You may also provide any other information that in your opinion describes your patient ’s limitations in their activities of daily living.

Section 7 and 9: Certificate of Approved HealthCare Professional

There are two signature pages:

If you are completing the Part B Health Status Report only (pages 1–8), please provide your signature and date on Section 7 (page 8).

If you are completing both the Health Status Report (pages 1–8) and the Activities of Daily Living (pages 9–10), only sign and date Section 9 (page 10).

By signing and dating Part B, you are confirming that the information provided is true, in your professional opinion.


APPENDIX A

Ministry of Community and Social Service’s Definitions

Condition ◼ The name of the disease or disease state, diagnosis,

or syndrome.

Continuous or Recurrent ◼ Continuous means marked by uninterrupted time.

◼ Recurrent means cyclical and repetitive in nature, happening time after time.

Duration ◼ Duration refers to how long the impairment, either

continuous or recurrent, is expected to last from the date the medical review form is completed.

Impairment ◼ Impairment refers to any loss or deviation in psychological,

physiological or anatomical structure or function.

Restriction ◼ Restriction refers to a limitation in activities of daily living

caused directly by the impairment.


APPENDIX B

Billing Guide for Additional Medical Information Requested by the Disability Adjudication Unit

The Disability Adjudication Unit may contact you if additional medical information is needed. Billing guide for additional medical information requested by the Disability Adjudication Unit:

1. Specifics of service rendered and amount claimed based on the following:

(Only requested report/information will be paid)

◼ Short narrative typed report

Chart review and medical report preparation (15–20 minutes time) ............................................... $50.00

◼ Full narrative typed report (at least two pages or 40–45 minutes time) .................................................. $100.00

◼ Photocopied information from the patient’s chart and/or a short statement/paragraph (first five pages) ........... $25.00

◼ Photocopied information from the patient’s chart and/or a short statement/paragraph after first five pages .......$1.08 /page


2. Please note your invoice will be returned if:

◼ Patient’s name is not legible or patient ’s name and identifier is not found in our database.

◼ Document is marked STATEMENT.

◼ Document is billed to the client.

◼ Printed/written on smaller piece of paper, which does not have space for approvals and signatures.

◼ Addressed to other government offices such as Service Canada, Human Resources, Canada Pension Plan, or Ontario Works.

◼ Amount billed is over the approved Ontario Disability Support Program rates.

3. Invoice must be on letter-sized paper and addressed to:

Ontario Disability Support Program Disability Adjudication Unit Box B18 Toronto, ON M7A 1R3

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