(Revised 7/1/21 ML #3628)
Purpose:
The Preliminary Authorization to Provide Medicaid waiver Services is used to preliminary authorize a qualified service provider (QSP) to provide services to an eligible Medicaid waiver individual. It serves as a "good faith" agreement that the individual is eligible, and that the services will be covered.
This form is only completed for individuals who have applied and have been determined to be functionally and financially eligible for Medicaid waiver service(s).
When Prepared:
The Preliminary Authorization to Provide Medicaid waiver Services is completed when arrangements are being made for the delivery of service as agreed to in the individual’s care plan. The individual must have an identified need for the services in order to be authorized to receive the services. While all final authorizations are to be completed in Therap, a Preliminary Authorization (SFN 410) is completed for those services that cannot yet be billed, but are being provided and incurring costs to be billed at a later time. These services include the following:
The SFN 410 can also be used as an agreement to provide the following services prior to exact dates and amounts being finalized:
Example 1. An individual is currently residing in a skilled nursing facility, but is working with HCBS to transition back into the community. The individual qualifies for Transition Coordination under Medicaid waiver and will open for Medicaid waiver upon discharge from the facility. In order for the provider to start these transition services while the individual is still in the nursing facility, the HCBS Case Manager will complete the SFN 410 to authorize both Transition Coordination and the Community Transition Service Set up Expenses. This will be signed by the provider, and will serve as a Preliminary Authorization for those services. Once the individual is discharged from the facility and is able to receive Medicaid waiver in the community, the HCBS case manager will create a final authorization in Therap, which will reflect the final and correct units, dollar amounts, and dates of services. This will be the authorization the provider utilizes to bill exact amounts for service rendered and costs incurred. As outlined in the SFN 410: If, for any unseen reason, the individual does not enroll in the waiver (e.g., due to death or significant change in condition), Community Transition Services may be billed to Medicaid as an administrative cost.
Example 2. An individual is on Medicaid waiver has been approved for Environmental Modification. Bids were received and a provider has been approved as a QSP to complete the modification job. However, it is not yet certain if the job will be completed in June or July and there may be minor cost changes from the bid and the final cost after work is completed. The provider only feels comfortable starting the work if they have an HCBS authorization in hand. The HCBS case manager will complete the SFN 410 to authorize Environmental Modification at the current approved bid. This will be signed by the provider, and will serve as a Preliminary Authorization for Environmental Modification. Once the job is finalized, the HCBS case manager will create a final authorization in Therap, which will reflect the final and correct dollar amount and dates of services. This will be the authorization the provider utilizes to bill exact amounts for the service rendered.
The HCBS Case Manager (CM) completes the “Preliminary Authorization to Provide Medicaid Waiver Services” form. The HCBS CM will determine that the Qualified Service Provider (QSP) the individual has selected is available and qualified to provide the service. The CM must ensure that the chosen QSP has the ability to provide the requested service by checking the web-searchable database.
Specific Instructions:
Identifying information
Enter the QSP’s name, QSP provider number, and physical address.
Enter the individual’s name, identification number (ND number), physical address, and phone number.
If a QSP will be receiving the Rural Differential (RD) rate for traveling to an individual within rural areas, mark the correct RD tier.
"Authorization Period" - Identify the period of time the preliminary authorization is in effect. The preliminary authorization period MAY NOT exceed six 90 days.
“Six Month Review Authorization 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. Should the transition take longer than 90 days, the HCBS case manager is required to inform the MFP program administrator and the HCBS program administrator. The MFP program administrator will facilitate a team meeting to staff the situation and provide more intensive attention to the situation to remediate identified barriers preventing timely transition.
Services Authorized
Select all authorized services and complete the preliminary unit or daily rate, number of units and record dollar amount for the service(s).
Column Headings
If RD is authorized, put in determined RD rate for service. Once the services are finalized and you are ready to create the final authorization in Therap, you must also submit an SFN 212 to Aging Services/HCBS State office.
Signatures
The case manager and identified provider must sign and date the form to preliminarily authorize services. The SFN 410 must be cancelled and submitted (along with updated SFN 404) to Aging Services/HCBS in the event that the individual is no longer going to transition to the community and no administrative costs will be paid out to the provider.
Number of Copies and Distribution
File a copy in the individual's case record and give a copy to the individual and/ortheir legal representative. Forward the original to the service provider(s) and scan a copy to Aging Services/HCBS with the first two pages of the Medicaid Waiver Person Centered Plan of Care (SFN 410).
An electronic copy is available through the state e-forms (SFN 404).