|Procedure: I.C.2.PR 009||Issue Date: July 7, 2003|
Subject: Individual Support Prior
Effective Date: Upon release
Revised: May 1, 2007
|Section: Service Delivery, Individual Supports|
To ensure that the review and prior approval or denial of individual cost items, within Individual Support Agreements, are processed and documented in a standardized and consistent manner throughout the department.
This procedure shall apply to DMR staff with responsibility for developing, reviewing and authorizing Individual Budgets, the Fiscal Intermediaries responsible for the financial management of individual budgets, and individuals and families who purchase services through an individual budget.
Prior Approval: means securing the department’s permission in advance to incur costs for those items, goods, services, rates, or fees designated as requiring prior approval or requiring review in the ISA Cost Standards.
Cost Standards: Requirements designed to provide department staff, Fiscal Intermediaries (FI's) who contract with the DMR and the recipients of DMR funds, the guidelines and standards required to assure the appropriate use of State funds, and that expenditures submitted for Federal reimbursement are approved in the Home and Community Based Waivers.
Individual Budget: A budget that details the service type, the rate, the amount of service and the annualized costs for these services for an eligible DMR participant. Individual budgets are authorized by the DMR Regions. A Fiscal Intermediary on contract with DMR administers the payment for supports and services to vendors, contractors, and employees in the authorized budget.
The Individual Supports Prior Approval process shall be implemented to request funding for items, goods, services, rates or fees that are identified as requiring prior approval or requiring review within the established cost standards, or for unique circumstances. This process shall be implemented prior to the authorization of any service, support, or cost that requires prior approval. The Individual Supports Prior Approval process was issued for all new amended, or adjusted Individual Budgets (ISA’s) initiated on or after July 1, 2003. All supports, services and costs in budgets that were approved before July 1, 2003 and that require a prior approval under the cost standards were required to go through the prior approval process by January 1, 2004.
The following criteria must be met for a prior approval request to be considered:
- Relates directly to the individual’s disability
- Relates directly to a specific need identified in the individual’s plan or plan summary
- Funds necessary to support the requested items, goods, services, rates or fees are available within the region’s current allocation.
The following criteria shall be used to further evaluate requests for prior approval:
- Prevents or minimizes a health or safety risk to the individual
- Directly supports the individual’s ability to maintain his or her home or work/day arrangement
- Represents a support arrangement that is significantly cost effective.
- Represents a one-time investment, which will lead to less dependence on the department in the future.
- When the case manager, support broker, or designated regional staff receives a request to include expenses that require prior approval, he or she shall complete the “Individual Supports Prior Approval Request Form” and shall email the form along with any relevant documents (bids for projects that require bids, T-19 denials, clinical recommendations) to the Operations Center Liaison.
- The Operations Center Liaison will review the request and ask for clarification from the case manager or broker when needed and consult with the Central Office Director of Waiver Services or other Central Office staff as needed. The Central Office liaison will email the form with any additional clarifications to the Self Determination Director and one PRAT member from the region of origin.
- If a consensus for approval is reached the Operations Center Liaison will send the request marked approved by email to the case manager and the assigned Fiscal Intermediary. Instructions or qualifications may be a condition of the approval and the approval can either be ongoing or one time. The Fiscal Intermediary will also receive contractor bids or other pertinent information needed to process payments. Denied requests will be returned to the case manager or broker with an explanation for the denial. The case manager, support broker, or designated regional staff may include approved items, goods, services, rates, or fees in the Individual Budget and shall attach a copy of the approved form to the Individual Budget.
- Denied requests for non-waiver services or items may be appealed through the regional PAR process. Denied requests for waiver services are made through the DSS appeal process.
- The central office Operations Center liaison shall maintain a log of all prior approvals that have been submitted along with the ruling and will post the prior approval log on the DMR LAN. Designated regional staff will have access to the database for review.
- An annual report will be developed by the Operations Center Liaison and reviewed with the CMS Design Team on an annual basis. This review is a systems review and will not overturn any approvals or denials. However, the review may change the allowability of cost items within the Individual Support Cost Standards.
- Individual Support Cost Standards
- Individual Budget Procedure
- Individual Support Prior Approval Form rev 5.2007
I.C.2.PR.009 Individual Support Prior Approval Process 2