What’s Inside
Medical-frailty exclusions depend on more than identifying a diagnosis. States must connect condition and impairment evidence to an approved methodology, apply controlled automation and manual-review pathways, communicate the actual decision basis, and retain enough historical evidence to reconstruct the result later.
This practical checklist turns that obligation into an operational control standard. It covers condition-list governance, ex parte source inventory, encounter-data quality, evidence sufficiency, exception handling, self-declaration, notices and appeals, annual reverification, vendor accountability, and Shadow PERM testing.
Use it to assess whether each exclusion determination can be explained from source evidence through the final eligibility action—under the policy, code set, system rule, and effective date that applied at the time.
Current through September 2026 | National Medicaid focus