(Revised 1/1/20 ML #3570)
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Purpose:
The Authorization to Provide Medicaid Waiver Services for is used to grant authority to a qualified service provider (QSP for the provision of agreed upon service tasks to an eligible Medicaid Waiver client.
This form is only completed for clients receiving Medicaid Waiver service(s).
When Prepared:
The Authorization to Provide Medicaid Waiver Services is completed when arrangements are being made for the delivery of service as agreed to in the individual’s care plan. The client must have an identified need for the services in order to be authorized to receive the services.
By Whom Prepared:
The HCBS Case Manager (CM) completes the “Authorization to Provide Medicaid Waiver Services” form. The HCBS CM will determine the Qualified Service Provider (QSP) the client has selected is available and qualified to provide the service. CM must ensure the chosen QSP has the ability to provide the requested service by checking the web-searchable database.
Specific Instructions:
Identifying information
Enter the QSP’s name, QSP provider number, and physical address.
Enter the client’s name, identification number (ND number), physical address, and phone number.
If a QSP will be receiving the Rural Differential (RD) rate for traveling to clients within rural areas, mark the correct RD tier.
"Authorization Period" - Identify the period of time the authorization is in effect. The authorization period MAY NOT exceed six (6) months except the initial. Renewal of the authorization would coincide with the 6-month Review or Annual Reassessment.
“Six Month Review Authorization Period” (this section is completed at the six-month review only if there is no change in the authorization). Identify the additional period of time the authorization is in effect. The additional authorization period MAY NOT exceed six (6) months.
Services Authorized
Select all authorized services and complete the unit or daily rate, number of units and record dollar amount for the service(s).
Column Headings
If RD is authorized, put in determined RD rate for service.
Tasks Authorized
Select all authorized tasks to be completed by the QSP. The explanation of the tasks on page two of the Authorization to Provide Medicaid Waiver Services (SFN 410) should be referenced in defining the parameters of the service tasks.
A written, signed recommendation for the task of vital signs provided by a nurse or higher credentialed medical provider must be on file which outlines the requirements for monitoring, the reason vital signs should be monitored, and the frequency. When the tasks of Temp/Pulse/Respiration/Blood Pressure are authorized, the individual to be contacted for readings must be listed on the SFN 410.
For the task/activity of exercise, a written recommendation and outlined plan by a therapist for exercise must be on file and is limited to maintaining or improving physical functioning that was lost or decreased due to an injury or a chronic disabling condition (i.e., multiple sclerosis, Parkinson’s, stroke etc.). Exercise does not include physical activity that generally should be an aspect of a wellness program for any individual (i.e., walking for weight control, general wellness, etc.).
“Global Endorsements” – These activities and tasks may be provided only by a QSP who has demonstrated competency and carries a global endorsement. Review the QSP list to determine which global endorsements the provider is approved to provide. If Temp/Pulse Respiration/Blood Pressure are checked, enter who is to be contacted for the readings.
“Client Specific Endorsements” – These activities and tasks may be provided by a QSP who has demonstrated competency and carries a client specific endorsement to provide the required care within the identified limitations. The case manager must maintain documentation that a health care professional has verified the provider’s training and competency specific to the individual’s need in the client's file.
The case manager must sign and date the form to officially authorize, reauthorize, or cancel the services authorized. The SFN 410 must be cancelled when a QSP is no longer providing services or when a client is no longer eligible. The cancelled authorization is to be filed in client’s case file but does not need to be submitted to Aging Services/HCBS State Office.
Authorization to Provide Medicaid Waiver Services must be sent to the identified provider for a returned signature – agreeing to provide the waiver service. Plan is not completed unless this signature is obtained.
Note: No signature from provider is required for ERS service– the signature on their provider agreement will be utilized.
If client is no longer eligible for RD, enter the date removed in the box beside the Tier selection and adjust rates by crossing off RD rate and enter new eligible date. Send copy to QSP and to Aging Services/HCBS State office. If QSP is no longer providing services to identified client, then cancel entire SFN 410. Complete the Rural Differential Unit Rate Authorization/Closure (SFN 212) form and send to Aging Services/HCBS.
The six-month review may be completed and signed if there are no changes in the plan.
Number of Copies and Distribution
File a copy in the client's case record and give a copy to the client. Forward the original to the service provider(s) and scan a copy to Aging Services/HCBS with the Medicaid Waiver Person Centered Plan of Care (SFN 404).
Number of Copies and Distribution:
File a copy in the client's case file and give a copy to the client/legal representative when completed. Forward the original to the QSP(s) and email or fax a copy to Aging Services/HCBS.
An electronic copy is available through the state e-forms (SFN 404).