Form 8599
Instructions

Individual Plan of Care (IPC) Cover Sheet

05-2012

PROCEDURE

In the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) waiver programs, the Individual Plan of Care (IPC) Cover Sheet must be completed when the waiver program provider is required to submit the IPC to the Department of Aging and Disability Services (DADS), Utilization Management and Review, IDD Waivers Program Enrollment/Utilization Review (PE/UR) unit for approval. This must be done when:

DETAILED INSTRUCTIONS

The Local Authority (LA) service coordinator (SC) for the TxHmL program and the program provider for the HCS program complete all information on the IPC Cover Sheet and submit to DADS with documentation justifying the services.

Program Type: (check one) — Mark the appropriate box to indicate the type of program.

Provider Name — Enter the name of the program provider.

Component Code — Enter the program provider component code.

Contract No. — Enter the contract number for the program provider.

Provider Contact Information

Provider Contact — Enter the name of the person who will act as the contact for the program provider. The provider contact should be someone who can answer questions about the action being requested.

Area Code and Telephone No. — Enter the area code and telephone number for the person who will act as the contact for the program provider.

Fax Area Code and Telephone No. — Enter the fax area code and telephone number for the person who will act as the contact for the program provider.

Email Address — Enter the email address of the program provider contact.

LA

LA Name — Enter the name of the LA.

Component Code — Enter the LA component code.

LA Service Coordinator Contact Information

LA Service Coordinator — Enter the name of the service coordinator who will act as the contact for the LA.

Area Code and Telephone No. — Enter the area code and telephone number of the service coordinator.

Fax Area Code and Telephone No. — Enter the fax area code and telephone number for the service coordinator.

Email Address — Enter the email address of the LA service coordinator.

Individual Information

Individual's Last Name — Enter the individual's last name.

Individual's First Name — Enter the individual's first name.

CARE ID No. — Enter the individual's Client Assignment and REgistration (CARE) system identification number.

Medicaid No. — Enter the individual's Medicaid number.

Local Case No. — Enter the individual's local case number with the program provider.

Date of Birth — Enter the individual's date of birth.

Age — Enter the individual's age.

Indicate IPC Review (check one) — Mark the box for the applicable IPC type: Renewal, Revision, PE/UR Request or Transfer (Program Provider or Consumer Directed Services option).

IPC Revision Date (from C62) of the IPC Review Requested Above — Enter the date the IPC began or will begin. For a revision or a transfer, the begin date will be the date the IPC services will change or be effective or the date the transfer is effective. If the IPC in question is a renewal, the begin date will be the date the IPC renewal is effective. For renewals, C62 will indicate the begin and revision date as the same.

IPC Begin Date — Enter the date the IPC began or will begin.

IPC End Date — Enter the date the IPC ends or will end.

Does any correspondence sent to the legally authorized representative (LAR) or individual need to be translated to another language? — Mark the appropriate box and indicate the language needed, if other than English. The program provider must update the individual's and LAR's address in CARE when it changes.

Instructions to HCS Provider or TxHmL LA Service Coordinator when cost is exceeded

The HCS program provider or TxHmL LA service coordinator will:

Instructions to be followed when the program provider has determined that it cannot ensure an individual's health, safety, and welfare in the provision of a service(s) because the individual has refused a comprehensive nursing assessment:

As appropriate to the situation, the HCS program provider for an HCS participant, the service coordinator for an applicant enrolling in HCS, or the TxHmL service coordinator will:

PE/UR Action

DADS PE/UR will: