DD Waiver Manual - Appendix A Draft (Service Auth) for Public Comment
GENERAL COMMENT:
While Service Facilitation does not require service authorization under the DD Waivers, it is a listed BI/FIS/CL Waiver Service in the regs and should be listed in the section of this Appendix where all other Waiver Services are listed. It is mentioned in the CD sections of this appendix, but it is not specifically listed as its own waiver service, and it should. We have billable codes just like every other service on these waivers. This manual should spell out who can and cannot be an SF, when it's appropriate to engage an SF (CD services only, for example), and what the minimum requirements are in order to provide SF services, etc.
ASSISTIVE TECHNOLOGY
Page 2-3. “Pend for Additional Information”
Pended requests from DBHDS and responses from SC/CM and Provider should be documented as part of the person’s records that are accessible to DMAS because DMAS receives consumer and provider complaints and appeals that often involve SA request pends.
Page 5. “To assure the provider that the individual is eligible and that services are authorized as requested, it is recommended that the required documents be submitted at least 30 days prior to the requested start of services.”
Please add, “but not required” or remove the entire recommendation. Providers are able to verify service eligibility in near real-time with DMAS information systems. In addition, there are several processes that have to occur before “the required documents” can be created for services that require SA, including meeting, consultation, and sometimes assessments by an independent clinician. These processes often take 30 days or more to complete before they can be submitted for SA. This current guidance recommends delaying a service start date by another month unnecessarily.
Bullet 6 and bullet 8 are redundant.
Bullet 9, which carries into the next page is more restrictive than the regulations, which do not stipulate that an individual MUST try to find an attendant first that lives outside of the home before hiring someone that lives "under the same roof". https://law.lis.virginia.gov/admincode/title12/agency30/chapter122/section460/ section C is where the regs talk about who can and cannot be a PCA and nowhere in the regs does it say that the PCA cannot live under the same roof. The regs do not even mention the words "Objective Documentation" anywhere. My opinion is that this bullet in the manual should be removed or language that matches the regs should be used in its place, such as Section C-9 in the regs.
Page 6. “Review Process: The DBHDS has 10 business days to review a request for service authorization… Upon the receipt of a response to a pend, DBHDS has 10 additional business days to process the request.”
Please add guidance for similar timeframe expectations for the SC/CM to submit requests and responses to DBHDS. Complaints about SC/CM refusals and delays in submitting requests and
responses to pends to DBHDS are increasing while DMAS regulations and guidance are silent. Please consider guidelines for the SC/CM or CSB responsibilities for providing appeal information and rights if they cannot submit requests or pend responses within 5 business days of receiving the required documents and/or response from the provider.
Page 7:
AT Only (T1999) is missing the 30% markup for providers.
Page 8-9. “For children under the age of 21 – EPSDT ASSISTIVE TECHNOLOGY (T5999) over $5000…. T5999 code for requests over $5000.”
Please correct this to clarify that all AT for children under the age of 21 uses code T5999. As stated, it sounds like only costs or requests over $5,000 are covered by EPSDT when the regulations and DMAS memos clearly designate all AT for children is coded as T5999 EPSDT AT, and none of it is designated as waiver AT with code T1999.
Page 9. “A 30% markup based on the provider cost is required.”
The 30% markup above the provider cost for EPSDT AT for children under 21 is not required. It is allowable if the provider is not also the manufacturer of the AT.
Page 9. “Items covered under DME cannot be considered as AT, if the AT item doesn’t meet the EPSDT criteria, then the item cannot be approved under the waiver.”
Please clarify this sentence that conflates two separate ideas. Suggest, “Items with a designated DME billing code and established rate cannot be considered for AT approval. AT requests for children under the age of 21 may only be approved under EPSDT AT and may not be approved under the waiver even if it doesn’t meet the EPSDT AT criteria.”
Paragraph 2 following the bullets, "Therefore, services that do not involve directly support the individual or environmental services dealing exclusively with an individual's surroundings rather than the individual are not covered." This language does not appear anywhere in the regulations: https://law.lis.virginia.gov/admincode/title12/agency30/chapter122/section270/ - section C. This is an interpretation by DMAS that is not supported by regs and is more strictive than the regs.
Page 10. “Requests for new Assistive Technology devices must contain the following: Provider to submit quote, showing cost and if request approved, then markup cost 30%.”
This sequence, adding 30% markup cost if the request is approved, will result in a claim submission that is 30% higher than the approved amount. Please revise to, “Provider to submit quote, showing cost and markup of 30% if the provider is not the manufacturer of the item.”
Page 18, COMPANION SERVICES:
"Documentation submitted with the service authorization request must confirm that the service is not purely recreational in nature." What does that even mean? How is that defined? I have the same comment for Page 19 under CD Companion Services, paragraph 3.
Page 20:
Paragraphs 2 and 3 are redundant
ELECTRONIC HOME BASED SUPPORTS
Page 23. “Service authorization request must include a description of the item requested by the support coordinator… A preliminary needs assessment shall be completed by an independent technology specialist (cannot be employed by the requesting provider) to determine the best type and use of technology and overall cost effectiveness of various options.”
These two statements are contradictory to one another and does not provide guidance for instances where the support coordinator does not agree with the needs assessment completed by an independent professional as required in the regulations. Suggest revision of, “Service authorization request must include a description of the item requested by the support coordinator and recommended by the independent professional assessment.”
INDIVIDUAL SUPPORTED EMPLOYMENT
Page 33 – Individual SE – Paragraph 3
Would like clarifying information indicating if requiring the contact name at DARS/the school is the SC or provider’s responsibility
Is this asking for above and beyond what the regulations require?
Page 33 – Individual SE – Paragraph 6
Would recommend adding that personal assistance can overlap
Page 52 - CD Respite:
CD Respite, paragraph 2, typo in the sentence, "...reminders to take self-administered medication or other medical needs, or monitoring OR her health status or physical condition." The word "OR" could probably be "OF".
THERAPEUTIC CONSULTATION
Page 64 – Therapeutic Consult – Bullet Point 3
Would recommend modifying the language to include “most recent completed period.” Quarter 4 data is not available at the time of submission as submission occurs prior to the end of the quarter.