(NEW 1/1/15 ML #3428)
View Archives
Purpose:
The Rural Differential Closure SFN 212 is used by the Case Manager to cancel the Rural Differential rate that a QSP is receiving for an authorized client. This is to be completed and forwarded to Medical Services /HCBS when the authorized client is no longer eligible for the service that the rural differential has been authorized for or if the mileage requirement is no longer met.
If closing the entire case in addition to the SFN 212, Rural Differential Closure, the SFN 474, HCBS Case Closure/ Transfer Notice and if Medicaid Waiver client the SFN 1288, CSSB Request for HCBS NF Determination, must also be completed in order to close the SNF screening and the HCBS case.
If rate needs to be closed for multiple clients a new form must be generated for each client.
All boxes must be completed in order to be accepted by the HCBS Administrator.
In the first section: Always complete the County Name and Case Manager section.
Qualified Service Provider Section: Print QSP last, first name, if employed by Agency list Agency Name, the QSP provider number, physical address to include city and zip. If an Agency employee is not required to report to their agency each day because of distance they must make their address available to the HCBS office for verification – put employee’s physical address in the box. Mark the correct tier level they have been authorized for, as stated on the care plan for authorized client.
Date Eligibility for RD to end: Enter the date the QSP will no longer be authorized for the rural differential and what services they had been authorized to complete.
Services Provided at RD Rate: Enter the service(s) the RD rate was applied to for identified client. Multiple services may be listed if QSP was providing these with RD rate included.
Funding Source: check the appropriate funding source(s) of the authorized client.
HCBS/TB Waiver SPED ExSPED MSP
Client Section: Print client last, first name, the recipient ID number, physical address to include town and zip code.
This form is available electronically through the state e-forms.