Form 2101, Authorization for Community Care Services
Effective Date: 7/2013
When to Prepare
The Community Care for Aged and Disabled (CCAD) case manager or authorizing agent completes this form when:
- referring an applicant for Primary Home Care (PHC), Community Attendant Services (CAS) or Day Activity and Health Services (DAHS);
- authorizing or reauthorizing CCAD services;
- authorizing changes to CCAD services;
- authorizing Consumer Directed Services (CDS); and
- terminating CCAD services.
All authorizations must be completed in the Service Authorization System (SAS) Wizards.
For initial PHC cases, the case manager generates Form 2101 using the SAS Authorization Wizard to complete a "Referral" by setting the service authorization status to "Pending" and sends the form to the provider to begin pre-initiation activities. After the practitioner's statement is received and all eligibility requirements are met, the case manager generates another Form 2101, changing the authorization status to "Authorize."
Initial CAS and DAHS
For initial CAS and initial DAHS referrals, the case manager generates Form 2101 using the SAS Authorization Wizards to complete a "Referral" by setting the service authorization status to "Pending" and sends the form to the provider/facility to begin the approval process. For these cases, eligibility is pending until the DADS regional nurse gives final approval. The DADS regional nurse:
- awaits receipt of the proper forms and documentation from the provider;
- makes an approval determination;
- if approval is granted, makes SAS entries that populate Items 1, 4 and 29-38; and
- changes the referral to an authorization by processing the Authorization Wizard and setting the authorization status to "Authorize."
For Title XX Services
The case manager processes the Authorization Wizard and sets the service authorization status to "Authorize." A separate Form 2101 is generated for each service the individual is determined eligible to receive.
For the CDS Option (For PHC, CAS or Family Care (FC))
The case manager generates Form 2101 using the appropriate service code for CDS in the specific program. The case manager also generates a second Form 2101 for the CDS Financial Management Service (FMS) fee.
Number of Copies
Print an adequate number of copies of Form 2101 for program requirements.
The case manager keeps a copy in the individual's case record and sends copies to the provider as required by the program. See Case Manager Community Care for Aged and Disabled Handbook, Appendix XIII, Content of Referral Packets, for requirements.
For all services except CAS and DAHS initial authorizations, the provider keeps a copy, completes the provider portion of the form or uses some other form of notification of service initiation, and returns it to the case manager within 14 days of the service initiation.
For CAS and DAHS initial authorizations, the provider sends the DADS regional nurse a copy of the "Referral" Form 2101 with the referral packet. The DADS regional nurse authorizes or denies service and sends a copy of the "Authorization" Form 2101 to the provider and the case manager.
Keep the copies in the case record for three years and 90 days. The provider keeps copies according to the terms of the contract.
1. Date — Enter the date (month, day and year) the form is prepared. The date entered must also be the date the form is mailed.
2. Contract No. — Enter the nine-digit number assigned by DADS to the contracted provider.
3. Type of Authorization — Inform the provider agency as to the type of authorization contained in the referral packet by checking the appropriate authorization (case action). Check one of the following:
1 – New, for initial authorizations/referrals in SAS;
2 – Update, for changes in the service plan or CAS annual reassessment; or
3 – Terminate, for terminations of service authorizations in SAS.
4. Begin Date —
For the referral to provider/facility, leave the begin date blank for:
- initial PHC;
- initial DAHS;
- initial CAS; and
- annual reassessments of CAS, if there are no changes.
Title XX-funded services do not require a referral for pre-initiation activities and only the authorization process is used.
The begin date is the day the individual is authorized for services after being determined eligible. This date is the same as the date in Item 1 (mail date) or the negotiated date.
For DAHS and CAS initial authorizations and CAS annual reassessments with no changes, the DADS regional nurse enters the begin date in the Service Authorization record.
Coverage Dates for Ongoing Services Plan Changes
- For service increases, the begin date is seven days from the Item 1 (mail) date.
- For service decreases, the begin date is 12 days from the Item 1 (mail) date (unless a weekend or a legal holiday). See the Care Manager Community Care for Aged and Disabled Handbook, Appendix XVIII, Time Calculation.
- For immediate increases, the begin date is the date the case manager verbally negotiated as the date the increase is to be effective.
5. End Date — Leave the end date blank for initial authorizations. For terminations, enter the last date the contracted provider is authorized to deliver service.
6. Term Code — Enter the appropriate termination codes to terminate the service authorization screen in SAS. Reminder: Termination of an individual's enrollment requires a separate entry in the Enrollment Termination screen.
01 – Client leaves the state/county (catchment area)
02 – Death of client
03 – Admitted to institution
05 – Client requests service termination
06 – Client denied Medicaid eligibility
07 – Threatens health/safety
10 – Denied due to income
11 – Denied due to resources
12 – Denied due to lack of functional need
13 – Denied due to unmet need, less than six hour rule
14 – No medical need
15 – Abused emergency response service
16 – Failure to provide information
17 – Failure to follow service plan
18 – Exceeds cost ceiling
19 – Client already registered as open to another worker or provider
20 – Fails to pay room and board/copayment
23 – Transferred to another service
24 – Denied due to functional score change
25 – Funds not available
26 – Withdrew/dissatisfaction with quality
27 – Withdrew/dissatisfaction with quantity
33 – Client transferred to hospice
34 – Client transferred to managed care
39 – Other
Terminate the Client Enrollment in SAS only if the individual is not going to receive any other community care service.
7. Individual Name — Enter the individual???s last name, first name and middle initial.
8. Individual No. — Enter the individual???s permanent nine-digit number. If a permanent individual number has not yet been assigned, enter individual information into SAS to get a individual number.
9. 2060 Score —Enter the functional assessment score, if one is required for service eligibility.
10. Priority — For personal attendant servers (PAS) only, enter whether or not the individual has priority status by entering:
- 1 for non-priority, or
- 2 for priority.
Leave blank for all other services.
11. County — Enter the county code where the individual resides.
12. Agency — Pre-populated on Form 2101 as agency code 324.
13. Provider Address — Enter the name and address of the contracted provider.
14. RUG — Resource Utilization Group. (Not used in CCAD services).
15. Fund Code — Enter 20 for Medicaid individuals eligible for FC. This item is also used for forced payments.
16. Group — Pre-populated on Form 2101 as Service Group 7, Community Care.
17. Code —
17 – PAS – PHC
17V – CDS – PHC
17C – PAS – FC
17CV – CDS – FC
17D – PAS – CAS
17DV – CDS – CAS
18 – Adult Foster Care
19 – Residential Care Assisted Living
20 – Emergency Response Services (ERS)
25 – Meals
26-26A – In-Home and Family Support Program (IHFSP)
27 – Client Managed Personal Attendant Services (CMPAS)
28 – Special Services to Persons with Disabilities (SSPD) – Adult Day Care
28 – SSPD 24-Hr. Care
28 – SSPD Other
29 – DAHS (Title XIX/XX)
63V – CDS FMS Administrative Fee
18. Units — Enter the number of units. Case managers may enter half units. For PHC, CAS or FC, half units must not exceed one digit. For example, if 16½ hours of PHC/CAS/FC are authorized, enter: 016.5. If the units are fewer than three digits, enter zeros in front of the units. For emergency response services always enter 001.0. For residential care, enter 001.0.
For CDS – Enter the total dollar amount of the Annualized Service Plan.
19. Unit Type — Enter the appropriate unit type based on the services being purchased.
1 – Week — PHC, CAS, FC, DAHS, Home Delivered Meals (HDM), SSPD, SSPD-Adult Day Care, CMPAS
2 – Month — ERS
3 – Year — CDS
4 – Per Authorization — IHFSP
5 – Daily — Adult Foster Care (AFC), Residential Care (RC), RC-Emergency Care, SSPD 24-Hour Shared Attendant Care
COPAYMENT — This item must be completed if the authorized service is RC. Leave blank for other services.
20. Initial Amt. — Enter the assessed individual copayment amount for the first calendar month of the authorized period. If there is no individual copayment, enter zeros. The initial copayment amount will always correspond to the first calendar month reflected in the begin date.
21. Ongoing Amt. — Enter the assessed individual copayment amount beginning with the second calendar month of the authorized period. The indicated copayment amount should continue indefinitely unless an increase or decrease occurs.
22. % CMPAS Only — The regional contract manager completes this item for CMPAS cases. Enter the percentage copayment amount as determined by the CMPAS contract and appropriate information letter.
23a. For PAS — Check the appropriate box to indicate whether the individual is receiving CAS, PHC or FC.
23b. For DAHS — Check the appropriate box to indicate whether the individual is receiving Title XIX or Title XX DAHS.
24. Service Items — For initial referrals and reassessments sent to providers, mark all tasks being purchased for CAS, PHC and FC.
|06 –||Grooming/Shaving/Oral care|
|07 –||Routine Hair/Skin Care|
|14 –||Meal Preparation|
|17 –||Assistance with Self-Administered Medications|
25. Comments — The case manager must use this item to document the number of days a PAS individual is requesting services based on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Example: Individual requests "a five-day plan" or "seven-day plan."
This item is also used to document information or communicate to the provider any applicable comments or circumstances which may include but are not limited to:
- Verbal negotiations between case manager and provider. Include the date the case manager contacted the provider, the name of the provider representative the case manager contacted for the negotiation, and the specific agreements made during the negotiation.
- Individuals who should not be hired as the paid attendant.
- Individuals who require a special schedule based on health or safety concerns.
- Priority status changes.
- Name of companion case.
- Other CCAD services individual receives.
- CAS annual reassessments with no change in services. Document "No Changes."
- DAHS facility-initiated referrals.
- CMPAS voucher individuals only – include the budget amount.
- CDS – enter weekly hours of service, the hourly rate, the Annual Service Plan (ASP) annualized hours, and the total ASP amount.
- Retroactive Reimbursement Case for PHC, including:
- approval for the retroactive period, but not for the ongoing period; and
- date the case manager notified the provider that the individual is eligible for only the retroactive period (ineligible for ongoing PHC/CAS) and the termination date.
Enter all appropriate authorizing agents.
26. Case Manager — Enter the case manager's name for all applicable cases.
27. Telephone No. — Enter case manager's telephone number including the area code and extension.
28. Mail Code — Enter case manager's mail code.
29. BJN — Enter case manager's budgeted job number (BJN).
30. Case Manager Address — Enter case manager's address.
31. Practitioner — The case manager enters the practitioner's name for PHC cases. The DADS regional nurse enters the practitioner's name for initial DAHS and CAS.
32. Telephone No. — Enter the practitioner’s telephone number, including the area code and extension. The DADS regional nurse completes this item for initial DAHS and CAS.
33. License No. — Enter the practitioner’s license number. For PHC, the DADS case manager must enter the license number. For initial DAHS and CAS, the DADS regional nurse must complete this item.
34. Date of Order — The DADS regional nurse enters the date as provided by Form 3055, Physician's Orders, (for DAHS) or Form 3052, Practitioner's Statement of Medical Need, (for CAS). For PHC, the DADS case manager enters the date from Form 3052.
35. Nurse —Enter the name of the DADS regional nurse who is authorizing services for CAS or DAHS.
36. Telephone No. — DADS regional nurse nurse enters telephone number.
37. Mail Code — DADS regional nurse nurse enters mail code.
38. BJN — DADS regional nurse nurse enters BJN.
39. Nurse Address — DADS regional nurse nurse enters address.
40. Diagnosis — DADS regional nurse enters the diagnosis or diagnoses from Form 3055 (for DAHS). This includes diagnosis of AIDS or HIV infection.
Contracted Agency May Complete This Section and Return a Copy to DADS
For AFC, PHC, CAS, ERS, FC and RC, the contracted agency may choose to complete and return the bottom portion of this form. However, the agency is not required to complete and return Form 2101.
For PHC, CAS and FC, based on 40 Texas Administrative Code ??47. 61(b), the provider must notify the case manager of service initiation. It is up to the provider if Form 2101 is used or if another written document is used for the notification.
For DAHS and HDM, the contracted agency must complete Form 2101 and return to the case manager.
If completion is required, the contracted agency enters the following:
Service Initiation Date — The contracted agency enters the date services are initiated.
Schedule — Self-explanatory. The contracted agency may complete this section for initial referrals for applicable community care services. Do not complete for AFC, RC or ERS.
Agency Contact Person — The contracted agency enters the name of the person the DADS case manager should contact regarding the individual.
Telephone No. — The contracted agency enters the telephone number of the provider contact person.
Comments — The contracted agency may enter this information including the name(s) of the attendant(s) delivering services to the individual, but it is not required. Add other comments as needed.
Signature – Agency Representative — Self-explanatory.
Date — Enter the date this form is mailed to the referring DADS case manager.