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Medicaid: How To Apply For

The Consultative Exam (Examination By A Doctor)

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If the Analyst is unable to make a decision based on your medical record, or if your records are believed to be too incomplete, you may be requested to see a doctor or psychiatrist for a Consultative Exam. The Exam will be paid for by Medicaid and performed by a doctor who contracts with Medicaid.

You will receive a letter, usually about a month after the interview, giving you the name, address and date and time of your appointment with a doctor. While it is not a written rule, the experience of many people who deal with the eligibility process leads them to believe that Medicaid requests a Consultative Exam when it is leaning toward denying a claim. The Consultative Exam can be useful in helping document in the file a reason for the denial.

You can imagine how little helpful information a doctor can provide if he or she has never seen you before and only spends fifteen to twenty minutes or less examining you.

You have the right to request that a Consultative Exam be conducted by your own doctor (called a Treating Physician Consultative Exam) at Medicaid's expense. In fact, the Social Security regulations, which Medicaid is a part of, state that it is preferred that your own doctor conduct the exam (at Medicaid expense), but different Medicaid offices interpret that differently.

If you receive a letter ordering you to an exam by a Medicaid doctor, immediately contact the Analyst assigned to your case and ask if your own doctor can conduct the physical or if additional information from your doctor, or from your therapist, would be sufficient (instead of the exam). Experience has shown that it is much better for such exams to be conducted by a doctor who has been treating you and knows you and your condition.

If your request to use your own doctor is refused, ask for a supervisor to press your argument that a doctor who sees you once for only a few minutes cannot possibly understand the true state of your condition.

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