Case Manager Community Based Alternatives Handbook
Foreword
- 1000
- Program Overview
- 1100
- Introduction
- 1200
- Legal Basis
- 1300
- Values
- 1400
- Categories of CBA Providers
- 1500
- Service Delivery Model
- 1600
- Program Services
- 1610
- Excluded Services
- 1700
- Eligibility for Enrollment
- 1800
- Disclosure of Information and Confidentiality
- 1810
- Establishing Identity for Contact Outside the Interview Process
- 1811
- Telephone Contact
- 1812
- In-Person Contact
- 1813
- Verification and Documentation
- 1820
- Custody of Records
- 1830
- Disposal of Records
- 1840
- Disclosing Information
- 1841
- Disclosing Information about Deceased Individuals
- 1850
- Confidential Nature of Medical Information – HIPAA
- 1851
- Privacy Notice
- 1852
- Authorization to Release Health Information
- 1853
- Minimum Necessary
- 1854
- Personal Representatives
- 1854.1
- Adults and Emancipated Minors
- 1854.2
- Unemancipated Minors
- 1854.3
- Deceased Individuals
- 1855
- Correcting Information
- 1900
- General Procedures
- 1910
- Alternate Means of Communication
- 2000
- Contracting and Rates
- 2100
- Contracting Requirements
- 2200
- Rights and Responsibilities
- 2300
- Advertising and Solicitation of Individuals by Providers
- 2400
- Reimbursement Rates
- 2410
- Rates and Service Authorization System (SAS)
- 3000
- Case Management Responsibilities
- 3100
- Overview
- 3110
- Case Management
- 3200
- Intake and Interest List Procedures
- 3210
- Initial Requests
- 3210.1
- Screening for Referral to CBA Versus Other CCAD Services
- 3210.2
- Referral Criteria Summary
- 3210.3
- Rural Addresses
- 3210.4
- Caregiver Support Assessment Initiative
- 3210.5
- Referrals from Midland Document Processing Center
- 3211
- Eligibility Criteria
- 3211.1
- Basic Eligibility Criteria
- 3211.2
- Criteria to Bypass the Interest List and Money Follows the Person Option Criteria
- 3211.3
- Applicants Residing in a Nursing Facility
- 3211.4
- Medically Dependent Children Program and Texas Health Steps Program
- 3212
- Placement on the Community Services Interest List (CSIL)
- 3212.1
- Additional Procedures for Money Follows the Person
- 3212.2
- Updates and Dispositions
- 3212.3
- Monitoring
- 3212.4
- Transfer to Other Regions for Individuals on the Community Services Interest List (CSIL)
- 3212.5
- Transfers Between Waiver Program Interest Lists
- 3213
- Conflict of Interest
- 3300
- Assessment and Eligibility Determination
- 3310
- Assignment to the Case Manager
- 3310.1
- Criteria for Determining Immediate or Expedited Response
- 3310.2
- Releases/Assignments from the Community Services Interest List (CSIL)
- 3310.2.1
- Release/Assignment of an Individual from the Community Services Interest List (CSIL) Who Requests Services in Another Region
- 3310.3
- CBA Referrals for Applicants Temporarily Out of County of Residence
- 3310.4
- Nursing Facility Diversion Procedures for People at Imminent Risk of Nursing Facility Placement
- 3311
- CBA Enrollment Process – Initial Assessment
- 3311.1
- Applicant Choice Among Services
- 3311.2
- Living Arrangement Options
- 3311.2.1
- Exploring Options
- 3311.2.2
- Assisted Living/Residential Care (AL/RC) Option
- 3311.2.3
- Adult Foster Care (AFC) Option
- 3311.2.4
- Mutually Exclusive Community Based Alternatives Services
- 3311.3
- Reserved for Future Use
- 3311.4
- Functional Assessment for Personal Assistance Services
- 3311.4.1
- Delegated Nursing Tasks
- 3311.4.2
- Family Members and Informal Supports
- 3311.4.3
- 24-Hour Supervision for Applicants Living at Home
- 3311.4.4
- Authorization of Protective Supervision as a Personal Assistance Services Task
- 3311.5
- Utilization of Other Resources
- 3311.5.1
- Non-Waiver Services and Third-Party Resources
- 3311.5.2
- Third-Party Information
- 3311.6
- Financial Eligibility
- 3311.6.1
- Medicaid Eligibility
- 3311.6.2
- Medicaid Estate Recovery Program Requirements
- 3311.6.2.1
- Documenting Executor Information in the Service Authorization System (SAS)
- 3311.6.3
- Citizenship Verification
- 3311.7
- Rights and Responsibilities, Form 2307
- 3311.8
- Choice of HCSSA
- 3311.9
- Opportunity to Register to Vote
- 3312
- Referral for Pre-Enrollment Home Health Assessment
- 3313
- Referral for Medicaid Eligibility Determination
- 3313.1
- Unsigned Applications
- 3314
- Applicants Currently Residing in a Nursing Facility – Money Follows the Person (MFP) Option
- 3314.1
- Requests for Services from Nursing Facility Residents
- 3314.2
- Referral to Relocation Specialists
- 3314.3
- Money Follows the Person Demonstration
- 3314.3.1
- Money Follows the Person Demonstration and the Service Authorization System
- 3314.3.2
- Money Follows the Person Demonstration 365-Day Entitlement Period
- 3314.3.3
- Money Follows the Person Demonstration Overnight Companion Services
- 3315
- Home and Community Support Services Agency (HCSSA) Responsibility for Pre-Enrollment
- 3315.1
- Delay in Completion of the Pre-Enrollment Assessment
- 3316
- Review and Authorization for Payment of Pre-Enrollment Assessment
- 3316.1
- Physician Signature for Nursing Facility Residents
- 3316.2
- Licensed Physicians Practicing at Military or Veterans Affairs Facilities
- 3317
- Authorization for Second Pre-Enrollment Home Health Assessment
- 3317.1
- Additional Assessments for Applicants with High Needs
- 3400
- Development of the Individual Service Plan
- 3410
- Waiver Requirements
- 3411
- Documentation of Waiver Requirements
- 3420
- Case Manager Procedures for the Individual Service Plan
- 3421
- Determining Cost Effectiveness
- 3421.1
- Income Diversion Trust
- 3421.2
- Denial or Termination When Proposed ISP Exceeds the Cost Limit
- 3421.3
- Requesting General Revenue Funds for Services Not Covered Within the Waiver Cost Limit
- 3421.3.1
- Procedures for Applicants and Individuals Receiving Services
- 3421.3.2
- Additional Procedures for Individuals Receiving Services
- 3421.3.3
- State Office Review and Process to Request General Revenue Funds
- 3421.3.4
- Authorizations in Service Authorization System (SAS)
- 3421.4
- New Service Limits and Exception Criteria
- 3422
- Interdisciplinary Team
- 3422.1
- Freedom of Choice
- 3422.2
- Applicant Choices in Development of the ISP
- 3422.3
- Regional Nurse Consultation and Approval
- 3422.4
- Review of Nursing Plans and Administration of Medication Documentation
- 3423
- Applicants and Individuals with High Needs
- 3423.1
- Identification and Designation of an Applicant or Individual with High Needs
- 3423.2
- Staff Responsibilities
- 3423.3
- Responsibilities of Complex Needs Coordinators
- 3423.4
- Procedures for Applicants and Individuals Residing in a Nursing Facility and the ISP Exceeds the Cost Limit
- 3423.5
- Special Procedures for MDCP or THS-CCP Transitioning to CBA
- 3423.6
- Notification of Refusal to Serve an Applicant or Individual with High Needs
- 3423.7
- Disposition of an Applicant or Individual with High Needs
- 3423.8
- Contacts from External Sources
- 3430
- Finalizing Enrollment
- 3430.1
- Additional Procedures for Medical Necessity Denials
- 3431
- Verifying Level of Care/Medical Necessity Determination
- 3431.1
- Medical Necessity Determination
- 3431.2
- Medical Necessity Determination for Applicants Residing in Nursing Facilities
- 3431.3
- Medical Necessity Determination for Applicants Not Residing in Nursing Facilities
- 3431.4
- Special Procedures for Individuals Whose Medical Necessity Was Determined by a DADS Nurse (Second MN)
- 3431.5
- Long Term Care Portal
- 3432
- Verifying Financial Eligibility and Coordination of Enrollment with Medicaid Eligibility
- 3432.1
- Procedures for Money Follows the Person Option Applicants
- 3432.2
- Procedures for Interest List Individuals Referred for Financial Eligibility
- 3432.3
- Procedures for Texas Integrated Eligibility Redesign System (TIERS) Applicants
- 3433
- Coordination of ISP with HCSSA, AFC and AL/RC Providers
- 3433.1
- Restrictions Regarding HCSSA Attendants
- 3434
- Establishment of the Eligibility Date and Effective Date on Form 2065-B
- 3434.1
- Notification of Eligibility for CBA Applicants Using Money Follows the Person Option
- 3434.2
- Pending Money Follows the Person Option Applications Due to Delay in Nursing Facility Discharge
- 3435
- Provider Authorization and Initiation of Services
- 3435.1
- Verbal Negotiation with CBA Providers Regarding Service Initiation Date for Applicants
- 3435.2
- Written Authorization to HCSSA
- 3435.3
- Written Authorization to ERS, HDM, AFC and AL/RC Providers
- 3435.4
- Delay in Initiation of Authorized Services by HCSSA
- 3436
- Coordination of Termination of CCAD Services Upon Community Based Alternatives (CBA) Enrollment
- 3436.1
- Continuation of Community Attendant Services Pending Initiation of Community Based Alternatives Services
- 3436.2
- Transferring an Individual Who Receives QMB or SLMB Recipients to Community Based Alternatives
- 3440
- Service Authorization System (SAS) Online Overview
- 3440.1
- Registration of the Individual Service Plan (ISP)
- 3440.1.1
- Nursing Facility Consumers Transitioning to the Community
- 3440.2
- Force Change Requests
- 3450
- Case Record Contents
- 3500
- Financial Eligibility
- 3510
- Financial Eligibility Criteria
- 3520
- Spousal Impoverishment
- 3530
- Applicants with Medicaid Eligibility
- 3540
- An Applicant or Individual Without Medicaid Eligibility
- 3541
- Monthly Income Below the SSI Standard Payment
- 3542
- Coordination with the MEPD Staff
- 3543
- Applicants Residing in the Community
- 3544
- Applicants Residing in Nursing Facilities
- 3544.1
- Applicants in Nursing Facilities with Monthly Income Below the SSI Standard Payment
- 3544.2
- Applicants in Nursing Facilities with Monthly Income At or Above the SSI Standard Payment
- 3545
- Disability Determination for Applicants Under Age 65 Applying for Services
- 3550
- Copayment and Room and Board
- 3550.1
- Determining Room and Board Charges
- 3550.2
- Determining Copayment Amounts
- 3550.3
- Copayment Changes
- 3550.4
- Qualified Income Trust
- 3550.4.1
- Qualified Income Trust Copayment Agreement
- 3550.4.2
- Refusal to Pay Qualified Income Trust Copayment
- 3560
- Texas Medicaid Estate Recovery Program
- 3561
- Introduction
- 3562
- Medicaid Estate Recovery Program Claims
- 3563
- Undue Hardship Waivers
- 3564
- Claim Filing Process
- 3565
- Allowable Claim Deductions
- 3566
- Transfer of Assets
- 3570
- Correcting County Codes in the Service Authorization System (SAS)
- 3600
- Ongoing Case Management
- 3610
- Revising the Individual Service Plan (ISP)
- 3610.1
- Routine Service Plan Changes to the Individual Service Plan
- 3610.2
- Case Manager Response to Routine Change Requests
- 3610.2.1
- Requests sent to Regional Nurse for Review
- 3610.3
- Emergency Service Plan Changes to the Individual Service Plan
- 3610.4
- Case Manager Response to Emergency Requests
- 3610.5
- Agency Response to Change Requests
- 3610.6
- Agency Flexibility
- 3610.7
- Provider Change Procedures
- 3610.7.1
- Provider Change Authorization
- 3610.7.2
- Assessing Satisfaction When a Provider Change is Requested
- 3610.8
- Optional Change Procedures for Adaptive Aids and Medical Supplies
- 3610.9
- Case Record Transfer to Another Service Area
- 3610.10
- Case Manager Activities for Individuals Transferring Between CBA and STAR+PLUS Waiver
- 3620
- Required Notifications from the HCSSA
- 3630
- Service Breaks
- 3640
- Annual Reassessments
- 3641
- Annual Reassessment Activities
- 3642
- Annual Medical Necessity Evaluation and Home Health Assessment
- 3642.1
- Physician Signature at Annual Reassessment
- 3643
- Annual Update of the ISP
- 3643.1
- Medical Necessity Denials at the Annual Reassessment
- 3644
- Annual Reassessment Copayment Procedures
- 3645
- Financial Eligibility
- 3650
- Advocacy
- 3660
- Individual's Safety
- 3661
- Ongoing Case Management Duties Related to Medicaid
- 3661.1
- Your Texas Benefits Medicaid Card and Replacement
- 3661.2
- Reporting Changes Affecting Eligibility
- 3661.3
- Medicaid Resource Limit
- 3661.4
- Income Eligibility Verification System
- 3661.5
- Medical Transportation
- 3670
- Prescriptions
- 3670.1
- Over-the-Counter Drugs
- 3671
- Incurred Medical Expenses
- 3680
- Reporting Service Delivery Issues to Consumer Rights and Services
- 3700
- Service Monitoring
- 3710
- Monitoring Contacts and Telephone Contacts
- 3711
- Six-Month Review of the Individual Service Plan (ISP)
- 3712
- Review by the DADS Regional Nurse
- 3713
- Monitoring of Providers
- 3714
- Monitoring of Adult Foster Care (AFC)
- 3715
- Monitoring of Assisted Living
- 3716
- Documentation of Monitoring
- 3716.1
- Service Authorization System (SAS) Monitoring Documentation
- 3717
- Actions Following Monitoring
- 3718
- Transmittable Diseases
- 3800
- Suspensions, Notifications, Denials and Terminations
- 3810
- Program Suspension or Termination to an Individual Receiving Services
- 3810.1
- 12-Day Adverse Action
- 3810.2
- Responding to Situations of Threat to Health and Safety
- 3810.3
- Denying Requests to Exceed the New Service Limit
- 3811
- Circumstances Requiring Termination of CBA Services with Advance Notice
- 3811.1
- Extension of Suspension
- 3811.2
- Reinstating CBA Services After Being Institutionalized
- 3811.2.1
- HCSSA Annual Assessments in a Nursing Facility or Hospital
- 3811.2.2
- Personal Assistance Services (PAS) and Temporary Nursing Facility or Hospital Stays
- 3811.2.3
- Code 35 Procedures
- 3811.3
- Medical Necessity (MN) Denials
- 3811.4
- Loss of Medicaid
- 3811.5
- Exceeding the Cost Limit
- 3811.6
- Refusal to Serve an Individual
- 3811.7
- Refusal to Comply with Mandatory Program Requirements and Service Delivery Provisions
- 3811.8
- Failure to Pay Copayment or Room and Board
- 3811.9
- Termination Due to Hazardous Condition for the Service Provider's Health and Safety
- 3811.9.1
- Active Tuberculosis (TB) Diagnosis
- 3812
- Circumstances Requiring Termination of Services and Medicaid Eligibility Without Advance Notice
- 3812.1
- Termination Due to Death
- 3812.2
- Other Mandatory Terminations Without Advance Notice
- 3813
- Circumstances Which May Result in Termination of Services and Require Advance Notice
- 3813.1
- Demonstrated Pattern of Abuse or Discrimination
- 3813.2
- Termination Due to Verbal Abuse, Harassment or Discrimination
- 3814
- Crisis Intervention Requiring Immediate Suspension or Reduction of Services Without Advance Notice
- 3814.1
- Suspension Procedures Pertaining to Imminent Danger
- 3814.2
- Administrative Payment During Suspension
- 3814.3
- Crisis Interventions
- 3814.4
- Termination After Suspension
- 3814.5
- Immediate Suspension with Advance Notice
- 3814.6
- Reinstatement of Services Terminated for Threats of Health or Safety
- 3814.7
- Reinstatement of Suspended Services
- 3815
- Sanctions
- 3820
- Individual's Rights
- 3821
- Notifications
- 3821.1
- General Information Regarding Notifications
- 3821.1.1
- Completion of Form 2065-B and Form 2065-C Notifications
- 3821.2
- Notification of Approval of CBA Application
- 3821.2.1
- Notification of Approval of CBA Application for Individual Aging Out
- 3821.3
- Notification of Denials and Terminations
- 3821.4
- Reasons for Denial and Termination of CBA Services
- 3821.5
- Notification of Approval of CBA at the Annual Reassessment
- 3830
- Appeals
- 3831
- General Information Regarding Appeals
- 3831.1
- Termination of Community Based Alternatives (CBA) Eligibility if the Individual Does Not Appeal
- 3831.2
- Continuation of Community Based Alternatives (CBA) Services During an Appeal
- 3831.3
- Case Manager Responsibilities and Effective Dates of Appeal Decisions
- 3832
- Appeal Procedures for MN Denial
- 3833
- Coordination of Appeals Involving Medicaid
- 3834
- Appeal Procedures for Utilization Review Findings
- 3835
- Fair Hearings Exception Process
- 3836
- Fair Hearings Evidence Packets and Presentation
- 4000
- Specific CBA Services
- 4100
- Home and Community Support Services
- 4110
- Program Overview
- 4111
- Service Introduction
- 4111.1
- Service Locations for Home and Community Support Services Agencies (HCSSAs)
- 4112
- General Contracting Requirements
- 4113
- General Requirements for Participation
- 4114
- Service Plan
- 4115
- Individual Agreement for Services
- 4116
- Refusal to Serve an Applicant or Individual
- 4120
- Description of Services
- 4121
- Personal Assistance Services
- 4121.1
- Description of Personal Assistance Services
- 4121.2
- Qualifications for Registered Nurse Supervisors
- 4121.3
- Qualifications of Personal Assistance Services Attendants
- 4121.4
- Types of Personal Care Attendants
- 4121.5
- Orientation and Training Responsibilities of the RN Supervisor
- 4121.6
- Required Training for Attendants
- 4121.7
- Training of Unpaid Family Members, Neighbors or Other Informal Support
- 4122
- Nursing Services
- 4122.1
- Role of the CBA Nurse with the TPR Nurse
- 4122.2
- Role of the Licensed Vocational Nurse
- 4122.3
- Nursing Services in Participant's Homes
- 4122.4
- Nursing Services in Personal Care Facilities
- 4122.5
- Nursing Services in Adult Foster Care Homes, Levels I and II
- 4122.5.1
- Nursing Services in AFC Homes Operated by Licensed Nurses
- 4122.5.2
- Orientation/Training and Delegation/Supervision of the Adult Foster Care Provider
- 4122.5.3
- Documenting Non-Delegation of Nursing Tasks in Adult Foster Care Homes
- 4122.6
- Semiannual Nursing Assessments
- 4122.7
- Utilization of Other Resources
- 4122.7.1
- Self-Determination Act
- 4122.8
- Post-Hospital Assessment Visits
- 4123
- Specialized Nursing
- 4130
- Therapy Services
- 4130.1
- Initiation of Assessment and Therapy
- 4130.2
- Responsibilities of Licensed Therapists in CBA
- 4140
- Adaptive Aids and Medical Supplies
- 4141
- List of Adaptive Aids and Medical Supplies
- 4142
- Case Manager Approval of Adaptive Aids and Medical Supplies
- 4142.1
- Lift Chair Approvals
- 4142.2
- Nutritional Supplement Approvals
- 4142.3
- Monitored Medication Unit Approvals
- 4142.4
- Vehicle Modification Requirements
- 4142.5
- Verification of Third-Party Resources for Adaptive Aids and Medical Supplies
- 4143
- Provider Responsibilities Pertaining to Adaptive Aids and Medical Supplies
- 4143.1
- Agency Responsibilities Pertaining to Optional Change Procedures for Adaptive Aids/Medical Supplies
- 4144
- Requesting Adaptive Aids or Medical Supplies Not on the Approved List
- 4144.1
- Requesting Regional Nurse Approval to Exceed Individual Service Cap
- 4145
- Emergency Procurement of Adaptive Aids and Medical Supplies
- 4146
- Effects of Changing Providers on Adaptive Aids Procurements
- 4147
- Time Frames for Adaptive Aids/Medical Supplies
- 4148
- Reserved for Future Use
- 4149
- Co-Insurance and Deductibles
- 4149.1
- Temporary Lease and Equipment Rental
- 4149.2
- Bulk Purchase of Medical Supplies
- 4149.3
- Reporting Medical Supplies on the Cost Report
- 4149.4
- Freight and Delivery Charges
- 4150
- Minor Home Modifications
- 4151
- List of Minor Home Modifications
- 4151.1
- Home Modification Service Cost Lifetime Limit
- 4152
- Case Manager Responsibilities for Minor Home Modifications
- 4152.1
- Interactions with Applicants/Participants Regarding Minor Home Modifications
- 4152.1.1
- Home Modifications Prior to Nursing Facility Discharge
- 4152.2
- Requesting Minor Home Modifications Not on the Approved List
- 4152.3
- Requesting Regional Nurse Approval to Exceed the Minor Home Modification Service Cap
- 4153
- Agency Responsibilities Pertaining to Minor Home Modifications
- 4153.1
- Minor Home Modification Procurement
- 4153.2
- Documentation of Necessity for Home Modifications
- 4153.3
- Accountability for Minor Home Modifications
- 4153.4
- Requests for Home Remodeling and Major Renovations
- 4153.5
- Time Frames for Minor Home Modifications
- 4153.6
- Changing Providers During a Home Modification
- 4153.7
- Minor Home Modifications in Adult Foster Care (AFC) Homes
- 4160
- Reserved for Future Use
- 4170
- Dental Services
- 4171
- Allowable Dental Services and Service Limits
- 4172
- HCSSA Responsibilities for Dental Services
- 4173
- Case Manager Responsibilities Pertaining to Dental Services
- 4174
- Emergency Procurement of Dental Services
- 4175
- Referrals to Dental Contractor for Review
- 4180
- Complaint Procedures
- 4200
- Adult Foster Care
- 4210
- Description
- 4211
- Services Provided by Adult Foster Care Providers
- 4211.1
- Other Services Available to Adult Foster Care Consumers
- 4211.2
- Adult Foster Care Provider Responsibilities
- 4212
- Four Bed Adult Foster Care Homes
- 4213
- Small Group Homes
- 4214
- Contract Manager and Case Manager Responsibilities
- 4214.1
- Contract Manager Responsibilities
- 4214.2
- Case Manager Responsibilities
- 4220
- Adult Foster Care Eligibility
- 4230
- Adult Foster Care Intake and Assessment
- 4231
- Response to Request for Services
- 4232
- Consumer’s Rights and Responsibilities
- 4233
- Assessing Potential Adult Foster Care Homes
- 4234
- Classification Levels of Adult Foster Care Consumers
- 4235
- Placement on the Interest List
- 4236
- Adult Protective Services and Adult Foster Care
- 4236.1
- Placement of Adult Protective Services Consumers in Adult Foster Care
- 4236.2
- Adult Protective Services Investigations of Adult Foster Care Providers
- 4237
- Private Pay in Adult Foster Care
- 4240
- Adult Foster Care Case Manager Procedures
- 4241
- Eligibility Determination
- 4242
- Service Planning
- 4250
- Finalizing the Care Plan
- 4251
- Consumer and Provider Agreement
- 4252
- Copayment and Room and Board Requirements
- 4253
- Trust Funds
- 4254
- Hospital Leave
- 4255
- Authorization of Adult Foster Care
- 4256
- Adult Foster Care and Day Activity and Health Services
- 4260
- Monitoring Quality of Care
- 4270
- Significant Changes
- 4271
- Termination of Adult Foster Care Services
- 4272
- Discharge and Termination Due to Health and Safety
- 4280
- Annual Reassessment
- 4300
- Residential Care Services
- 4310
- Introduction
- 4311
- Housing Options in Licensed Personal Care Facilities
- 4320
- Description of Services
- 4321
- Case Management Duties Related to Assisted Living/Residential Care
- 4322
- Initial Responsibilities for Individuals Residing in an Assisted Living Facility
- 4323
- Admission to Facility
- 4324
- Personal Care 3
- 4325
- Nursing Services for AL/RC Consumers
- 4326
- Response to AL/RC Consumer Condition Change
- 4327
- RUG Resets
- 4330
- Other Services Available to Consumers
- 4340
- Copayment/Room and Board/Leave
- 4341
- Room and Board and Copayment Requirements
- 4341.1
- Room and Board Requirements
- 4341.2
- Copayment Requirements
- 4342
- Personal Leave
- 4343
- Institutional Leave
- 4344
- Termination Due to Failure to Pay the Required Contribution to the Cost of Care
- 4350
- Standards for Operation
- 4351
- Facility Reporting and Notification Requirements
- 4351.1
- Assisted Living Provider Transfers or Termination Due to Refusal to Comply Issues
- 4352
- Assisted Living Facility Documentation
- 4360
- Reserved for Future Use
- 4370
- Trust Funds
- 4371
- Trust Fund Management
- 4372
- Trust Fund Transactions
- 4373
- Payment of Copayment and Room and Board from Trust Fund
- 4374
- Trust Fund Refunds
- 4375
- Trust Fund Refunds for Consumer Discharge or Death
- 4400
- Respite
- 4410
- Case Management Duties Related to Respite
- 4410.1
- Requesting Regional Nurse Approval to Exceed the Respite Service Limit
- 4420
- In-Home Respite
- 4430
- Out-of-Home Respite Services
- 4431
- Introduction
- 4432
- Consumer Eligibility
- 4433
- Provider Qualifications
- 4434
- Description of Services
- 4435
- Respite Service in a Personal Care Facility or Adult Foster Care Home
- 4436
- Respite Service in a Nursing Facility
- 4440
- Room and Board
- 4450
- Billing Documentation
- 4451
- Billing Units of Respite Services
- 4500
- Emergency Response Services
- 4510
- Introduction
- 4511
- Program Purpose
- 4511.1
- Program Definitions
- 4512
- Eligibility and Referral Procedures
- 4512.1
- Eligibility
- 4512.2
- Referral Process
- 4513
- Case Management Duties Related to Emergency Response Services (ERS)
- 4520
- Service Delivery Requirements
- 4521
- Service Initiation
- 4522
- Securing Responders
- 4523
- Home Visit
- 4524
- Provider Follow-Up Procedures
- 4525
- Selection of Providers and Provider Changes
- 4530
- Service Delivery
- 4531
- Alarm Calls
- 4532
- Systems Checks
- 4533
- Equipment Malfunction
- 4540
- Suspension and Termination of Emergency Response Services
- 4541
- Interdisciplinary Team (IDT) Meetings
- 4550
- Rates and Contracts
- 4551
- Advertising and Solicitation
- 4552
- Disclosure of Previous Employment and Certification
- 4553
- Consumer Records
- 4600
- Home-Delivered Meals
- 4610
- Description
- 4620
- Provider Responsibilities
- 4620.1
- Frozen or Shelf-Stable Meals
- 4700
- Transition Assistance Services
- 4710
- Introduction
- 4711
- Service Description
- 4720
- Case Manager Procedures at the Initial Interview
- 4730
- Assistance from Relocation Specialists
- 4740
- Identification of Needed Items and Services
- 4741
- Items and Services Included Under TAS
- 4741.1
- Deposits
- 4741.2
- Household Needs
- 4741.3
- Housewares
- 4741.4
- Small Appliances
- 4741.5
- Cleaning Supplies
- 4741.6
- Other Items Not Listed
- 4742
- Services and Items Not Included in Transition Assistance Services (TAS)
- 4743
- Site Preparation
- 4750
- Estimated Cost of Items and Services
- 4751
- Totaling the Estimated Cost and Authorization of Transition Assistance Services (TAS)
- 4752
- Changes to the Authorization
- 4753
- Authorization of Transition Assistance Services (TAS) in Service Authorization System (SAS)
- 4760
- Transition Assistance Services (TAS) Agency Responsibilities
- 4770
- Three-Day Monitor Required
- 4780
- Failure to Leave the Facility
- 4790
- Client Notifications and Appeals
- 5000
- Consumer Directed Services (CDS)
- 5100
- Overview
- 5110
- Definitions
- 5120
- CBA Service Options Available Under the CDS Option
- 5130
- Risks and Advantages of the CDS Option
- 5131
- Risks Associated with the CDS Option
- 5132
- Advantages of CDS Service Delivery
- 5140
- Consumer and Consumer Directed Services Agency (CDSA) Responsibilities
- 5141
- Consumer Responsibilities
- 5142
- CDSA Responsibilities
- 5143
- Consumer Directed Services Contact Chart
- 5200
- Consumer Choice in the CDS Option
- 5210
- Presentation of the CDS Option
- 5220
- Consumer Choice Regarding Use of the CDS Option
- 5220.1
- Consumer Directed Services Agency Choice
- 5221
- Designated Representative
- 5300
- Determining the Individual Service Plan (ISP)
- 5310
- Skilled Nursing Tasks Available for Delegation in the CDS Option
- 5311
- Nursing in the CDS Option
- 5320
- Respite Services
- 5320.1
- Consumer Directed Services Agency Choice
- 5321
- In-Home Respite in the CDS Option
- 5322
- Out-of-Home Respite in the CDS Option
- 5330
- Employer Support Services
- 5340
- Therapy
- 5400
- Transitioning to the CDS Option
- 5410
- Initiation of and Transition to the CDS Option
- 5420
- Initiation and Orientation of the Consumer as Employer
- 5430
- Employer and Employee Acknowledgment
- 5440
- Authorizing CDS
- 5500
- CDS Service Planning
- 5510
- Service Back-Up Plans
- 5520
- Corrective Action Plans
- 5530
- Budgets
- 5600
- Monitoring
- 5610
- Thirty Day Contact
- 5700
- Transfers and Changes in Participation in the CDS Option
- 5710
- Transfer to a Different Consumer Directed Services Agency (CDSA)
- 5720
- Suspension of Participation in the CDS Option
- 5730
- Termination of Participation in the CDS Option
- 5740
- Re-Enrollment for Participation in the CDS Option
- 6000
- State of Texas Access Reform Plus (STAR+PLUS) Managed Care
- 6100
- Program Overview
- 6110
- Services Available Under STAR+PLUS
- 6111
- Services Provided Under STAR+PLUS
- 6112
- Transition Between DADS and STAR+PLUS
- 7000
- Case Management Procedures for Utilization Review
- 7100
- Community Based Alternatives Utilization Review
- 7110
- New Service Limit Exception Procedures and Utilization Review
- 7200
- Prospective Reviews and Referral Packets
- 7210
- Determining Prospective Review Threshold
- 7220
- Initial Enrollments and Annual Reassessments
- 7230
- Individual Service Plan Changes
- 7240
- Referral Packet Transmission
- 7250
- Utilization Review Unit Responsibilities and Time Frames for Prospective Reviews
- 7300
- Concurrent Reviews and Referral Packets
- 7400
- Utilization Review Observations and Findings
- 7410
- Reporting Observations by the Utilization Review Nurse
- 7420
- Utilization Review Finding Reports to the Regional Director
- 7430
- Regional Director Response to Utilization Review Findings
- 7440
- Final Utilization Review Findings
- 7450
- Exception Process for Concurrent Utilization Review Findings
- 7500
- Implementation of Utilization Review Observations, Recommendations and Findings
- 7510
- Implementing Prospective Utilization Review Findings
- 7520
- Implementing Concurrent Utilization Review Findings
- 8000
- Sanctions, Fraud and Abuse
- 8100
- Provider Fraud and Abuse
- 8110
- Determination of Provider Fraud
- 8120
- Determination of Abuse
- 8130
- Civil Penalty
- 8140
- Reporting Fraud and Abuse
- 8150
- Responding to Allegations of Provider Fraud and Abuse
- 8160
- Development of the Fraud Referral Packet
- 8161
- Expedited Referrals
- 8162
- Referral of Potential Provider Fraud
- 8170
- After Referrals of Potential Provider Fraud are Made
- 8200
- Fraud Detection and Referrals for Individuals Receiving Services
- 8210
- Determination of Fraud Committed by an Individual
- 8220
- Responding to Allegations of Fraud Committed by an Individual
- 8230
- DADS Development of Fraud Referral
- 8240
- Expedited Referrals
- 8250
- Referral of Potential Fraud Committed by an Individual
- 8260
- After Referrals of Potential Fraud Committed by an Individual are Made
- 8300
- Sanctions
- 9000
- Service Authorization System Help File
- 9100
- Service Authorization System (SAS) Wizards
- 9110
- SAS CBA Wizard
- 9111
- Wizard Sequencing — CBA Wizard
- 9112
- Automatically Populated Folders — CBA Wizard
- 9113
- Records that Require User Entries Prior to Completing the SAS CBA Wizard
- 9114
- Address — CBA Wizard
- 9115
- Phone — CBA Wizard
- 9116
- Other Information — CBA Wizard
- 9120
- CCAD Functional Wizard — CBA
- 9120.1
- Service Request Window (Read Only) — CCAD Functional Wizard — CBA
- 9120.2
- Interview Window — CCAD Functional Wizard — CBA
- 9120.3
- Household Window — CCAD Functional Wizard — CBA
- 9120.4
- Health Concerns Window — CCAD Functional Wizard — CBA
- 9120.5
- Impairment Scoring Window — CCAD Functional Wizard — CBA
- 9120.6
- Task Purchased Details Window(s) — CCAD Functional Wizard — CBA
- 9120.7
- Support Assisting Client Window — CCAD Functional Wizard — CBA
- 9120.8
- Caregiver Support Details Window — CCAD Functional Wizard — CBA
- 9120.9
- Paid Attendant Window — CCAD Functional Wizard — CBA
- 9120.10
- Other Agency Support Details Window — CCAD Functional Wizard — CBA
- 9120.11
- Task/Time Allocation Window — CCAD Functional Wizard — CBA
- 9120.12
- Task/Hour Guide Summary Window — CCAD Functional Wizard — CBA
- 9120.13
- Supervisor Window — CCAD Functional Wizard — CBA
- 9120.14
- Attendant Hours Adjustment Window — CCAD Functional Wizard — CBA
- 9120.15
- Home Environment Window — CCAD Functional Wizard — CBA
- 9120.16
- Eligibility Determination Window — CCAD Functional Wizard — CBA
- 9130
- Pre-Enrollment Assessment — CBA Wizard
- 9131
- Service Request Window/Pre-Enrollment Assessment — CBA Wizard
- 9132
- Service Action Window/Pre-Enrollment Assessment — CBA Wizard
- 9133
- Service Arrangement Window/Pre-Enrollment Assessment — CBA Wizard
- 9134
- Provider Selection Window/Pre-Enrollment Assessment — CBA Wizard
- 9135
- Worker's BJN Window/Pre-Enrollment Assessment — CBA Wizard
- 9136
- Service Summary Window/Pre-Enrollment Assessment — CBA Wizard
- 9140
- Create Transition Assistance Services (TAS) — CBA Wizard
- 9141
- Service Request Window/Create TAS — CBA Wizard
- 9142
- Service Action Window/Create TAS — CBA Wizard
- 9143
- Service Arrangement Window/Create TAS — CBA Wizard
- 9144
- Provider Selection Window/Create TAS — CBA Wizard
- 9145
- Worker's BJN Window/Create TAS — CBA Wizard
- 9146
- Service Unit/Rate Entry Window/Create TAS — CBA Wizard
- 9147
- Service Summary Window/Create TAS — CBA Wizard
- 9150
- Draft ISP — CBA Wizard
- 9151
- Service Request Window/ Draft ISP — CBA Wizard
- 9152
- Service Action Window/Draft ISP — CBA Wizard
- 9153
- Service Code Selection/Draft ISP — CBA Wizard
- 9154
- CBA Service Information/Draft ISP — CBA Wizard
- 9155
- Service Unit/Rate Entry Window/Draft ISP — CBA Wizard
- 9156
- Worker's BJN/Draft ISP — CBA Wizard
- 9157
- Service Summary Window/Draft ISP — CBA Wizard
- 9200
- Initial ISP — CBA Wizard
- 9210
- Service Request Window/Initial ISP — CBA Wizard
- 9220
- Service Action Window/Initial ISP — CBA Wizard
- 9230
- Service Arrangement Window/Initial ISP — CBA Wizard
- 9240
- Provider Selection/Initial ISP — CBA Wizard
- 9250
- CBA Service Information/Initial ISP — CBA Wizard
- 9260
- Service Unit/Rate Entry/Initial ISP — CBA Wizard
- 9270
- Worker's BJN Window/Initial ISP — CBA Wizard
- 9280
- Service Summary Window/Initial ISP — CBA Wizard
- 9290
- Service Approval Window/Initial ISP — CBA Wizard
- 9300
- ISP Change — CBA Wizard
- 9310
- Service Action/ISP Change — CBA Wizard
- 9320
- Service Code Selection Window/ISP Change — CBA Wizard
- 9330
- ISP Change Window/ISP Change — CBA Wizard
- 9340
- Service Arrangement Window/ISP Change — CBA Wizard
- 9350
- Provider Selection Window/ISP Change — CBA Wizard
- 9360
- CBA Information Window/ISP Change — CBA Wizard
- 9370
- Service Unit/Rate Entry/ISP Change — CBA Wizard
- 9380
- Worker's BJN Window/ISP Change — CBA Wizard
- 9390
- Service Summary/ISP Change — CBA Wizard
- 9400
- Provider Transfer — CBA Wizard
- 9410
- Service Request Window/Provider Transfer — CBA Wizard
- 9420
- Service Action Window/Provider Transfer — CBA Wizard
- 9430
- Service Code Selection Window/Provider Transfer — CBA Wizard
- 9440
- Service Arrangement Window/Provider Transfer — CBA Wizard
- 9450
- Provider Selection Window/Provider Transfer — CBA Wizard
- 9460
- Service Unit/Rate Entry/Provider Transfer — CBA Wizard
- 9470
- Worker's BJN Window/Provider Transfer — CBA Wizard
- 9480
- Service Summary Window/Provider Transfer — CBA Wizard
- 9500
- Reassessment — CBA Wizard
- 9510
- Service Request Window/Reassessment — CBA Wizard
- 9520
- Service Action Window/Reassessment — CBA Wizard
- 9530
- Service Code Selection Window/Reassessment — CBA Wizard
- 9540
- Service Arrangement Window/Reassessment — CBA Wizard
- 9550
- Provider Selection Window/Reassessment — CBA Wizard
- 9560
- CBA Service Information/Reassessment — CBA Wizard
- 9570
- Service Unit/Rate Entry/Reassessment — CBA Wizard
- 9580
- Worker's BJN Window/Reassessment — CBA Wizard
- 9590
- Service Summary Window/Reassessment — CBA Wizard
- 9600
- Code 35 Actions — CBA Wizard
- 9610
- Stop Services/Code 35 Actions — CBA Wizard
- 9611
- Service Action/Stop Services/Code 35 Actions — CBA Wizard
- 9612
- ISP Change/Stop Services/Code 35 Actions — CBA Wizard
- 9613
- CBA Service Information/Stop Services/Code 35 Actions — CBA Wizard
- 9614
- Service Unit/Rate Entry/Stop Services/Code 35 Actions — CBA Wizard
- 9615
- Worker's BJN/Stop Services/Code 35 Actions — CBA Wizard
- 9616
- Service Summary Window/Stop Services/Code 35 Actions — CBA Wizard
- 9620
- Reinstate Services When ISP Has Not Expired/Code 35 Actions — CBA Wizard
- 9621
- Service Request/Reinstate Services When ISP Has Not Expired/Code 35 Actions — CBA Wizard
- 9622
- Service Action/Reinstate Services When ISP Has Not Expired/Code 35 Actions — CBA Wizard
- 9623
- ISP Change/Reinstate Services When ISP Has Not Expired/Code 35 Actions — CBA Wizard
- 9624
- CBA Service Information/Reinstate Services When ISP Has Not Expired/Code 35 Actions — CBA Wizard
- 9625
- Service Unit/Rate Entry/Reinstate Services When ISP Has Not Expired/Code 35 Actions — CBA Wizard
- 9626
- Worker's BJN/Reinstate Services When ISP Has Not Expired/Code 35 Actions — CBA Wizard
- 9627
- Service Summary/Reinstate Services When ISP Has Not Expired/Code 35 Actions — CBA Wizard
- 9630
- Reinstate Services When ISP Has Expired/Code 35 Actions — CBA Wizard
- 9631
- Terminate/Service Request/Reinstate Services When ISP Has Expired/Code 35 Actions — CBA Wizard
- 9632
- Terminate/Service Action/Reinstate Services When ISP Has Expired/Code 35 Actions — CBA Wizard
- 9633
- Terminate/Worker's BJN/Reinstate Services When ISP Has Expired/Code 35 Actions — CBA Wizard
- 9634
- Terminate/Service Summary/Reinstate Services When ISP Has Expired/Code 35 Actions — CBA Wizard
- 9640
- Authorizing Reassessment/Service Request/Reinstate Services When ISP Has Expired/Code 35 Actions — CBA Wizard
- 9641
- Authorizing Reassessment/Service Action/Reinstate Services When ISP Has Expired/Code 35 Actions — CBA Wizard
- 9642
- Authorizing Reassessment/Service Code Selection/Reinstate Services When ISP Has Expired/Code 35 Actions — CBA Wizard
- 9643
- Authorizing Reassessment/Service Arrangement/Reinstate Services When ISP Has Expired/Code 35 Actions — CBA Wizard
- 9644
- Authorizing Reassessment/Provider Selection/Reinstate Services When ISP Has Expired/Code 35 Actions — CBA Wizard
- 9645
- Authorizing Reassessment/CBA Service Information/Reinstate Services When ISP Has Expired/Code 35 Actions — CBA Wizard
- 9646
- Authorizing Reassessment/Service Unit/Rate Entry/Reinstate Services When ISP Has Expired/Code 35 Actions — CBA Wizard
- 9647
- Authorizing Reassessment/Worker's BJN/Reinstate Services When ISP Has Expired/Code 35 Actions — CBA Wizard
- 9648
- Authorizing Reassessment/Service Summary/Reinstate Services When ISP Has Expired/Code 35 Actions — CBA Wizard
- 9650
- Close Services/Code 35 Actions — CBA Wizard
- 9651
- Service Request/Close Services/Code 35 Actions — CBA Wizard
- 9652
- Service Action/Close Services/Permanent Stay Exceeds 180 days or Death/Code 35 Actions — CBA Wizard
- 9653
- Worker's BJN/Close Services/Code 35 Actions — CBA Wizard
- 9654
- Service Summary/Close Services/Code 35 Actions — CBA Wizard
- 9700
- Terminate Program Group — CBA Wizard
- 9710
- Service Request Window/Terminate Program Group — CBA Wizard
- 9720
- Service Action Window/Terminate Program Group — CBA Wizard
- 9730
- Worker's BJN Window/Terminate Program Group — CBA Wizard
- 9740
- Service Summary Window/Terminate Program Group — CBA Wizard
- 9800
- Authorizing CBA Services Without the Wizards
- 9810
- Pre-Enrollment Home Health Assessment — CBA
- 9811
- Client Details/Pre-Enrollment Home Health Assessment — CBA
- 9812
- Authorizing Agent/Pre-Enrollment Home Health Assessment — CBA
- 9813
- Service Authorization/Pre-Enrollment Home Health Assessment — CBA
- 9820
- Transition Assistance Services — CBA
- 9821
- Authorizing Agent/Transition Assistance Services — CBA
- 9822
- Service Authorization/Transition Assistance Services — CBA
- 9823
- Terminating Transition Assistance Services — CBA
- 9824
- Terminating TAS for Individual Remaining in Nursing Facility — CBA
- 9830
- Initial Service Authorization — CBA
- 9830.1
- Client Details/Initial Service Authorization — CBA
- 9830.2
- Address Folder/Initial Service Authorization — CBA
- 9830.3
- Location/Initial Service Authorization — CBA
- 9830.4
- Phone/Initial Service Authorization — CBA
- 9830.5
- Authorizing Agent/Initial Service Authorization — CBA
- 9830.6
- Enrollment/Initial Service Authorization — CBA
- 9830.7
- Service Plan/Initial Service Authorization — CBA
- 9830.8
- Service Authorization/Initial Service Authorization — CBA
- 9830.9
- Service Item/Initial Service Authorization — CBA
- 9830.10
- Applied Income/Initial Service Authorization — CBA
- 9830.11
- Level of Service/Initial Service Authorization — CBA
- 9830.12
- Diagnosis/Initial Service Authorization — CBA
- 9830.13
- Medical Necessity/Initial Service Authorization — CBA
- 9840
- Reassessment Service Authorization — CBA
- 9840.1
- Client Details/Reassessment Service Authorization — CBA
- 9840.2
- Address/Reassessment Service Authorization — CBA
- 9840.3
- Location/Reassessment Service Authorization — CBA
- 9840.4
- Phone/Reassessment Service Authorization — CBA
- 9840.5
- Authorizing Agent/Reassessment Service Authorization — CBA
- 9840.6
- Enrollment/Reassessment Service Authorization — CBA
- 9840.7
- Service Plan/Reassessment Service Authorization — CBA
- 9840.8
- Service Authorization/Reassessment Service Authorization — CBA
- 9840.9
- Service Item/Reassessment Service Authorization — CBA
- 9840.10
- Applied Income/Reassessment Service Authorization — CBA
- 9840.11
- Level of Service/Reassessment Service Authorization — CBA
- 9840.12
- Medical Necessity/Reassessment Service Authorization — CBA
- 9850
- ISP Changes — CBA
- 9851
- ISP Changes/Provider Transfers — CBA
- 9852
- All Other ISP Changes — CBA
- 9860
- Nursing Facility Placement for an Individual
- 9861
- Temporary Nursing Facility Placement for an Individual
- 9862
- Reassessment for an Individual in a Nursing Facility
- 9870
- Money Follows the Person (MFP) Authorization for an Individual
- 9880
- Miscellaneous Actions
- 9881
- Mutually Exclusive Services Within CBA
- 9882
- Significant Change in Status Assessment — CBA
- 9883
- CBA Respite Authorization in a Nursing Facility
- 9890
- Terminations — CBA
- 9891
- Terminating All Services — CBA
- 9892
- Terminating a Specific Service Code — CBA
- 9900
- Monitoring Wizard — CBA
- 9900.1
- Services Request Window — Monitoring Wizard — CBA
- 9900.2
- Services Authorized Window — Monitoring Wizard — CBA
- 9900.3
- Contact Window — Monitoring Wizard — CBA
- 9900.4
- Monitor Detail Window — Monitoring Wizard — CBA
- 9900.5
- Reasons for Dissatisfaction Window — Monitoring Wizard — CBA
- 9900.6
- Actions Selection Window — Monitoring Wizard — CBA
- 9900.7
- Client Satisfaction Window — Monitoring Wizard — CBA