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Home and Community-based Services (HCS) Cost Containment Reminder: Provider Requirements To Request Exceptions to New Service Limits

As part of ongoing implementation of the DADS cost containment initiative, post the December 1, 2011, effective date of new HCS service limits, as identified in DADS Information Letter No. 2011-82, DADS continues to require HCS providers to submit Form 5035, Request for Exception to Service Limit, to the IDD Waivers Program Enrollment/Utilization Review (PE/UR) unit, no later than seven calendar days after the Monday the individual's name first appears on the Client Assignment and Registration system (CARE) JHSXPTR-HC063680 report, identifying service component(s) on the individual's Individual Plan of Care (IPC) which exceed(s) new service limit(s). This report is available to all HCS providers on a weekly basis, every Monday.

Through August 31, 2013, requests for an exception to a new service limit(s) must be:

• re-submitted at the time of an IPC renewal if a service(s) exceeds a new service limit(s); and
• at the time of an IPC revision if a service(s) exceeds a service limit(s) amount that has previously been authorized.

In accordance with the instructional guide issued as part of IL no. 2011-82, requests for exceptions not submitted via fax or mail to PE/UR along with the required documentation per the instructions on form 5035 within the required time frame will result in the following:

After seven calendar days after the Monday the individual's name first appeared on the JHSXPTR-HC063680 report, the service(s) are still over the service limit(s), these services will be put on hold in CARE. This action will result in the HCS provider being unable to receive compensation for claims submitted for the provision of those service component(s) that exceed the new service limit(s).

Although described in IL no. 2011-82 as one of the process steps in cost containment for HCS, please note that at this time PE/UR staff are not making phone calls to each HCS provider who has individuals appearing on the JHSXPTR-HC063680 report prior to issuing a hold in CARE.

Per executive direction received following issuance of DADS IL no. 2011-82, PE/UR will not reduce an individual's services if a request for an exception to a service limit(s) is not submitted to DADS by the HCS provider. However, as outlined in this alert the hold process in CARE will continue.

For questions regarding the submission of a request for an exception to a service limit(s), please contact the PE/UR message line at (512) 438-5055.

Posted: 5/24/2012