(Revised 7/1/15 ML #3460)
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Purpose: The Authorization to Provide Services is used to grant authority to a qualified service provider for the provision of agreed upon service tasks to an eligible SPED and EXSPED client.
When Prepared:
The Authorization to Provide Services is completed when arrangements are being made for the delivery of service as agreed to in the individual’s care plan. The client must have an identified need for the services in order to be authorized to receive the services. For example, if a client is not scored as being impaired in bathing, no authorization can be given for a provider to assist the client with bathing.
By Whom Prepared:
The HCBS Case Manager completes the "Authorization to Provide Services" form. The HCBS Case Manager will determine the Qualified Service Provider (QSP) the client has selected is available and qualified to provide the service.
SPECIFIC INSTRUCTIONS:
Section I is identifying information.
Enter the name, physical address, telephone number, and Medicaid provider number of the provider.
If services are to be provided by multiple providers and all providers are authorized /endorsed to complete the same tasks, multiple provider names can be listed on the SFN 1699 but each provider must receive a copy.
If QSP will be receiving the Rural Differential rate for traveling to clients within rural areas, mark the correct tier.
Do not combine services on the same authorizations, e.g. If you have a client that is receiving SPED homemaker services and SPED personal care services from the same provider you still need to send two SFN 1699’s one with homemaker and one with personal care. In addition, do not combine Medicaid Waiver services and SPED or Ex-SPED services on the same authorization e.g. If you have a client who is receiving a service under SPED and the waiver from the same provider you must send one SFN 1699 listing the SPED services and the recipient ID number and one SFN 404 authorization listing the Waiver service and the recipient ID number.
Enter the client’s name, SPED/EXSPED/physical address, and telephone number.
"Authorization Period" - Identify the period of time the authorization is in effect. The authorization period MAY NOT exceed six (6) months except the initial. Renewal of the authorization would coincide with the 6-month Review or Annual Reassessment.
“Six Month Review -- Service Period” (this section is completed at the six month review only if there is no change in the authorization). Identify the additional period of time the authorization is in effect. The additional authorization period MAY NOT exceed six (6) months.
Section II is the authorizing of the service(s).
Column Headings
If Rural Differential was marked in Section I put in determined RD rate for service.
Section III is the authorizing of the service(s) Tasks Authorized.
Check tasks authorized to be completed by this Qualified Service Provider. The explanation of tasks found on the back of the HCBS Authorization to Provide Services should be referenced in defining the parameters of the service tasks.
After the marked task write in the approved number of units for this service.
Example:
SERVICE: HMK Procedure Code: 00010 UNITS: 41 Dollar Amount: $208.69
Task: X Meal Prep:__31 units
X Housekeeping: 10 units
A written, signed recommendation for the task of vital signs provided by a nurse or higher credentialed medical provider must be on file which outlines the requirements for monitoring, the reason vital signs should be monitored, and the frequency. When the tasks of Temp/Pulse/Respiration/Blood Pressure are authorized, the individual to be contacted for readings must be listed on the SFN 1699.
For the task/activity of exercise a written recommendation and outlined plan by a therapist for exercise must be on file and is limited to maintaining or improving physical functioning that was lost or decreased due to an injury or a chronic disabling condition (i.e., multiple sclerosis, parkinson’s, stroke etc.). Exercise does not include physical activity that generally should be an aspect of a wellness program for any individual (i.e., walking for weight control, general wellness, etc.).
“Global Endorsements” These activities and tasks may be provided only by a service provider who has demonstrated competency and carries a global endorsement. Review the QSP list to determine which global endorsements the provider is approved to provide. If Temp /Pulse Respiration/Blood Pressure are checked, enter who is to be contacted for the readings.
“Client Specific Endorsements” These activities and tasks may be provided by a service provider who has demonstrated competency and carries a client specific endorsement to provide the required care within the identified limitations. The case manager must maintain documentation that a health care professional has verified the provider’s training and competency specific to the individual’s need in the client's file.
The case manager must sign and date the form to officially authorize, reauthorize, or cancel the services authorized. The SFN 1699 must be canceled when a QSP is no longer providing services or when a client is no longer eligible.
If client is no longer eligible for RD, mark RD removed box at end of Tier selection, enter end date, adjust rates by crossing off RD rate and enter new eligible date. Send copy to QSP and to HCBS State office. If QSP is no longer providing services to identified client, then cancel entire SFN 1699.
Complete SNF 212 and send to the HCBS State Office.
The six-month review may be completed and signed if there are no changes in the plan.
Number of Copies and Distribution
When a service is provided by multiple providers only one SFN 1699 is completed listing all providers, noting the units are shared. If one of the providers does not have a required /needed endorsement a separate SFN 1699 must be provided and reflect limits in the units authorized to assure that all providers do not provide units over the total authorized amount.
Complete separate authorizations for each service authorized (even if the services are provided by the same provider).
File a copy in the client's case record and give a copy to the client. Forward the original to the service provider(s).
This form is available from the State office in triplicate format and an electronic copy is available through the state e-forms.