(Revised 2/1/22 ML #3663)
Purpose:
The Rural Differential Unit Rate Authorization/Closure (SFN 212) is used by the HCBS Case Manager to add and/or end a Rural Differential (RD) rate for a QSP. The SFN 212 is to be completed and forwarded to Aging Services /HCBS when a rural differential rate is being added, removed, or if the individual or the QSP has a change in address.
A rural differential rate can be authorized for any individual receiving the following services under Medicaid Waiver (MW), Service Payments to the Elderly & Physically Disabled (SPED), Expanded Service Payments to the Elderly & Disabled (EX-SPED), and/or Medicaid State Plan Personal Care (MSP-PC):
An SFN 212 must be developed for each provider that is authorized a RD rate for a individual.
All appropriate boxes must be completed in order to be accepted by the HCBS Administrator.
Determining Distance
Case managers are required to verify distance between the HCBS individual’s home and the QSP’s home base by using a reputable internet-based mapping service. The Case Manager is responsible to choose the most reasonable route and print a copy of the mapped verification of distance, a copy must be kept in the individual's file and submit to Aging Services/HCBS along with the SFN 212.
Individual Information:
Enter the individual’s name, ND number, physical address, case manager’s name, and county of residence.
Qualified Service Provider (QSP) Information:
Enter the QSP's name, provider number, and physical address. Advise the QSP that this address will be checked against the Department of Transportation’s database, if the two do not match, the RD rate will be stopped.
When an Agency is providing care, list agency name, the agency's QSP number, and the physical address. If an agency employee is not required to report to their agency each day, they must make their name and address available to the HCBS office for verification. Enter the employee's name and physical address in the appropriate box.
Rural Differential (RD) Rate Authorization/Closure:
Mark the correct RD tier level the QSP has been authorized to bill.
Check the appropriate funding source(s). More than one funding category may be selected.
Enter the service(s) that will be billed at the RD rate. More than one service may be entered.
Document the rate that will be billed by the provider and the date that the provider is eligible to start billing the RD rate. When the RD rate is terminated for this provider and individual, enter the date of the last day the provider is eligible to bill the RD rate.
Address Change:
Complete this section if there is a change in address for the provider or the individual. Update the RD tier and rate if necessary. When an address change occurs, a new Map Quest must be submitted to Aging Services/HCBS with the SFN 212.
Signature:
The HCBS Case Manager is to sign and date the SFN 212 when adding a RD rate and when cancelling the provider’s RD rate.
Number of Copies and Distribution:
The original is maintained in the individual’s case file, a copy of this form must be sent to Aging Services/HCBS within three working days of adding, changing, or cancelling a rural differential rate.
A map generated on a reputable internet-based mapping service is required with this form showing the distance between the individual and provider’s addresses when adding or changing a RD rate.
This form is available electronically through the state e-forms (SFN 212).