Instructions for Completing the Authorization to Provide Personal Care Services, SFN 663 535-05-70-05

(Revised 5/1/2015 ML #3444)

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The Authorization to Provide Personal Care Services SFN 663 is used to grant authority to a qualified service provider or basic care assistance provider for the provision of agreed upon service tasks to an eligible individual.

The Authorization to Provide Personal Care Services is completed when arrangements are being made for the delivery of personal care as agreed to in the individual’s Personal Care Services Plan. The individual must have an identified need for the services in order to be authorized to receive the services. For example, if an individual is not identified on the PCSP as being impaired in bathing, no authorization can be given for a provider to assist the individual with bathing.

The case manager must complete an Authorization to Provide Personal Care Services for all providers, including basic care assistance providers, selected by the individual to perform personal care services. If personal care services are to be provided by multiple providers, without specific identification of authorized services to each provider, only one SFN 663 is completed and each provider must receive a copy of the SFN 663. The use of one form for multiple providers may only be used if all providers are authorized to perform the same tasks. The case manager must determine that the provider(s) the individual has selected is available and when service(s) will begin.

Enter the name, Medicaid provider number of the personal care service provider(s), and Physical Address in the “Qualified Service Provider(s) Name and Number” block. If the provider is a basic care provider enter the date the individual was admitted or is anticipated to be admitted to the facility in the “Date of Admit to Basic Care” block.

Enter the client’s name, Medicaid ID number, physical address, and telephone number, in the applicable blocks.

"Authorization Period" - Identify the period of time the authorization is in effect. The authorization period MAY NOT exceed six (6) months or 3 months for Level C Personal Care, except for an initial authorization which can include a partial month in excess of 6 months. Renewal of the authorization should coincide with the 6-month Review or Annual Reassessment. The authorization period should begin on the first of a month, except if this is an initial authorization for personal care services for an individual or if a change in status or provider occurs, and must end on the last day of a month.

“Six Month Review Authorization Period” - this section is to be completed at the six month or 3 month for Level C Personal Care review only if there is no change from the existing authorization in the amount of units, tasks, or providers. Identify the additional period of time the existing authorization is to be in effect. The additional authorization period MAY NOT exceed six (6) months or (3) month for Level C Personal Care.  

“Total Authorized Units” – enter the total units authorized to be provided, this includes the total of the units approved in the Authorized Units per Task Category behind the correct procedure code. If the procedure code is T1020 (Daily Rate) complete the per day rate/cost.

“Authorized Units per Task Category” - enter the total authorized units of service based on 15-minute increments for each personal care services tasks authorized under ADL - activities of daily living, Meal Prep -meal preparation, Med Assist – medication assistance, Ldry/Shp/Hskp - laundry, shopping, housekeeping, and Other. Total of the five subgroups must equal total authorized units. NOTE: Total authorized housekeeping, laundry, and shopping units of service may not exceed 30% of the total units of all personal care services authorized for the client. Authorized units must be supported by documentation in the individual’s case file.

• Some flexibility is anticipated in the provision of tasks amongst the categories of ADL, Other, Meal Prep, and Med Assist and the provider is allowed to bill up to the total units approved in these 4 categories; however, the provider may not bill for units in excess of the units authorized in the category of Ldry/Shp/Hskp.
• A written, signed recommendation for the task of vital signs provided by a nurse or higher credentialed medical provider must be on file that outlines the requirements for monitoring, the reason the task is required and 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 633.
• For the task/activity of exercise a written recommendation and outlined plan by a therapist for exercise must be on file. Exercise is limited to maintain or improve physical functioning that was lost or decreased due to a 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).

• For individuals receiving Personal Care Services in a Basic Care setting, enter ADL, Meal Prep and Medication Assist to verify the daily rate. Do not need to identify units for laundry, shopping and housekeeping.

In addition, prior authorization from a State HCBS or DD Program Administrator is required to authorize units for meal prep, laundry, shopping, and housekeeping when performed by a live in provider or for a client who lives with other capable persons. Prior authorization must be renewed annually.

“Personal care services tasks authorized” - check the specific service tasks to be completed by the personal care service provider(s). The explanation of tasks found on the back of the Authorization to Provide Personal Care Services should be referenced in defining the parameters of the service tasks. Include the amount of units that are authorized for each task. If use of a daily rate is authorized, 1 or more of the tasks of dressing/undressing, feeding, incontinence, inside mobility, toileting, transferring/turning/positioning, meal preparation, and medication assistance must be needed and provided on a daily basis.

The activities and tasks identified as global endorsements may be provided only by a personal care service provider who has demonstrated competency and carries a global endorsement. Review the QSP list to determine which global endorsements the provider is approved to provide.

Activities and tasks authorized as a client specific endorsement may be provided only by a personal care service provider who has demonstrated competency and carries a client specific endorsement to provide the required care within the identified limitations. The case manager must obtain from the QSP, a completed SFN 830, Request for Client Specific Endorsement. A copy of SFN 830 must be included in the individual’s file, and a copy sent to Medical Services.

Check the appropriate Rural Differential Rate if applicable. Include the unit rate that is authorized. Note: If more than one provider is authorized and not all have Rural Differential Rate or different Rural Differential Rates a separate SFN 663 must be completed for each rate.

When a QSP is no longer receiving rural differential for this client complete Date RD removed and submit the SFN 662 and SFN 663 to Medical Services and the QSP. See Rural Differential Rates 535-05-38.

The case manager must sign and date the form to officially authorize, reauthorize, or cancel the personal care services. The only time a authorization to provide service is not canceled is when the service period expires.

Distribution

The original and any changed Authorization to Provide Personal Care Services is given to each personal care service provider(s) and a  copy of the form is filed in the individual’s case record, and a copy is provided to the individual or legal representative, and a copy is sent to the appropriate State Office.

The SFN 663 is available from Office Services and an electronic copy is available through the state e-forms.