Form 8600
Instructions

Individual Plan of Care (IPC) Backdating Cover Sheet

02-2012

PROCEDURE

When an Individual Plan of Care (IPC) is not entered into the Client Assignment and REgistration (CARE) system before expiration of the previous IPC, in order for the provider to be reimbursed for uninterrupted provision of services the Local Authority (LA) must request that the IPC be backdated for the Texas Home Living (TxHmL) program or the Home and Community-based Services (HCS) program provider must request that the IPC be backdated for the HCS program. (If an individual receiving HCS services does not have an HCS program provider because the individual is only receiving services through the Consumer Directed Services option, then the LA must request that the IPC be backdated.)

DETAILED INSTRUCTIONS

The LA or program provider will complete all the information on Form 8600 and submit to the Department of Aging and Disability Services (DADS), Utilization Management and Review, IDD Waivers Program Enrollment/Utilization Review (PE/UR), along with a copy of both pages of the signed IPC.

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

Date — Enter the date to be faxed to PE/UR.

Provider Contact Information

Provider Name — Enter the name of the program provider.

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.

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.

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.

Component Code — Enter the program provider component number.

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

LA Contact Information

LA Name — Enter the name of the LA.

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

LA 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 LA.

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

Individual Information

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

Individual Name (First) — 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.

Date IPC Entered  — Enter the date the IPC was entered into CARE.

Requested IPC Begin Date — Enter the date to which you are requesting the IPC be backdated.

Comments

Enter any comments you wish to provide to DADS. The service coordinator must document the reason for not entering the IPC on time.

PE/UR Action

DADS PE/UR will: