Eligibility Assessment and Individual Plan of Care (IPC) Submission Standards for Community Living Assistance and Support Services (CLASS) Provider Agencies

Included in this alert please find minimum submission standards for CLASS case management agencies (CMA) and direct service agencies (DSA) for the submission of Individual Plans of Care (IPC) and eligibility documentation to DADS. All IPC and MR/RC submissions received at DADS March 1, 2012, or later must comply with these submission standards. All submissions received prior to this date will be reviewed using the current process.

Please note that as part of the current process and ongoing as necessary, DADS may request additional documentation or clarifying information regarding any submission to gather adequate information about a submission with which to make an authorizing determination.

DADS developed these standards in response to feedback from the CLASS provider community. DADS anticipates this clarification of documentation submission to DADS will make it easier for CMAs and DSAs to identify which forms and records must be included in IPC and eligibility documentation submission packets to DADS. Implementation of these standards is an attempt to reduce DADS processing time and the frequency of remanded or returned submissions. DADS will include these standards in a future revision to the CLASS Provider Manual.

With the implementation of these submission standards, DADS will discontinue the use of the following forms for the CLASS program:

• 3658 – Justification for Exceeding Service Threshold
• 6509 – Request for Authorization of ISP Over Cost Ceiling

IMPORTANT — Also effective with the issuing of this alert a revised version of Form 3626 – Request for an Exception of Service Limit. Revised form 3626 is available in the CLASS forms link and must be used by CMAs for the submission of all IPC packets which include one or more proposed services that exceed a service limit. Earlier versions of Form 3626 may be submitted by CMAs after February 1, 2012, only if these forms have been initiated, signed and dated prior to the effective date of this form revision. Please note the revised Form 3626 no longer requires the inclusion of summary service justification information.

Beginning March 1, 2012, the following submission standards must be implemented by CMAs and DSAs when submitting IPCs and MR/RCs to DADS:

Enrollment IPC:

• Form 1577, Personal Care Services Selection (only applicable to applicants under the age of 21)
• Form 3587, Selection Determination
• Form 3590, CLASS – Nursing Assessment
• Form 3596, CLASS – Habilitation Plan
• Form 3597, CLASS – Habilitation Training Plan*
• Form 3598, CLASS – Individual Transportation Plan*
• Form 3621-R, CLASS – Individual Plan of Care
• Form 3626, Request for an Exception of Service Limit**
• Form 3660, CLASS – Request for Adaptive Aids, Medical Supplies or Minor Home Modifications
• Form 3849-A, CLASS – Specifications for Adaptive Aids/Minor Home Modifications, incl. bids
• Form 8578, Mental Retardation/Related Condition Assessment
• Form 8598, Non-Waiver Services
• Form 8601, Verification of Freedom of Choice, Waiver Program
• Form 8604, Transition Assistance Services (TAS) Assessment and Authorization*
• Form 8606, Individual Program Plan (IPP)
• Form 8606-A, Therapy Justifications - Attachment to IPP*

Renewal IPC:

• Form 1577, Personal Care Services Selection (only applicable to applicants under the age of 21)
• Form 3587, Selection Determination
• Form 3590, CLASS – Nursing Assessment
• Form 3596, CLASS – Habilitation Plan
• Form 3597, CLASS – Habilitation Training Plan*
• Form 3598, CLASS – Individual Transportation Plan*
• Form 3621-R, CLASS – Individual Plan of Care
• Form 3626, Request for an Exception of Service Limit**
• Form 3660, CLASS – Request for Adaptive Aids, Medical Supplies or Minor Home Modifications
• Form 3849-A, CLASS – Specifications for Adaptive Aids/Minor Home Modifications, incl. bids***
• Form 8578, Mental Retardation/Related Condition Assessment
• Form 8598, Non-Waiver Services
• Form 8606, Individual Program Plan (IPP)
• Form 8606-A, Therapy Justifications - Attachment to IPP*

IPC Revision:

• Form 3590, CLASS – Nursing Assessment
• Form 3596, CLASS – Habilitation Plan*
• Form 3597, CLASS – Habilitation Training Plan*
• Form 3598, CLASS – Individual Transportation Plan*
• Form 3621-R, CLASS – Individual Plan of Care
• Form 3626, Request for an Exception of Service Limit**
• Form 3660, CLASS – Request for Adaptive Aids, Medical Supplies or Minor Home Modifications
• Form 3849-A, CLASS – Specifications for Adaptive Aids/Minor Home Modifications, incl. bids
• Form 8598, Non-Waiver Services
• Form 8606, Individual Program Plan (IPP)*
• Form 8606-A, Therapy Justifications – Attachment to IPP*

Termination IPC:

• Form 3621-R, CLASS – Individual Plan of Care
• Form 3624, Termination, Reduction or Denial of CLASS
• Documentation of circumstances that support the termination of CLASS services.

Transfer IPC:

• Form 3621-T, CLASS – Individual Plan of Care
• Form 3587, Selection Determination

LOC 8 determination:

• Form 8578, Mental Retardation/Related Condition Assessment
• Form 8662, Related Conditions Eligibility Screening Instrument
• ABL assessment scoring summary

Request of a Fair Hearing

• Form 3624, Termination, Reduction or Denial of CLASS
• Written documentation established by the CMA in the event of a verbal request for appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights using Form 3624)
• Form 4800-D, Fair Hearing Request Summary
• Form 4800-DA, Fair Hearing Request Summary (only if there are more than three other hearing participants who require notification of a hearing)

Request for funding for completed pre-enrollment assessment:
(CMAs – SVC 40):

• Form 3625, CLASS – Documentation of Services Delivered
• Form 3657, Pre-Enrollment Assessment (partial assessment fee) , OR
• Form 3621, CLASS – Individual Plan of Care (full assessment fee)

(DSAs – SVC 40B):

• Form 3625, CLASS – Documentation of Services Delivered
• Form 8578, Mental Retardation/Related Condition Assessment

Asterisk Key:

* Only include if this specific service has been proposed as part of an enrollment/renewal IPC.
Or
Only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621-R.

** Only include if one or multiple Service Limits have been exceeded.

*** Only include Form 3849-A if funding for specifications has been proposed as part of an enrollment / renewal IPC.
OR
Only include Form 3849-A if funding for specifications has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621-R

Only include bids if these are required as per 40 TAC Chapter 45, Subchapter F.

For questions related to these submission standards please contact the DADS IDD Waivers Program Enrollment/Utilization Review unit in Access and Intake at DADS at (512) 438-3609.

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