1. There appears to be a conflict of requirements as it relates to discharge from services. The DDWS Manual, section Provider Participation Requirements under Therapeutic Consultation Service, indicates "a final disposition summary is to be forward to support coordinator within 30 days following the end of the service" (pg 147). However, in the same manual, section Quality Management and Utilization Review under Provider Discontinues Services states, "In non-emergency situations in which a participating provider intends to discontinue services to an individual, the provider will give the individual or family/caregiver, and support coordinator/case manager ten (10) days advance written notice for services provided in non-residential settings." (pg 25)

Which requirement does Therapeutic Consultation Services abide by? Please note that after the individual's end date on a service authorization, a provider may not upload documents into WaMS due to a WaMS feature to end the provider's access to the individual after the last date of the authorization.  

2. Source DDWS Manual, section Therapeutic Consultation (pg 59).
   1. We find there is a pressing need for Nursing Consultation Services to assess for possible medical conditions that may attribute to behavioral displays, help with recommendations to medical providers as to why a particular test is being requested based on clinical assessments and observations, evaluate for medication interactions, and navigate the caregivers through the medical language. There is not always a need for the level of care provided by skilled nursing or home health.  The nurse consultant is less expensive than skilled nursing or in-home and can provide a broader range of education. Our individuals are aging and facing barriers with primary health care, such as acquire comorbidity diagnoses, multiple medical providers without continuity of care between disciplines, lack of medical providers who see our population, and lack of staff/caregiver resources to understand quality health care practices.
   2. I am surprised a BCaBA or a LABA (assistant/associate), who have limited skill sets set forth by the BCBA Board, can bill at the same rate as a BCBA or LBA. The final approved regulations in 2017 did not allow for BCaBA or LABA's to provide behavior consultation services. The requirements for a BCaBA are a BS degree with 225 hours of ABA theories and 1300 of supervision. If assistants are allowed to perform Therapeutic Consultation Services, we should approve COTA's, PTA's, SLPA's, and proposed PBSF-A.
   3. I suggest that PBSF's who have a minimum of a BS degree with one year of classroom work and one year of supervision should be paid equal to the BCaBA/LABA at code 97139. LCSW and LPC should be paid at the 97139 rates.

3. Telehealth Services Supplement, section Definitions (pg 1).
   4. Telemedicine does not include an audio-only telephone. There are 697,000 Virginians who do not have access to a wired internet connection. https://broadbandnow.com/Virginia
   5. People in the Commonwealth of Virginian who have limited or no access to internet service are due to rural geographic location, lack of connectivity, lack of money to pay for internet, or lack of skill set to use the internet. Lack of access to a video meeting should not negate the fact of the desired access to care. This limitation of no audio is a direct violation of an individual's human rights by denying them access to care.
   6. Waiver consultation codes of 97139 and 97530 are missing from the Code Table (Attachment A)