Comprehensive Rehabilitation Services (CRS) Standards for Providers

Chapter 1: CRS Program Overview

The Comprehensive Rehabilitation Services (CRS) Standards for Providers manual is the official reference document of provider requirements for contracted goods and services for the CRS program.

The CRS program service arrays may be provided to eligible persons who have a traumatic brain injury (TBI), traumatic spinal cord injury (TSCI), or both.

The CRS program offers the following service arrays for TBI and TSCI:

  1. Inpatient Comprehensive Medical Rehabilitation Services
  2. Outpatient Therapy Services
  3. Post-Acute Rehabilitation Services
  4. Ancillary Goods and Services

The specific services provided to a participant are based on the participant’s rehabilitation needs. The services are available based on service setting and services governed by the contract’s terms and conditions and by contract standards.

This CRS standards manual is available online. This is CRS's preferred method of providing access to the CRS standards and all revisions. Revisions to these CRS standards are made periodically, and a log noting all revisions is also available online. Changes to the CRS standards are published on the website at least 30 days in advance of the effective date of the changes. Each provider is contractually responsible for maintaining compliance with the most recent CRS standards.

Any questions about the CRS Standards for Providers, please contact a standards specialist by emailing CRS_Program@hhsc.state.tx.us.

If a printed copy is needed of the CRS Standards for Providers, contact the CRS Inquiries Unit at:

Phone: 512-438-4718
Fax: 512-206-3981
Mail: CRS Program, 701 W. 51st Street, MC 3084 Austin, TX 78751

1.2 Referrals to CRS

Referrals for the CRS program come from a variety of sources, such as hospitals, therapists and other community providers. The source must inform the participant being referred that the CRS counselor determines eligibility. The CRS Referral Form (Form 3106), must be sent to via email (CRS_Program@hhsc.state.tx.us) or eFax (512-206-3981). The referral source is not required to submit all the information requested however will assist in expediting the application process. The referral source may attach all necessary supporting documentation with the referral. If the referral source does not have access to one or more of the necessary documents, these documents will need to be received before the program application can be considered complete. Items that will assist in expediting the referral process are included in the instructions on the HHSC Forms website link above.

Upon receipt of the referral, a CRS coordinator will respond within two business days. CRS recommends the referral source provide the participant with a copy of the CRS brochure that outlines CRS services. Please refer to the CRS website and our brochures for more information on the program. All referrals will be added to the CRS interest list.

The CRS counselor and the participant, having informed choices, jointly:

  • complete the application process including obtaining releases and applicable CRS forms;
  • review disability information and CRS counselor will determine eligibility;
  • if determined eligible, develop an Individualized Written Rehabilitation Plan (IWRP) including determining necessary services to meet the participant's goals and objectives, and if determined, select a provider of the planned services. Completion of the IWRP will place the participant on the waiting list which is first come first serve.

Chapter 2: Credentialing and Enrollment

2.1 Overview

The CRS program only purchases services from providers that comply with the appropriate standards in this manual, applicable federal and state licensing standards, and certification. Each provider is required to undergo an enrollment approval process, and periodic monitoring ensures continued compliance with these standards. A provider who enrolls must demonstrate the ability to deliver all the core services in the service array that the provider has chosen. Services may be delivered to the participant directly or through a third party. Not all services are provided to all participants.

2.2 Changing a Provider’s Service Locations and Adding Service Locations

Once the provider’s contract is in place, the contract must identify the provider’s services that comply with these standards and, if applicable, the physical location of the facility.

If the location changes or if the provider wishes to offer additional services, the contract manager must first determine that the changes comply with the relevant standards. If the changes comply, a contract amendment must be developed and signed by both parties at least 60 days before the changes are implemented.

2.3 Enrollment

Procurement solicitations are published on the Electronic State Business Daily under the Texas Comptroller of Public Accounts website. Vendors may search daily for open solicitations. A provider uses it to monitor the expiration date of their contract to determine when to renew.

If a provider has no renewal options, the provider may respond to an open solicitation for services. If a provider does not see a solicitation for a service, the provider may contact the designated contract manager or CRS program staff member.

Chapter 3: Environmental Standards

3.1 Overview

 A facility-based provider that provides CRS must follow all state and federal guidelines for accessibility and must maintain a safe environment for participants. A facility-based provider must develop and maintain safety protocols and meet all of the applicable building occupancy codes as outlined in this chapter.

3.2 Language Services

CRS purchased for its participants must be accessible in the participant’s primary language. The provider is responsible for ensuring translation services are provided to the participant.

3.3 Accessibility

Comprehensive rehabilitation services purchased for participants must be accessible.

A provider who is subject to these standards must complete the self-evaluation survey published on the Americans with Disabilities Act (ADA) Checklist for Existing Facilities page:

  • before being approved to provide services to CRS participants for the first time;
  • before renewing a contract;
  • before being approved to provide services at a new address; and
  • at the request of CRS program staff members.

The self-evaluation explains how the provider will make services accessible. In addition to completing the survey, the provider may also submit a written explanation, if necessary.

If the CRS program receives a complaint about the accessibility of services, the CRS program will investigate to determine whether the provider has violated the terms and conditions of the contract.

The Architectural and Transportation Barriers Compliance Board has issued the ADA Accessibility Guidelines (ADAAG) that must be applied during the design, construction, and alteration of buildings and facilities covered by Titles II and III of the ADA. The U.S. Department of Justice has adopted these guidelines as Appendix A to its ADA Title III rules. These guidelines are published on the United States Access Board's ADA Standards page. To obtain a copy of the ADAAG or other information from the U.S. Department of Justice, call 800-514-0301 or 800-514-0383 TTY. For technical questions, contact the Architectural and Transportation Barriers Compliance Board at 800-USA-ABLE.

In addition, the Texas Department of Licensing and Regulation administers the state’s Elimination of Architectural Barriers Act, Texas Government Code, Chapter 469. The Texas Accessibility Standards (TAS) are based on the ADAAG Standards and apply to buildings and facilities constructed on or after April 1, 1994.

3.4 Facility Safety Protocol

The provider must identify the person or persons serving as the governing body of the facility and directing the facility’s general policy, budget, and operation.

The provider’s facility must comply with all applicable federal, state, and local laws, regulations, and codes pertaining to health, safety, and sanitation. The provider must have a plan to ensure that continuing attention is provided to the safety and health of the staff members, the participants, and the visiting public.

The plan must include:

  • quarterly fire drills for each shift of personnel;
  • procedures for following in emergencies and disasters (such as, fire, severe weather, or when a participant is missing);
  • emergency exit diagrams;
  • procedures for getting emergency medical services from a doctor, hospital, or emergency medical service unit; and
  • special procedures for participants with disabilities who require particular attention or action, including those whose behavior may be detrimental to his or her own or to others health, safety, or successful program completion.

The provider must develop a form for reporting incidents and a system for reporting and responding to incidents. The incident report form must include:

  • the date, time, and place of the incident;
  • the nature of incident;
  • the names of CRS participants, witnesses, or others involved;
  • the name of the person making the report;
  • a description of the incident; and
  • any actions taken and planned by the provider because of the incident.

Upon request, the provider must make copies of incident reports pertinent to CRS participants available to CRS program staff members.

The following incidents must be reported to CRS at the time of the incident to CRS_Program@hhsc.state.tx.us or eFax at 512-206-3981:

  • the use of emergency medical services;
  • treatment at an emergency room;
  • allegations of abuse, neglect, or exploitation involving a CRS participant;
  • injuries involving a CRS participant;
  • hospitalization;
  • participant substance abuse;
  • inappropriate behavior(s) that may result in participant being removed or dismissed from the facility;
  • elopement; or
  • death.

3.5 Provider Vehicles

The provider must ensure that transportation for the participant is safe and accessible. Access to transportation must be available in accordance with the Americans with Disabilities Act (ADA) and with all applicable state laws.

Each vehicle used to transport participants must have:

  • appropriate inspections and liability insurance;
  • a working safety belt for each passenger;
  • a first aid kit;
  • a working heating and air conditioning system; and
  • a working ABC fire extinguisher.

The Class ABC fire extinguisher can be used on the following three kinds of fires:

  • Class A (ordinary combustibles, such as wood or paper)
  • Class B (flammable liquid fires, such as grease or gasoline)
  • Class C (electrical fires)

The Federal Transit Administration in Washington, D.C., has information about transportation accessibility, including small passenger vans. Contact the administration at 888-446-4511 or 800-877-8339 (TDD/Relay).

3.6 Building Occupancy Codes

Environmental safety must comply with local building occupancy codes, the Americans with Disabilities Act, National Fire Protection Association (NFPA) codes, and all applicable state laws and standards. Documentation of compliance is provided to the CRS program at the time of the original approval and the effective date when there is a change of a location of services. Renters should contact the property owner to get such documentation. A certificate of occupancy from the local municipality is also required.

Chapter 4: General Provider Responsibilities

4.1 Overview

To ensure the health and safety of participants who receive CRS and the employees who provide services to CRS participants, providers must ensure that information is kept confidential and that there is appropriate staff and staff-training.

The general provider guidelines explained in this chapter apply to all CRS services. For information related to a specific service, see the chapter on that service.

4.2 Participant Records

A provider must make available to CRS program staff members all documents and records related to the CRS participant.

Provider records must document compliance with applicable CRS standards. These records must be legible, reflective of services rendered to the participant, easily retrievable, and made readily available to CRS program staff members.

Required documentation for both the participant’s case records and the services purchased must include the following, as applicable to the service offered:

  • participant referral information that includes the Individualized Written Rehabilitation Plan received from the CRS counselor;
  • documentation of admission, including initial assessments that must include the Mayo Portland Adaptability Inventory or the Functional Inventory Measure;
  • documentation reflecting that the CRS counselor, participant, and provider are jointly involved in the planning of services, and measurable goals and objectives;
  • documentation of all interdisciplinary team meetings and participant participation in meetings, including admission, revisions to the treatment plan that occur at least monthly, and discharge meetings;
  • financial records, including copies of service authorizations, copies of invoices submitted for payment of services, and records of CRS payments;
  • evidence of communication with all pertinent interdisciplinary team members;
  • evidence of participant participation in the planning and implementation of the rehabilitation process;
  • documentation that the Individualized Program Plan (IPP) was signed by the CRS counselor, or evidence that the IPP was provided to the CRS counselor by fax, email, or post;
  • documentation that the IPP was signed by the participant or representative;
  • documentation that the IPP was signed by the case manager;
  • prior approval for services (if applicable);
  • correspondence and collaborative of services with other providers;
  • consents; and
  • critical incident reports, including the use of physical or chemical restraint.

The provider must ensure that documentation of interventions is based on desired treatment goals and objectives that are measurable and reflect changes to the participant’s status.

Documentation of daily progress and efficacy to support services must include:

  • the date, time or duration of the service;
  •  signature of the person providing the service and credentials (if person’s position or certification requires clinical supervision, the supervisor must also sign the documentation);
  • clear details regarding the service provided and how the provided service is related to treatment plan goals and objections;
  • the subjective and objective dates, which may include symptoms, participant statements and clinical observations;
  • interventions and methods used to address goals and objectives;
  • information on the participant’s progress or lack of progress toward meeting the treatment goals and objectives; and
  • plans that may be necessary to help the participant meet the treatment goals and objectives.

Additional information may be requested from CRS program staff members, as required to support the services provided.

4.3 Confidentiality of Participant or Employee Information

To protect the integrity and dignity of each participant, staff members must maintain confidentiality with respect to participant or employee information, when applicable, as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The provider must have policy and procedures in place that facilitate access to confidential records.

The provider must develop and maintain a recordkeeping system that includes a separate record for each participant, and must keep confidential all information contained in the participants' records, regardless of the form or storage method of the records.

The provider must develop and use physical safeguards for confidential records and ensure that the records are available to authorized staff members only. Participant case records must be locked in a location where maximum protection against fire, water damage, and other hazards is in place.

4.4 Staff Ratios

The provider must provide sufficient direct-care staff members, per state licensing requirements, to manage and supervise participants in accordance with their Individualized Program Plan (IPP). The provider must have enough direct-care staff members to provide care and services so that participants do not injure themselves, do not injure others, and do not destroy property. Special staffing needs identified by the IPP (for example, one-to-one ratios) must be provided. Adequate numbers of direct-care staff members must be available to supervise participants when other direct-care staff members are unavailable (for example, during breaks, meals, meetings, and training).

4.5 Staff Training

Before assuming job responsibilities, and at least annually thereafter, direct-care staff members must receive in-service training in the following areas:

  • reporting abuse, neglect or exploitation;
  • maintaining confidentiality of participant information, including data use agreements;
  • taking universal precautions (that is, following the approach to infection control established by the Occupational Safety and Health Administration);
  • conditions in which they should notify the facility manager;
  • understanding the participants' rights;
  • following emergency and evacuation procedures;
  • taking safety measures to prevent accidents and injuries;
  • following emergency first-aid procedures, including the Heimlich maneuver and what actions to take when a participant falls, suffers a laceration, or experiences a sudden change in physical or mental status;
  • managing disruptive behavior and implementing behavior management (for example, prevention of aggressive behavior and de-escalation techniques, practices to decrease the frequency of the use of restraint, and alternatives to restraints);
  • appropriate physical restraint procedures and techniques for staff members with direct participant contact;
  • fall prevention;
  • cardiopulmonary arrest (CPR) and basic life support (BLS) training; and
  • substance abuse training, including how to recognize substance abuse and understanding reporting protocols.

4.6 Staff Qualifications

Services are provided by qualified staff members who are licensed in accordance with Texas state law and applicable licensing boards, or as specified in the standards explained in this chapter.

 

Aquatic Therapy

Aquatic therapy services must be delivered by a licensed physical or occupational therapist, or licensed physical or occupational therapist assistant.

 

Art Therapy

Art therapy services must be provided in accordance with state law by a licensed professional counselor art therapist (LPC-AT) or licensed clinical social worker - art therapist (LCSW-AT).

 

Behavior Management Plans

Behavior management plans must be developed by a board-certified behavior analyst (BCBA), licensed clinical social worker (LCSW), licensed professional counselor (LPC), licensed psychiatrist or licensed psychologist. The licensed professional responsible for developing the interventions must train staff members who implement behavior management interventions.

 

Chemical Dependency Services

Chemical dependency services must be provided by a licensed professional with experience delivering services to participants who have a brain or spinal cord injury or both, such as a licensed chemical dependency counselor (LCDC), licensed professional counselor (LPC), licensed clinical social worker (LCSW), licensed masters social worker (LMSW), licensed psychologist or licensed psychiatrist.

 

Cognitive Rehabilitation Therapy

Cognitive rehabilitation therapy services must be provided directly by or supervised in accordance with licensing requirements by a licensed occupational therapist, licensed speech and language pathologist, licensed psychologist or licensed psychiatrist.

 

Community Independence Supports (CIS)

Community independence supports must be provided by a certified brain injury specialist (CBIS) or a paraprofessional with at least one year of documented experience working with people with traumatic brain injury (TBI), traumatic spinal cord injury (TSCI) or both, but do not have a professional license themselves.

 

Dietary Services

Dietary services must be provided by a professional who applies and integrates scientific principles of nutrition in social, cultural, psychological, and physical conditions and is licensed by the Texas State Board of Examiners of Dieticians.

 

Drivers

Prior to transporting a participant, the provider must ensure that employees who transport them have the type of driver's license that is appropriate for the type of vehicle used (Class B or C). Prior to transporting a participant, a driver who transports CRS participants in motorized vehicles must prove that they have an acceptable driving record by providing an official document from the Texas Department of Public Safety showing that the driver has:

  • a valid driver's license;
  • no more than one at-fault accident within the past three years;
  • no more than three moving violation convictions within the past three years; and
  • vehicle liability insurance that meets or exceeds the minimum coverage required by state law.

 

Family Therapy

Family therapy services must be provided by a licensed or certified professional, such as a psychologist, licensed marriage and family therapist (LMFT), licensed professional counselor (LPC), licensed master’s social worker (LMSW), or licensed clinical social worker (LCSW).

 

Massage Therapy

Massage therapy services must be provided by a licensed physical therapist (PT), licensed physical therapy assistant (PTA), licensed occupational therapist (OT), or licensed occupational therapy assistant (OTA), as specified in the guidelines of the Executive Council of Physical and Occupational Therapy Examiners.

 

Music Therapy

Music therapy services must be provided by a person who is certified by the Certification Board for Music Therapists or listed with the National Music Therapy Registry and is a licensed professional, such as a licensed clinical social worker (LCSW), licensed masters social worker (LMSW), licensed professional counselor (LPC), or licensed marriage and family therapist (LMFT).

 

Neuropsychiatry

Neuropsychiatric services must be provided by a person who is licensed by the Texas Medical Board. This category of licensed professional includes neurologists, psychiatrists, and others who are permitted to provide neuropsychiatric services in their scope of professional practice, as designated by the appropriate licensing board.

 

Neuropsychology

Neuropsychological services must be provided by a person who is licensed by the Texas State Board of Examiners of Psychologists. This category of licensed professional includes psychologists whose professional experience, education, and background permit neuropsychological services in the scope of their professional practice, as designated by the appropriate licensing board.

 

Occupational Therapy

Occupational therapy services must be provided by a person who is licensed by the Executive Council of Physical and Occupational Therapy Examiners. This category of licensed professional includes licensed occupational therapists and licensed occupational therapy assistants. The appropriate licensing board designates the practice of occupational therapy.

 

Paraprofessional Services

Paraprofessional services must be provided by a person who is qualified by their experience, training, or both, and has at least a high school diploma or its equivalent.

 

Physical Therapy

Physical therapy services must be provided by a person who is licensed by the Executive Council of Physical Therapy and Occupational Therapy Examiners. This category of licensed professional includes licensed physical therapists and licensed occupational therapy assistants. The appropriate licensing board designates the practice of physical therapy.

 

Recreational Therapy

Recreational therapy services must be provided by a person who has a current certification from the National Council for Therapeutic Recreation Certification.

 

Speech-Language Pathology

Speech-language pathology (speech therapy) services must be provided by a licensed speech language pathologist (SLP) or a licensed speech language pathologist assistant (SLPA), under the supervision of an SLP who is licensed by the State Board of Examiners for Speech-Language Pathology and Audiology.

4.7 Background Checks

A provider is directly responsible for obtaining and maintaining for agency review the criminal history records of any staff member or employee of a provider and sub-contractor or employee of a sub-contractor who provides services to participats under the terms of a contract.

The provider shall conduct criminal background checks and maintain this information for the agency no later than 30 days after execution of the contract for all employees and prior to any contact with participants for new employees. The provider is responsible for reporting to the agency all changes to an employee’s criminal history, in writing within three business days of the provider discovering the change in the criminal history.

Chapter 5: Allegations or Incidents of Abuse, Neglect, or Exploitation of Persons with Disabilities

5.1 Overview

Texas law requires that a provider immediately reports all allegations or suspected incidents of abuse, neglect, or exploitation of persons with disabilities to the appropriate investigative agency, or, if taking place in other than a residential situation, the local law enforcement agency. If a licensed professional is involved, a provider reports to the appropriate professional licensing agency and the local law enforcement agency.

The provider must develop policies and procedures for recognizing and appropriately reporting allegations or incidents. If a CRS participant is involved in an allegation of abuse, neglect or exploitation, the provider must notify the CRS counselor immediately by phone, email at CRS_Program@hhsc.state.tx.us, or eFax at 512-206-3981. The appropriate investigating agency's toll-free number and the CRS counselor's office number must be posted in a location that is readily accessible to participants and to staff members.

5.2 Reporting Procedure

Upon notification of abuse, neglect, or exploitation allegations that involve a CRS participant, the provider must cooperate with CRS program staff members with respect to providing information about the incident.

The following documents must be provided to the designated CRS program staff member, as the documents become available:

  • the incident report;
  • progress notes on the incident;
  • medical assessments;
  • a copy of the participant’s Individualized Program Plan;
  • a copy of meeting notes related to the incident;
  • the provider’s investigation report with supporting documentation;
  • documentation to illustrate that a report was made to the proper investigative agency, including the intake number, as applicable;
  • a copy of the investigative agency’s report upon completion, as applicable; and
  • a copy of a deficiency report with the investigation report, as applicable.

5.3 CRS Service Number

All facility-based providers must post the HHSC Office of the Ombudsman Inquiry line at 877-787-8999 that is easily visible and accessible to the participant, and must specify that the number is for CRS participants’ use. Inquiries can also be made via email at CRS_Program@hhsc.state.tx.us.

5.4 Grievance Procedure

At admission, the provider must provide and explain their facilities written grievance procedures to participants. Additionally, the facilities must post the role, purpose, and contact information listed below for the Texas Health and Human Services (HHS) Ombudsman’s Office in a public area for participants and visitors to view it.

HHS Ombudsman’s Contact Information:
Website: hhs.texas.gov/about-hhs/your-rights/hhs-office-ombudsman
Phone: 877-787-8999
Fax: 888-780-8099
Mailing Address:
HHS Office of the Ombudsman
P.O. Box 13247
Austin, Texas 78711-3247

Chapter 6: General Billing Guidelines

6.1 Overview

General billing guidelines are applicable to all services arrays. Some service arrays have additional billing requirements. For additional information, see the chapter that describes the respective service array.

Providers are required to follow all billing guidelines and requirements.

6.2 Service Authorization

Service authorizations are authorizations for services to be rendered. Providers must not provide services until a service authorization has been received.

For all service arrays except outpatient services, the request for services must be based on the recommendations resulting from an interdisciplinary team meeting. The CRS counselor approves the service authorizations for the participant.

The service authorization identifies who is to receive services, what services are to be received, and the dates for which services are to be rendered. To continue a service on a service authorization after an end date, the provider must notify the agency about the need to continue the service and obtain approval to continue the service.

Upon approval, the CRS counselor issues an updated service authorization. If the provider provides services outside of the scope of the originally proposed or outlined dates, payment for those services is not guaranteed. All invoices associated with an issued service authorization must be sent to the appropriate CRS office as indicated on the service authorization.

6.3 Consumer Participation

The term consumer participation refers to the monthly contribution the participant may be required to pay for participation in the CRS program. Consumer participation applies to participants in active services, as well as those on the interest list who are both eligible and receiving services.

The CRS program staff members use net monthly income, liquid assets, and family size as they relate to the federal poverty guidelines for the current fiscal year to determine the amount a participant must contribute to the cost of services. This is a monthly amount and is applied only in months that a provided billable service or good requires participation in cost of services.

The participant’s monthly cost to participate cannot exceed the cost of the billable services provided in each month. A consumer participating in the cost of goods or services pays the provider directly and that amount is deducted from the provider's payment from the agency. The cost determined is stated in the service authorization.

The provider is responsible for the billing, collecting, or writing-off the participant's cost owed by the liable party.

For additional information about consumer participation, see TAC§107.714, Consumer (Client) Participation.

6.4 Invoices

When billing the CRS program for services, providers must submit with the invoices:

  • the participant’s Explanation of Benefits; and
  • the denial letters from the insurance company, including denial letters from Medicaid, Medicare or both, or other pay sources.

When the provider’s facility is closed within a participant's dates of service, payment is not made for that date.

Invoices must be submitted at least monthly, and no later than the fifteenth of each month following the service, using one of the following forms:

  • UB-04 Centers for Medicare and Medicaid (CMS) 1450;
  • HHSC generated invoice; or
  • Health Insurance Billing Form (CMS 1500).

To receive payment, a contractor must follow §TAC 20.487 and submit an invoice to the address on the CRS service authorization, comply with the terms and conditions of the CRS contract, and include, at a minimum, the following:

  • contractor's complete name, mailing address, and e-mail (if applicable) address;
  • contractor's phone number;
  • the name and phone number of a person designated by the contractor to answer questions regarding the invoice;
  • HHSC agency number 529, CRS delivery address;
  • CRS service authorization number;
  • HHSC CRS contract number;
  • contractor’s valid Texas identification number (TIN) issued by the comptroller;
  • a description of the goods or services provided, in sufficient detail to identify the order which relates to the invoice. This may include but is not limited to the CPT (current procedural terminology) codes;
  • Maximum Affordable Payment Schedule (MAPS) rate, or general codes set by the program;
  • dates of service;
  • quantity and unit-cost being billed, as documented on the service authorization;
  • if submitting an invoice after receiving an assignment of a contract, the TIN of the original contractor and the TIN of the successor vendor;
  • other relevant information supporting and explaining the payment requested;
  • participant’s Individualized Program Plan (IPP), signed by the interdisciplinary team (IDT) (for initial billing for services only), if applicable;
  • summaries of monthly meetings, signed by the IDT (for monthly services that are not admission or discharge services), if applicable; and
  • discharge summary, signed by the IDT or other appropriate team member (upon final billing).

The provider must:

  • respond to billing-related inquiries and disputed invoices from CRS program staff members within two business days; and
  • submit all documentation requested within five to 10 business days following the request.

The CRS Program must;

  • confirm that goods or services were received in accordance with the service authorization;
  • receive, inspect, and accept delivery of goods or services covered by the invoice; and
  • receive and accept a complete accurate invoice to request payment from the comptroller.

6.5 Use of Comparable Benefits or a Third-Party Payer

If a CRS participant has comparable benefits, the provider must bill the comparable benefit before billing the CRS program.

If comparable services and benefits are available, the CRS program may participate in the cost of services if the combined amount of the CRS payment and the comparable benefit payment does not exceed the maximum amount allowed by the following, as appropriate:

  • Maximum Affordable Payment Schedule (MAPS) rate;
  • contracted payment rate; or
  • retail or negotiated lower price (for non-MAPS, noncontract items).

If the comparable benefit is paid by:

  • major medical insurance, a health maintenance organization, or preferred provider organization, the CRS program may pay the participant's portion (co-payment, coinsurance, and any unmet deductible), not to exceed the MAPS rate, contract rate, or retail price, as applicable.
  • Medicare, the CRS program may pay the participant's portion (co-payment, coinsurance, and any unmet deductible), not to exceed the MAPS rate, contract rate, or retail price, as applicable.
  • Medicaid, the CRS program pays nothing. The CRS program does not supplement a Medicaid payment for a specific service or procedure.
  • Out of Network, the CRS program may pay up to but not exceeding the contracted rate.

Chapter 7: Quality Assurance

7.1 Overview

A provider participates in monitoring activities as explained in this chapter, per CRS policy and the provider’s contract. Program monitoring applies to a provider of post-acute residential and non-residential rehabilitation services and inpatient comprehensive rehabilitation services.

7.2 Quality Reviews

Designated CRS program staff members continuously monitor the services provided to CRS participants and make regular on-site visits to a provider’s facility. The tasks completed during the visits may include the review of case files.

The quality review process focuses on how well the provider complies with the contract to provide and deliver services.

Ongoing quality reviews of the providers include ensuring that:

  • the services identified by the interdisciplinary team are necessary and appropriate;
  • the services are provided in accordance with the respective service array and other needed services and interventions are provided, as appropriate;
  • participants are free from abuse, neglect or exploitation;
  • participants, families, and guardians participate in identifying and selecting services;
  • services are provided based on assessed need;
  • services are continued, based on their efficacy and promote greater independence;
  • services are billed and paid correctly based on services provided and contracted rate;
  • the staff members interact appropriately and effectively with participants; and
  • all the participant’s identified needs are being addressed.

7.3 On-Site Quality Reviews

 A provider is subject to periodic administrative, programmatic, and financial monitoring by CRS program staff members. Each fiscal year, state and regional offices assess providers to identify which will be monitored on-site during a 12-month period.

If a provider’s facility is selected for an announced quality review, the lead monitor sends a letter announcing the review, provides information about the scope of the review, and provides instructions about how to prepare for the review.

If the CRS program determines the need, a provider that is not identified on the risk assessment may also be monitored. Agency staff members may conduct an unannounced quality review, if the CRS program determines it is necessary.

The unannounced quality review or reviews may consist of:

  • an entrance conference;
  • a records review;
  • interviews;
  • observation;
  • tours of the provider’s facility and grounds; and
  • an exit conference.

7.4 Notification of Quality Review Results

The lead monitor sends the provider a report about the results of the quality review after it is completed. This report includes findings of noncompliance with program or financial standards, if any.

The provider is responsible for providing further documentation to help resolve the findings or completes a correction action plan.

7.5 Corrective Action Plan

Within 28 calendar days after the date on the initial report of findings, the provider must submit:

  • an acceptable written corrective action plan that addresses all the findings that require a written response;
  • financial restitution for overpayments or questioned costs; or
  • a rebuttal of the findings (financial or otherwise), including documentation to substantiate the rebuttal.

The written corrective action plan may include corrective actions other than those recommended in the initial report, if the provider identifies additional ways of correcting the findings. The monitoring team reviews the corrective action plan and may accept it or recommend changes to it. If the provider does not submit an acceptable corrective action plan or make financial restitution when required, the agency may take adverse action against the provider, in accordance with the terms of the contract.

7.6 Quality Review Closeout

If there are no findings, or when the monitoring team accepts the corrective action plan, the monitoring review is closed. A letter is sent to the provider documenting this result.

Chapter 8: Utilization Review for Post-Acute Rehabilitation Residential Services for Traumatic Brain Injury

8.1 Overview

Compliance and quality reviews help ensure that the appropriate scope and level of services are provided to CRS participants. The compliance and quality review may be performed as a clinical or purchasing review. Compliance and quality reviews can occur with any service array provided or paid for by the CRS program.

8.2 Review Types

  • Clinical — Review of services when the participant is actively receiving services within a specified date range or after delivery or discontinuation of services. These reviews ensure that services are provided as recommended by the Individualized Program Plan and interdisciplinary team.
  • Purchasing — Review of participant case file to verify justification and delivery of purchased goods and services based on purchasing guidelines and policy.

8.3 Review Processes

Reviews of a participant’s records, services, and billing can occur from the point of entry into the CRS program until after the participant ends or completes treatment and may include prospective, concurrent, and retrospective review activities.

The purpose of a CRS quality and compliance review is to:

  • ensure the program fiscal integrity of the provider;
  • address the state laws and regulations that require program funds be spent only as allowed; and
  • ensure that services are provided based on medical necessity and are continued based on their efficacy.

A participant’s records may be chosen for review through a random sample or based on necessity, as noted by CRS program staff members.

8.4 Clinical Reviews

During a prospective review, services are reviewed before they are authorized to determine if the participant, the current processes, or both were followed.

The purpose is to ensure that:

  • a participant meets eligibility requirements;
  • services will meet the participant’s needs; and
  • CRS program staff members are following CRS policies and procedures.

The review may include:

  • a review of intake and assessment information;
  • a diagnostic interview;
  • a review of the participant’s records that support eligible diagnosis or diagnoses;
  • a determination of eligibility by the CRS counselor;
  • a review of the participant’s Individualized Written Rehabilitation Plan;
  • a review of the participant’s records documenting the care of the participant provided by the provider, paraprofessionals and professionals;
  • medical and nursing assessment and diagnoses;
  • changes in treatment strategies based on data or assessments;
  • a review of the interdisciplinary team meeting summaries;
  • participant schedules;
  • a review of the consents from the participant;
  • a review of the participant restraints reports;
  • on-site visits and outings;
  • assessments made at the request of or by the CRS counselor;
  • interviews held with the participant, participant’s family or guardian; and
  • discharge planning.

8.5 Purchasing Reviews

Purchasing reviews can occur during or after services have been provided and purchased.

The purpose is to ensure that:

  • a participant is receiving or has received services based on medical necessity;
  • the services occur or occurred in the frequency and duration specified in the Individualized Written Rehabilitation Plan and the treatment outcomes meet or met the participant’s needs; and
  • CRS program staff members are following billing requirements from CRS policies and procedures and providers are rendering services as determined by the CRS counselor and participant.

The review may include:

  • a review of the Individualized Program Plan and Individualized Written Rehabilitation Plan;
  • therapy assessments and therapy notes, along with treatment plans and treatment data;
  • review of medical necessity;
  • review of explanation of benefits or denials;
  • review of number of hours or days of service provided; and
  • review of documentation confirming all billing activities in accordance with CRS policy and standards.

8.6 Review Outcomes

Recoupment of Overpayments

Recoupment is required if the results of a utilization review indicate overpayment for services delivered, payment made for services not delivered, or payment made for services provided without preauthorization.

The agency notifies the provider in writing about the overpayment identified and explains the method of recoupment to be used.

Administrative Actions and Sanctions

The administrative actions or sanctions from a utilization review may result in one or more of the following being taken by the agency:

  1. Closure of the review with written notification to the provider.
  2. Discussion and interpretation of the results of the review with the provider.
  3. Referral to the appropriate state licensing board or to the Texas Office of the Inspector General.

8.7 Appeal Process for Providers

After a utilization review, the CRS program gives the provider a report of the findings.

The provider may appeal the report within 30 days of receiving the findings by submitting a written report that includes supporting documentation disputing the findings.

The CRS program reviews the provider’s appeal and sends the outcome of the review to the provider.

Chapter 9: Admission Policies and Procedures

9.1 Overview

The provider must develop written criteria and procedures for admission. Admission policy and procedures must be communicated clearly in writing with requirements to CRS counselors as requested. Any changes or updates must be communicated once completed. It is the provider’s responsibility to notify CRS staff of their procedures.

The criteria and procedures do not release the provider from the obligation to obtain consent from the consumer, guardian, or representative before using restrictive procedures or behavior modification plans. Representative signatures are not valid, unless the consumer completes Form 1487, Designation of Representative, at the time of admission. In that case, the CRS counselor informs the provider that the participant has agreed to be represented and has a signed Form 1487.

The provider is encouraged to develop a referral form for use by the counselors. The form should list available services and admission criteria. It should also capture the information required before the participant is admitted.

9.2 Intake Process

During the intake process providers must familiarize the participant with the services that the participant has selected. Provider must have participant sign an acknowledgement form and place it in the participant’s file. Familiarizing the participant shall include but is not limited to:

  • explaining the physical arrangements;
  • explaining the provider’s expectations of the participant (such as expectations for attendance and hygiene);
  • explaining the processes for reporting grievances and complaints; and
  • discussing what the participant may expect to receive from the CRS program.

9.3 Participant Information

A participant may designate someone to serve as their representative in all or part of the rehabilitation process. The legal guardian or representative may be authorized to sign documents, speak on the participant’s behalf, or serve in other capacities indicated on Form 1487. The 1487 form must be completed and submitted to the CRS counselor at the time of admission. The provider must inform the participant about the consumer’s responsibilities, safety concerns, and other matters of importance. This information can be provided in a brochure, manual or fact sheet. The provider must explain all CRS program rules or house rules to the participant, and the participant or the participant’s legal guardian, or representative must consent in writing to all of the rules. The provider must have the participant sign an acknowledgement form and place it in the participant’s file. The CRS counselor may request this at any time.

Chapter 10: Assessment and Planning

10.1 Overview

The provider must ensure that appropriate assessment and planning policies and procedures are in place, so that each participant receives the maximum benefit from the CRS program.

The services for CRS are individualized to ensure that a participant gets the maximum benefit identified in the service arrays and the variety of processes described in this manual.

10.2 Assessment

Each staff member of the interdisciplinary team (IDT), as appropriate, assesses a participant's abilities and limitations in relation to that staff member's area of expertise. The case manager writes a report of the assessments within two weeks of a participant's admission into the program. Each member of the IDT receives a copy of the report. Discharge planning utilizing the wraparound approach should be completed during the assessment and ongoing during IDT meetings.

The assessment of the participant must address each of the following areas:

  • Specific developmental strengths and participant preferences
  • Specific functional and adaptive social skills that the participant acquires from treatment
  • Presenting disabilities and, when possible, their causes
  • Need for services (without regard to their availability)
  • Preauthorization of benefits
  • Medical or physical history, or both
  • Nutritional status including determining the appropriate diet, the adequacy of the participant’s total food intake, the participant’s eating skills, including disorders related to chewing, sucking, and swallowing disorders, the food service practices, and the participant’s ability to monitor and supervise their own nutritional status
  • Social history
  • Mental health needs
  • Substance misuse needs
  • Ability to self-administer medication
  • Cognitive status
  • Activities of daily living, as follows:
    • Bathing and showering
    • Dressing
    • Self-feeding
    • Functional mobility
    • Personal hygiene and grooming
    • Toilet hygiene
    • Managing money
    • Shopping for groceries or clothing
    • Using the phone or other form of communication
    • Using technology
    • Transportation within the community
  • Mobility
  • Behavior
  • Communication
  • Required level of supervision
  • Avocational skills
  • Ongoing support needs
  • Access to public benefits, including the Supplemental Nutritional Assistance Program
  • Initial discharge plan
  • Recommended course of treatment, duration and frequency of therapy and how progress will be tracked and monitored.

10.3 Development of Individualized Program Plan

The Individualized Program Plan (IPP) is based on the findings of the assessment and must address all deficit areas noted therein. All planned and needed services for the participant must be documented in the IPP. All interdisciplinary team (IDT) members must participate in developing the IPP, and must document their participation as shown by their attendance on sign-in sheets with signatures. The IDT meets to develop the IPP after the assessment is completed, but no later than 30 days after a participant's admission to the program. After the initial IPP is developed it must be reviewed every 30 days unless otherwise specified for a specific service array. The CRS counselor and the participant's representative, if applicable, are notified at least one week in advance about the date, time, and location of the IPP review meeting.

The IDT process is designed to allow team members to review and discuss information and make recommendations that are relevant to the participant's needs. The IDT reaches decisions as a team, rather than individually, about how best to address the participant’s needs. Everyone involved in the participant's care must work together to provide a uniform and consistent approach to implementation of the IPP.

Note: The word participate means to provide input through whatever means is necessary to ensure that the participant's IPP meets the participant's needs.

The IPP must identify means to prevent or slow regression and prevent the loss of current optimal functional status.

The IPP must include opportunities for participant choice and self-management and identifies the following:

  • Assessments performed by licensed professionals in the areas of service, including but not limited to occupational therapy, physical therapy, speech therapy, cognitive rehabilitation therapy, neuropsychological, or other assessments used to develop and provide therapy services.
  • The frequency and duration of therapy services (as noted in the recommendations section of the assessments), if the assessments indicated that services are warranted.
  • The goals and objectives to be met, including long-and short-term goals that are stated in measurable terms and that relate to increasing a participant's ability to live more independently.
  • The team member who will implement the plan and the specific strategies that will be used.

The provider must provide a copy of the assessment report and the IPP to the CRS program staff member within 10 working days of the IPP meeting. A copy is made available to the participant and to the participant's representative. The results of the assessment and the IPP may be combined into a single report, signed by all pertinent IDT members (as applicable).

Each participant must receive a continuous program of needed interventions and services in sufficient intensity and frequency to support the achievement of the IPP objectives. Except for those facets of the IPP that must be implemented only by licensed personnel, each participant’s IPP must be implemented by all staff members who have been trained to work with the participant, including professional and paraprofessional staff members.

10.4 Interdisciplinary Team Meetings

The interdisciplinary team (IDT), at a minimum, must include the:

  • CRS counselor;
  • participant;
  • participant’s representative or advocate (if applicable);
  • professional staff appropriate to the participant’s needs;
  • professional staff currently providing services or planned to provide services, provider case manager; and
  • any community resources such as family members, friends, or people invited by the participant, and community resource providers.

The Interdisciplinary team meeting is also known as a medical team conference and can occur with or without the participant or family member. The expectation is to always include the participant, family member or both, unless extenuating circumstances prevents them from attending. Attendance and participation in the IDT meetings by such IDT members must be documented. Professionals must add their credentials to the signatures.

For example, if a participant is experiencing health problems, their nurse would attend the IDT meeting, or the participant may ask their best friend to participate in the IDT meeting.

The IDT process is designed to allow team members to review and discuss information and make recommendations that are relevant to the participant’s needs. The IDT reaches decisions as a team, rather than individually, about how best to address the participant’s needs. Everyone involved in the participant’s care must work together to provide a uniform and consistent approach to implementation of the IPP.

  • Meetings formally occur every 30 days to develop and review measurable goals and objectives;
  • review a participant’s progress or lack of progress in attaining the goals and objectives;
  • review the efficacy of the services being provided;
  • determine whether to change the participant’s goals, objectives, and timelines and the persons designated as responsible; and
  • review and assess on-going discharge plan and identify needs.

The CRS counselor, the participant, and the participant’s representative or advocate must be notified in writing of the date, time, and location of all IDT meetings at least one week in advance.

The results of the IDT meeting must be documented in a written report. A copy of the report is provided to the CRS counselor within 10 working days after the meeting. A copy must be made available to the participant or the participant’s representative.

In addition to holding the required meeting every 30 days, the IDT must meet as frequently as prudent and necessary, based on need, to maintain an effective treatment program. Adjustments to the IPP, including discharge planning, are made as necessary. Meetings must provide enough time for the participant to ask questions to ensure the participant or family members understanding of the treatment plan.

10.5 Behavior Management Plans

Behavior management plans are developed and monitored by licensed professionals or board certified professionals to address behaviors, to ensure the participant can obtain maximum gains from services being delivered. Plans may include therapeutic medication, interventions that include positive reinforcement, verbal cues and rewards.

If restrictive procedures, such as the use of routine, sedative, or psychotropic medications to control behavior, the removing or restricting of access to personal property, and the use of restraint are used as a behavior modification technique, the provider's policies and procedures must clearly state when and how the procedures are implemented.

In the case of participants who are minors or persons who are incapacitated, as determined by a court, informed consent for use of restrictive programs, practices, or procedures must be obtained from the participant’s legal guardian or representative (see 9.3 Participant Information), in accordance with state law, to act on behalf of the participant.

Informed consent, signed by the participant or the participant’s representative, for restrictive procedures must be indicated on a separate document from the general programmatic consents obtained when a participant enters the program. The consent lists the risks and benefits of the restrictive interventions and states how the restrictive interventions are monitored and faded.

Standing or as-needed programs to control inappropriate behavior are not permitted. All interventions addressing the control of inappropriate behaviors must be justified by the assessment and the participant’s current level of behavior.

A behavior management plan:

  • must be developed and signed by a licensed professional (see Appendix B Post-Acute Rehabilitation Core Services – Modality and Staff Qualifications for provider qualifications);
  • must identify the triggers and prevention strategies that are incorporated into the plan;
  • must be reviewed and approved by the interdisciplinary team (IDT) member and CRS counselor, as indicated by an attendance sheet with the IDT members’ signatures and a short summary of the team’s discussion before the plan is implemented by the IDT;
  • must be written in a manner that can be understood by the participant and staff;
  • must provide evidence that staff members were trained before implementing the behavior management plan;
  • must indicate that a licensed professional must oversee the staff members who implement the plan; and
  • must be incorporated into the participant’s Individualized Program Plan.

10.6 Emergency Restrictive Procedures

Emergency restrictive procedures are the least-restrictive procedures possibly used for the briefest time necessary to control severely aggressive or destructive behaviors that place the participant or others in imminent danger and when those behaviors could not have been reasonably anticipated. Emergency restrictive procedures are used only as necessary within the context of positive behavioral programming.

Each time a participant is restrained, a written report must document the details of the incident. This written report must be filed in the participant’s file maintained by the provider. The participant’s interdisciplinary team (IDT) must review each report by the next scheduled monthly team meeting to determine whether modifications to the treatment plan are needed.

The provider may use restraint as an emergency measure only if necessary to protect the participant or others from injury.

The provider's policy must include providing training on the appropriate procedures and techniques for physical restraint to staff members who have direct contact with participants. The procedures must clearly indicate the training required for all staff members at hire and at least annually thereafter.

The use of restraints to control inappropriate behavior:

  • must be approved by the IDT, noted in the participants’ s Individualized Program Plan (IPP), and agreed to by the CRS counselor, as indicated by an attendance sheet with the CRS counselor’s and IDT members’ signatures and a short summary reflecting team discussions;
  • must be used only as an integral part of the participant's IPP and specifically to reduce and eventually eliminate the behaviors for which the restraint, drugs or both are employed;
  • must be monitored by the IDT closely in conjunction with the physician to ensure appropriateness, desired responses and adverse consequences;
  • must be justified in that the harmful effects of the behavior clearly outweigh the potentially harmful effects of the restraint; and
  • must be part of a developed plan that includes less-restrictive interventions to address behaviors that require more than two physical or chemical restraints in 30 days.

If chemical or physical restraints are used more than twice in 30 days, or more than once in 30 days for minors, the IDT must meet to discuss changing the participant’s treatment to address behaviors that place the participant or others at risk. Changes must be made to treatment approaches, treatment goals and strategies, and behavior management strategies must be developed.

If restraints are required to participate in the program, the IDT must determine whether the program is in the participant’s best interest or whether the participant should be discharged from the program.

The CRS counselor must be notified within 48 hours after restraint is used.
Documentation of the IDT meeting must indicate the modifications made to the treatment plans or treatment approaches. Efficacy of this intervention should be reflected in data and decreasing trends in the use of emergency restrictive procedures.

10.7 Substance Abuse

If the CRS participant has a substance abuse disability and there are observations or other evidence of the use of alcohol or drugs, the provider must report the observations and evidence immediately to the CRS counselor. The provider must document that the counselor was informed and document all observations and other evidence of the participant's use of alcohol or drugs. Chemical dependency services must be delivered to the participant.  

Chemical dependency services must:

  • be provided based on assessed needs;
  • be developed and approved by the interdisciplinary team; and
  • become part of the participant’s Individualized Program Plan.

Chapter 11: Traumatic Brain Injury and Traumatic Spinal Cord Injury – Inpatient Comprehensive Medical Rehabilitation Services

11.1 Overview

To address medical and rehabilitation issues that require 24-hour-a-day nursing services, inpatient comprehensive medical rehabilitation services (ICMRS) are provided as recommended by an interdisciplinary team in a hospital setting. These services are available to people who have a traumatic brain injury (TBI), a traumatic spinal cord injury (TSCI), or both. An interdisciplinary team of professionals closely coordinates services to achieve the team’s treatment goals, thereby minimizing a person's physical or cognitive disabilities and maximizing a person's functional capacity. HHSC negotiates contracts with inpatient and outpatient facilities to provide services based on data from the ratio to cost to charges.

Inpatient comprehensive medical rehabilitation services are delivered through contract with hospitals and are governed by the terms of those contracts. The services are specified in the service array and, unless otherwise specified, should be considered all inclusive. If a participant requires medication, the hospital pharmacy provides the medication. Pharmacy charges appear as a line item on the invoice and are paid per the contracted rate. Goods or services approved by the CRS program that are not part of the contracted rate for inpatient comprehensive medical rehabilitation services are considered ancillary. See Chapter 14: Traumatic Brain Injury and Traumatic Spinal Cord Injury – Ancillary Goods and Services for additional details.

11.2 Required Documentation

The primary medical and rehabilitation (PM&R) physician overseeing the participants care while in ICMRS is a separate service which requires pre-authorization. It is the responsibility of the ICMRS provider to notify CRS staff of the PM&R physician’s identity for CRS to pre-authorize and issue a service authorization.

The provider submits:

  • a list of specialists who provide inpatient comprehensive medical rehabilitation services;
  • an estimate of the number of visits that will be needed during the participant’s hospitalization; and
  • a report detailing the charges and services provided during the participant’s stay in the hospital.

See Chapter 4: General Provider Responsibilities for additional documentation requirements.

11.3 Assessment, Planning and Interdisciplinary Meetings

An assessment (see Chapter 10.1) and Individualized Program Plan (IPP) (see Chapter 10.2) must be completed to address participant’s deficits. The CRS counselor may request additional supporting documentation as needed. All planned and needed services for the participant must be documented. This must be reviewed to preauthorize services.

The IDT must meet every 30 days to review the IPP to determine medical necessity for on-going services.

The IPP and supporting data must include information on:

  • the participant’s condition;
  • medical necessity;
  • the course of treatment;
  • the progress the participant’s is making toward the treatment goals;
  • the physician’s hand-written prescriptions for the rehabilitation service;
  • the physician’s current treatment plan;
  • data supporting the treatment plan;
  • staffing summaries and assessments; and
  • the participant’s current medication regime.

Reauthorization may not be approved, if the CRS program does not receive an updated status every 30 days.

 

11.4 Billing Guidelines

Inpatient comprehensive medical rehabilitation services are billed at a contracted rate. Ancillary goods and services must be preauthorized by a CRS program staff member and are reimbursed based on the fee for service in accordance with 1 TAC §355.9040.

The provider:

  • submits a prescription or a physician’s order to the CRS program staff member to issue a service authorization;
  • submits the participant’s Individualized Program Plan, which identifies the services needed; and
  • obtains authorization from the CRS program staff member.

The CRS program does not pay for personal items, such as television rental, phone calls, gourmet meals, cots and guest trays. In addition, the CRS program does not pay for a private room unless the physician orders it as medically necessary, or no other room is available. If the provider provides services without a service authorization or outside of the scope of originally proposed or approved dates, payment for those services is not guaranteed. Invoices must be submitted at least monthly, and no later than the fifteenth of each month following the service. See Chapter 6: General Billing Guidelines.

11.5 Exceptions and Limitations

Inpatient comprehensive medical rehabilitation services are approved only when no more than one year has elapsed between the date of injury and the date of initial contact. All services must be preauthorized by the CRS counselor. ICMRS services are approved in 30-day increments and cannot exceed a total of 90 days.

Chapter 12: Traumatic Brain Injury and Traumatic Spinal Cord Injury – Outpatient Therapy Services

12.1 Overview

Outpatient therapy services refer to any core service identified in Appendix B: Post-Acute Rehabilitation Core Services – Modality and Staff Qualifications including, but not limited to: occupational therapy, physical therapy, speech therapy, mental health counseling, and substance abuse services. Outpatient therapy services are provided on a one-on-one basis by licensed therapists to participants who have a traumatic brain injury, a traumatic spinal cord injury, or both.

A physician must prescribe outpatient therapy services (as applicable) and are provided without admittance to a hospital. The goal is to correct or modify a stable or slowly progressive physical or mental impairment that constitutes a substantial impediment to independence.
Goods and services that are not considered outpatient therapy services are considered ancillary. See Chapter 14: Traumatic Brain Injury and Traumatic Spinal Cord Injury – Ancillary Goods and Services for billing guidelines and reimbursement of ancillary services.

12.2 Required Documentation

Assessments for outpatient therapy services must be completed by a qualified, licensed professional, as defined in Appendix B: Post-Acute Rehabilitation Core Services – Modality and Staff Qualifications.
Before providing outpatient therapy services, the provider must recommend to the CRS program the specific type of service, frequency, and duration necessary for the participant to reach the outcomes noted in the treatment plan. The assessment and treatment plan can be contained in the same document, if all the essential elements of both are included.

The treatment plan must be developed with the participant or the participant’s family, guardian or representative and licensed professional before outpatient therapy services are provided. The treatment plan must contain clearly defined, measurable objectives and be sent by the provider to a CRS program staff member.

To justify continuing outpatient therapy services, the licensed professional must provide data at least monthly. The data provided must support the need to provide services to the participant. If the participant’s progress is inadequate or the participant regresses, additional documentation is necessary to revise the treatment plan and continue the outpatient therapy services. Providers must keep on file documentation showing that the services were preauthorized by the CRS program. The provider must respond to CRS program staff member inquiries pertaining to billing within two business days after receiving the request. The provider must submit documentation within five business days after receiving the request. See Chapter 4: General Provider Responsibilities for additional documentation requirements.

12.3 Assessment, Planning and Interdisciplinary Team Meetings

An assessment (see Chapter 10.1) and Individualized Program Plan (IPP) (see Chapter 10.2) must be completed to address participant’s deficits. The CRS counselor or CRS program staff member must receive an update or participate in a team meeting to discuss the participant’s status. The update should include the individual’s condition, course of treatment, progress, or lack of progress made toward reaching the treatment goals, with supporting data. The CRS counselor may request additional supporting documentation as needed. This must be reviewed to preauthorize additional services based on the following schedule:

  • if the participant is receiving 2-4 hours of service per week, the provider must submit an update every 60 days;
  • if the participant is receiving 5 or more hours of service per week, the provider must submit an update monthly.

 
*Note: outpatient services differ from post-acute rehabilitation services (PARS) non-residential which requires a full interdisciplinary team meeting. Outpatient therapy should be reserved for individualized services with a lower level of care while PARS non-residential require more intensive level of care for services.

12.4 Billing Guidelines

The provider must submit a prescription (as applicable) or physician’s recommendation for requested outpatient therapy services for the CRS program staff member to issue a service authorization. Following the evaluation, if the provider determines that it is necessary for the participant to receive therapy, the provider submits a written report and recommendations identifying the type of therapy needed, the duration and the frequency. If the CRS program staff member approves the therapy, a service authorization will be issued.

If the provider provides services without a service authorization or provides services outside of the originally proposed or approved dates, payment for the services is not guaranteed.

Invoices must be submitted at least monthly, and no later than the fifteenth of each month following the service. Data supporting the service must accompany each invoice. Outpatient therapy services are delivered per the contract or the terms and conditions set forth in the service authorization. These services are authorized by CRS counselors and are reimbursed according to the reimbursement methodology described in 1 TAC §355.9040.

Ancillary goods and services must be identified on the Individualized Program Plan and preauthorized by a CRS program staff member and are reimbursed based on fee for service in accordance with 1 TAC §355.9040. See Chapter 6: General Billing Guidelines for general billing guidelines.

12.5 Exceptions and Limitations

Outpatient therapy services are approved only when no more than two years have elapsed between the date of injury and the date of initial contact. CRS participants may receive up to 120 hours of outpatient services if medical necessity is determined.

Chapter 13: Traumatic Brain Injury and Traumatic Spinal Cord Injury – Post-Acute Rehabilitation Services (PARS)

13.1 Overview

Post-acute rehabilitation services (PARS) for traumatic brain injury (TBI) and traumatic spinal cord injury (TSCI) are advanced rehabilitation services provided through an interdisciplinary team approach. For residential services, the participant must have a TBI or have a TBI with a TSCI and for a non-residential setting, the participant may have a TBI or TSCI.

Services that are provided are based on an assessment of the individual's deficits. The goal is to achieve independence in the home and community and establish new patterns of cognitive activity or compensatory mechanisms. HHSC Rate Analysis sets PARS rates and can be located here.

13.2 Required Documentation

For a participant receiving PARS, the provider uses the Mayo Portland Adaptability Inventory (MPAI-4) or Functional Inventory Measure (FIM), as applicable, based on service:

  • on admission;
  • on discharge; and
  • when the six-month follow-up is provided, after discharge.

The Individualized Program Plan (IPP) must document the progress or lack of progress that the participant is making toward reaching the measurable goals and objectives.

Activity schedules must facilitate participation and provide opportunities for the participant to be independent. Schedules must indicate the participant’s general activities for the day, including meals, therapeutic activities, recreation and leisure activities. The activity schedule must address the goals in the IPP and be made available to each participant. Copies of schedules for each participant must be made available to CRS counselors for review. The activity schedule directs the intensity of the daily work that the participant must do to implement the IPP, about both informal and formal training.

The provider must submit and maintain all documentation pertaining to billing. Providers for residential and non-residential services are required to submit service record details into the CRS Data Reporting System. The service record details must be submitted by the 10th working day of the month following service delivery (for example, services delivered in September must be uploaded by the tenth of October). Providers are supplied with an Excel file format or layout and with access to the web-based system to upload the service record details. The details required are outlined in Appendix D: Service Record for CRS Data Reporting System. (See Chapter 4: General Provider Responsibilities for additional documentation requirements.) For technical assistance related to issues with the CRS Data Reporting System contact CRS_Program@hhsc.state.tx.us.

13.3 Assessment, Planning and Interdisciplinary Meetings

An assessment (see Chapter 10.1) and Individualized Program Plan (IPP) (see Chapter 10.2) must be completed to address participant’s deficits. The CRS counselor may request additional supporting documentation as needed. All planned and needed services for the participant must be documented. This must be reviewed to preauthorize services.

The IDT reviews the IPP at each monthly meeting to determine whether to continue and possibly modify the services. The IDT may also meet as frequently as is prudent and necessary to maintain an effective treatment program. Adjustments to the IPP, including discharge planning, are made as necessary.

13.4 Outcome Measures

Providers of PARS residential and non-residential services for traumatic brain injury must administer the Mayo-Portland Adaptability Inventory (MPAI-4) to all CRS participants. For non-residential services for traumatic spinal cord injury, providers must administer the Functional Independence Measure (FIM) to all CRS participants.  MPAI must be completed and signed by a licensed professional.

The MPAI-4 or FIM scores must be administered at:

  • Admission
  • Discharge
  • Six months after discharge (when possible) with documented effort to obtain it.

Providers must report all outcome measures and send the report to the CRS Program. Below are the state fiscal year quarters and due dates:

Table 1, State Fiscal Year Quarters and Due Dates

Months

Due dates

September

Quarterly progression measures due Dec. 10

October

November

December

Quarterly progression measures due March 10

January

February

March

Quarterly progression measures due June 10

April

May

June

Quarterly progression measures due Sept. 10

July

August

If the due date falls on a weekend or state holiday, the report is due the following business day.

13.5 Customer Satisfaction

All providers who provide PARS in a residential setting must include participation satisfaction measures based on input from participants about benefits received from the services.

Each provider may develop its own survey instrument and procedure. However, at a minimum, the survey instrument must include the following prompt:

Using the Likert scale in the table below, rate the following statements:

  1. I was treated in a friendly, caring, and respectful manner by the staff of [insert provider’s name].
  2. Services were provided in a timely manner.
  3. The services met my needs.
  4. I was satisfied with the services provided.
Likert Scale

1

Strongly disagree

2

Disagree
3 Niether agree nor disagree
4 Agree
5 Strongly agree

Providers must give all participants, both successful and unsuccessful, an opportunity to respond upon discharge from the CRS program. Providers must keep in the participant's file all attempts to obtain participant response to the participant satisfaction survey. The CRS program may request the responses from the provider every six months.

13.6 Residential

PARS for participants who have a traumatic brain injury (TBI), or who have both a TBI and a traumatic spinal cord injury (TSCI), are provided in a residential setting and are based on a tiered billing system. Each tier is a preauthorized level of service.

The tiers are:

  • Tier Base;
  • Tier Base Plus; and
  • Core Therapy services.

13.6.1 Licensure and Accreditation

All providers who provide PARS in a residential setting that do business with the CRS program must be licensed by at least one of the following regulatory agencies, as appropriate:

The providers must maintain accreditation from:

  • the Commission on Accreditation of Rehabilitation Facilities;
  • the Joint Commission on Accreditation of Healthcare Organizations; or
  • the Disease-Specific Care Certification in Brain Injury Rehabilitation Program.

New facility-based providers doing business with CRS that do not already meet this requirement are granted up to two years from the date of their CRS contract for post-acute brain injury or post-acute spinal cord injury services to obtain the accreditation.

13.6.2 Billing Guidelines-Tiers

HHSC negotiates contracts with providers to provide post-acute rehabilitation, which is reimbursed in accordance with 1 TAC §355.9040. Residential services for traumatic brain injury are authorized based on a tiered rate structure. Each tier represents a preauthorized number of hours allotted for providing core therapy services. A week is defined as Sunday through Saturday. To determine the appropriate tier, use the clinical recommendation for services, frequency, and duration. For example, if the interdisciplinary team (IDT) recommends the following core therapy service—PT 2 times per week for 1 hour, OT recommended 3 times a week for 1 hour and Art Therapy 1 times a week for 1 hour—the appropriate tier would be Tier 1.

Based on the participant’s need determined during the initial pre-admission assessment, the provider may request an admission tier of level 2 through level 8. This request is to be submitted in writing using Form 3149, Comprehensive Rehabilitation Services Request for Tier Change, or included in the pre-admission evaluation, which identifies services needed, frequency, duration and requested tier. With prior authorization, the tier may be changed to reflect the level recommended on a weekly basis by the IDT.  Justification must include information related to the participant's needs, goals, and recommended core therapy services.

Note: Additional supporting documentation (i.e., daily therapy notes, etc.) may be requested during utilization review activities.

All post-acute rehabilitation residential services providers must submit billing for services within 30 days of the last date of services. Participants should receive core therapy services at the authorized tier.

The invoice submitted by the provider indicates the tier level and the core therapy services provided to the participant each day of service. The CRS counselor or CRS program staff member then confirms the data in the CRS Data Reporting System to ensure that the total hours for the week do not exceed the approved tier.  For example, a participant is authorized for Tier 4 services, the number of hours of core therapy services provided cannot exceed 28 hours within the week. Payment will be based on the services provided within the authorized tier.

When submitting an invoice, Post-Acute Rehabilitation providers are required to submit a monthly summary that includes a descriptive breakdown of services provided including frequency, duration, progress, or lack of progress made towards the participant's goals, actions to be taken, and preliminary discharge information. Providers are also required to upload service record details of daily services provided in the CRS Data Reporting System, per Chapter 13.2, Required Documentation. Providers will only be required to submit daily therapy documentation if a participant’s file is randomly selected for utilization review. The provider will receive a written request with a time frame outlining when documentation is to be returned to the CRS requestor.

Participant needs are the foundation of the CRS program and as such, minor fluctuations in the delivery of core therapy services is expected to accommodate a participant’s medical needs. If a participant is unable or unwilling to participate in core therapy services for a day or two, the provider must provide appropriate clinical documentation for increasing core therapy service hours on a subsequent day. Core therapy service hours must not be increased for the purposes of maximizing billing. For example, a participant is authorized for Tier 4 services, the participant is ill for three of the seven days that week. Upon recovery, the participant must not be asked to participate in increased hours of core therapy services that could potentially be harmful to the participant simply to ensure that maximum billing occurs for the assigned tier.

Patterns where Base or Base Plus Tier services are provided, followed by days with increased hours of therapy services above the recommended number of hours of core therapy services per day, must be supported by written clinical justification from assigned therapists.

The CRS counselor or other CRS program staff member compares the submitted invoice and the supporting documentation (which includes the approved tier) to what has been submitted in the CRS Data Reporting System. Disparity between the submitted documentation and invoice will be addressed by CRS program staff members and resolution obtained before payment is issued.

13.6.3 Co-Pay and Co-Insurance

Co-pay and co-insurance is covered when a participant has third-party insurance that is being billed for services. All other pay sources must be exhausted before the CRS program is billed for services.

13.6.4 Tier Base and Tier Base-Plus

Tier Base services include administrative costs, room and board, paraprofessional services, medical services (that is, physician and nursing services), dietary and nutritional services, and case management. These services may not be billed separately to the CRS program.

Tier Base-Plus services include the base services plus one-quarter to three-quarter hours of core therapy services.

13.6.5 Core Therapy Services

See Appendix B for a complete list of core therapy services and provider qualifications. Core therapy services for PARS residential services including, but not limited to physical therapy, occupational therapy, speech therapy, cognitive therapy and neuropsychological services.

Core therapy services are based on the recommended tier and must be provided by a licensed or certified professional. If an identified core therapy service is provided by a non-licensed or certified professional, the service is not billable as part of the core therapy service for the tier.

For example, nursing services are considered part of base services and therefore are not billable as part of core therapy services. Goods and services that are not considered base or core therapy services are defined as ancillary and must be authorized by the CRS counselor.

See Chapter 14 for details.

13.6.6 Preauthorization for Changing Tiers

Changes in the approved tier require preauthorization from a CRS program staff member. The provider must document in the participant’s record why a participant received less than the preauthorized or approved tier or why it is clinically recommended to increase the tier.

When a provider requests a change in Tier for a participant, the provider must complete the Form 3149, Comprehensive Rehabilitation Services Request for Tier Change. The form will include the requested Tier change and the justification of need detailing goals, progress or lack of progress and the type, frequency and duration of therapy services. The Request for Tier Change Form must be faxed or sent via secure email to the CRS Counselor. The CRS Counselor will review, make a determination and return to the requesting provider within five business days. Unauthorized services may not be reimbursed by the CRS program. The CRS program staff member may request documentation supporting the provider’s request. If requested, the documentation must be submitted before delivering services at the newly requested tier or the change in tier is considered unauthorized.

13.6.7 Exceptions and Limitations

PARS that are provided in a residential setting are limited to 180 days from the first day of services and are sponsored by the CRS program. All services must be preauthorized.

Tier Base: A participant does not receive any core therapy services on a given day. The provider bills Tier Base for that day to indicate that the provider is being reimbursed only for the base services and that no core therapy services were provided. The CRS program does not expect that participants will be approved for Tier Base. The tier is provided to account for days of service that fall below the authorized tier.

Tier Base Plus: A participant receives a limited core therapy service of one- to three-quarter hours per day. The CRS program does not expect that participants will be approved for Tier Base Plus. The tier is provided to account for days of service that fall below the authorized tier.

Core Individual and Group Therapy: One hour of individual therapy or two hours of group therapy count as one hour toward a tier. The total number of hours applied to a tier equals the sum of the individual and group hours. For example, one hour of individual and one hour of group equals 1.5 hours total and is billed as Tier 1. One hour of individual and four hours of group equals three hours total and is billed as Tier 3. For group therapy, group size is limited to ten participants.

Billing Core Therapy Services: Two therapists cannot bill for the same period. Divide therapy units and time by the number of therapists delivering the service to determine the number of hours attributed to each. For example, if a physical therapist and an occupational therapist deliver one hour of individual therapy to a participant together, the therapy counts as one hour toward the tier. On the supporting documentation, the therapy is shown as .5 hours of physical therapy and .5 hours of occupational therapy. (The providers may split the hour differently, such as three-quarter hours of physical therapy and one-quarter hours of occupational therapy, if the sum does not exceed one hour. For staff qualifications, see Appendix B Post-Acute Rehabilitation Core Services – Modality and Staff Qualifications.

Billing for a partial week: If billing for fewer than seven calendar days, the billing guidelines for the maximum number of hours provided at the approved tier apply. For example, if a participant is approved for Tier 4, the sum must not exceed 28 hours, regardless of the number of days involved.

Copays: Providers bill a third party or the participant ’s insurance company for services. The CRS program pays the consumer’s required copay or coinsurance for the service. Tiered rates do not apply. However, the provider must still submit detailed billing information on the services delivered to the participant.

Day of Admission or Discharge: Admission and discharge days are handled the same as any other service day. If no core therapy services are delivered, the provider bills for Tier Base services. If core therapy services are delivered, the provider bills for the appropriate tier for the number of hours delivered, in accordance the prior authorization.

Therapeutic Passes: A therapeutic pass allows a participant to leave a residential facility unaccompanied by facility staff. Therapeutic passes are reviewed and incorporated into the participant’s plan of care by the treatment team. The purpose of the therapeutic pass is to facilitate a participant’s transition from a residential facility to their own home and the community. For example, a participant may go home for the weekend to practice skills learned and apply them to the home environment, go shopping with family members, or practice taking the bus or public transportation. While a participant is on therapeutic pass, staff members from the residential facility must be available to provide the participant, the participant’s family, or others who are supporting the participant with guidance and instruction, usually by phone as needed.

Within one day of the participant’s return to the facility, the facility team must review and address with the participant all of the issues identified while on the therapeutic pass. If the facility team determines that changes in the participant’s therapy services or ancillary services are required, a team member must notify the CRS counselor and schedule a follow up interdisciplinary team meeting. If the counselor and the interdisciplinary team approve, the facility team incorporates techniques into the participant’s therapy or ancillary services to address the issues.

Providers must document services provided and may bill for services rendered while the participant is at the residential facility on the same day as a therapeutic pass. For example, a participant has a pass scheduled to leave the facility from 11 a.m. to 5 p.m. but requires assistance for ADL’s, medications, and meals before and after the pass so, the provider may bill for this date. If the participant will be out of the facility for a 24-hour period with no services provided, the provider cannot bill for that time.

13.7 Non-residential

Post-acute rehabilitation non-residential services for traumatic brain injury and traumatic spinal cord injury offer the same core therapy as residential services. Also included are case management, community independence supports, medical team conferences, and a standard facility or community base fee for non-residential services which covers dietary and nutritional services, medical (nursing and physician) services, and administrative/operational costs. Staff qualifications for providing core services remains unchanged. See Appendix B for Post-Acute Rehabilitation Core Services – Modality and Staff Qualifications.

13.7.1 Licensure and Accreditation

All post-acute rehabilitation non-residential service providers that do business with the CRS program and are not licensed by Texas Health and Human Services (HHS) as an assisted living facility or nursing home and are not licensed by the Department of State Health Services as a hospital or chemical dependency center, must be:

13.7.2 Billing Guidelines

HHSC negotiates contracts with providers which are reimbursed in accordance with 1 TAC §355.9040.

Post-acute rehabilitation non-residential services for traumatic brain injury and traumatic spinal cord injury can be either facility based or community based. Providers will bill a standard facility or community base fee for each hour the consumer is present plus a bill for each service that was provided.

For example, a participant receives services in a non-residential setting on Monday from 9 a.m. to 2 p.m. The participant receives one hour of physical therapy, one hour of occupational therapy, one hour of speech therapy, and one hour of art therapy. The provider bills for four hours of therapy, submitting a bill for each therapy code(s) and one hour of base for each hour at the facility for a total of five hours of base. The provider also submits supporting documentation for services provided.

If the participant does not receive therapy services from an approved certified or licensed professional while at the facility, the provider bills only for the time that the participant is at the facility and bills only at the base rate. For example, the participant attends the program for four hours, but does not receive any therapy services. The provider submits a bill for four hours at the base rate.

Bills for services must be submitted monthly. Data supporting the service must accompany each invoice. See Chapter 6 General Billing Guidelines for additional billing guidelines and must be uploaded in the CRS Data Reporting System.

Note: All services must be pre-authorized by the CRS counselor before services can be provided to a consumer.

13.7.3 Exceptions and Limitations

PARS are limited to 180 days starting on the first day of services sponsored by the CRS program.

Chapter 14: Traumatic Brain Injury and Traumatic Spinal Cord Injury – Ancillary Goods and Services

14.1 Overview

Goods and services related to a person’s traumatic brain injury (TBI) or traumatic spinal cord injury (TSCI), which are not outpatient therapy services and are not delivered as part of inpatient comprehensive medical rehabilitation services or post-acute rehabilitation services, are considered ancillary. Ancillary services are preauthorized by CRS counselors according to CRS policy, and are reimbursed according to the reimbursement methodology described in 1 TAC §355.9040. These services may include durable medical equipment, orthotics, prosthetics, assistive technology devices, medications, medical equipment and supplies, home modifications, transportation that is required to enable participation in a CRS approved service, and paraprofessional services that are required to enable participation in therapy sessions to assist with meeting treatment goals and independence in the home and community.

14.2 Durable Medical Equipment

Durable Medical Equipment (DME) is any equipment that provides therapeutic benefits to a person with a medical condition and should be purchased utilizing contracted providers and must be pre-authorized by the CRS counselor. If no contracted provider is available, a vendor may be utilized if appropriate approvals are obtained.

14.3 Home Modifications

Home modifications are changes made to the participant’s physical environment to increase their accessibility to perform activities of daily living to function independently in the home and community. Any home modifications that the CRS program approves needs to have an assessment and gather professional recommendations prior to approval and purchase.

The home modification process begins with a full assessment of needs, followed by consideration of accommodation alternatives. This includes the need for participant training and education on the use of rehabilitation technology. The participant needs to make an informed choice about how to best meet their needs, considering the advantages of low-tech equipment over high-tech equipment, the need to maintain equipment, the possibility of maintenance costs, and the timeliness with which the equipment can be purchased. Creating an accessible environment for independent living may include, but is not limited to ramps and adaptive equipment such as stair glides and lifts.

Adaptive equipment may require installation, but usually does not result in permanent structural changes. Household equipment may be specially designed, selected, or altered to enable the participant to perform homemaker duties despite their functional limitations.
Modifications are limited to equipment that can be removed from the residence without permanent damage to the property should the participant move or fail to cooperate in achieving the planned objective.

Obtain a written agreement using the Form 3107, CRS Resident Site Modification Waiver and Agreement, signed by the participant, the property owner or both for any equipment such as a porch, ramp, or bathroom grab bars is attached (for example, bolted or nailed) to the property.  This document needs to be filled in completely and clearly justify the reason that the modification supports the participant's planned rehabilitation outcome. If the lien holder or property owner will not sign the disclaimer or there are circumstances of minor edits to the agreement, contact Legal Services for guidance. Provide a copy of Form 3107, CRS Resident Site Modification Waiver and Agreement, to the participant, lien holder or property owner, and keep the original in the participant’s case file.

14.4 Required Documentation

The provider must submit an Individualized Program Plan that identifies the ancillary goods and services needed for the participant to obtain authorization from the CRS program staff member. For durable medical equipment an evaluation or a prescription is required to verify medical necessity. A quote with the MSRP must be submitted to the CRS program staff for pre-authorizations. The provider summarizes in detail the ancillary goods and services provided, justifies the need (for example, by including assessments and quotes for costs), and submits supporting documentation (such as receipts for prescriptions). See Chapter 6 General Billing Guidelines for additional information.

14.5 Billing Guidelines

The provider must submit quotes or a request for pre-authorization of services. The provider must submit a detailed summary of the ancillary goods or services provided, along with the invoice. For verification of contracted DME discounts, the provider must submit a copy of the manufacturer’s suggested retail price (MSRP) with the invoice. Warranties and repairs must be included in the quotes if applicable. If a participant has a third-party insurance or comparable benefit, the contracted DME provider must also submit a copy of the explanation of benefits or denial before payment can be authorized. If the provider provides services outside of the proposed or confirmed dates, payment is not guaranteed. The provider is responsible for billing, collecting, or writing-off costs owed by the liable party. The CRS program is the payer of last resort.

14.6 Exceptions and Limitations

If a participant requires medical treatment for an injury sustained while receiving rehabilitation services or requires treatment for an illness that is not related to the participant’s TBI or TSCI, the participant is considered medically unstable and the services are not covered by the CRS program.

If products or services are not under contract or a Maximum Affordable Payment Schedule purchase and the cost is less than $5,000.00, the purchase should be completed using a commercial source. Purchases of goods and services in the amount of $5,000 or less from a single vendor are not required to have competitive bids, but must conform to the purchasing guidelines. All purchases, except contracted services, costing more than $5,000, must be competitively bid or approved as a Proprietary or Sole Source Purchase. The following approvals are required for ancillary goods and services:

Purchase costs per item Approval needed from Competitive bids required
$2,000 or less Counselor No
$2,000 to $5,000 Supervisor No
$5,000 -$25,000 Supervisor

Required for goods or services greater than $5,000 if the purchase is:

  • Not a contracted item
  • Not using the Maximum Affordable Payment Schedule fee schedule
$25,000 and more Manager

Required for goods or services greater than $5,000 if the purchase is:

  • Not a contracted item
  • Not using the Maximum Affordable Payment Schedule fee schedule

 

Chapter 15: Discharge and Termination

15.1 Overview

The provider must develop and establish policies and procedures with respect to participant discharge and termination. Discharge planning should start at admission and continue throughout services.

15.2 Discharge Summary

The provider must develop a discharge summary for each participant and provide a copy to the CRS program staff member within 10 business days after services are completed or terminated.

The discharge summary must include:

  • the strengths, abilities, needs and preferences of the participant;
  • the goals established in the Individualized Program Plan;
  • the services provided, and the relationship to the status of each goal;
  • the reason for discharge; and
  • referrals and recommendations, and any necessary physician's orders, to help the participant maintain or improve functioning and increase independence.

15.3 Termination from Program

The provider must document interventions attempted to prevent termination from a program. The provider must inform the CRS counselor, or their designee, directly that a participant's services are being terminated as soon as the provider is aware that the participant’s services will be terminated. The provider must document that the provider informed the counselor about the termination of services to a participant.

The provider must follow the state and federal requirements applicable to the license or certification relating to discharge procedures. The provider must ensure that the participant is safe and must determine a discharge site and facilitate placement.

Some reasons for termination are:

  • behaviors dangerous to one’s self or others;
  • no progress made toward rehabilitation goals; or
  • refusal to participate in services.

Appendices

Appendix A: Definitions

The following key terms are important and used throughout this manual. These terms are used to describe activities, services, and processes associated with the CRS program and defined by the Texas Administrative Code (TAC) for CRS, 40 TAC §107, or are program specific definitions.

Abuse – The negligent or willful infliction of injury, unreasonable confinement, intimidation, or threat thereof, or cruel punishment with resulting physical or emotional harm or pain. Sexual abuse, including any involuntary or nonconsensual sexual conduct that would constitute the offenses of indecent exposure or assault, committed by the person's caretaker, family member, or other individual who has an ongoing relationship with the person.

Agency – Texas Health and Human Services Commission (HHSC) or its successor agencies

Ancillary services – Goods and services that support core CRS services but are not primary interventions. Examples of ancillary services include supplies, medications and transportation.

Aquatic therapy – A type of therapy that involves an exercise method in water to improve a person’s range of motion, flexibility, muscular strength and toning, cardiovascular endurance, fitness, and mobility.

Art therapy – A type of therapy in which persons use art media, the creative process, and the resulting artwork to explore their feelings, reconcile emotional conflicts, foster self-awareness, manage behavior, develop social skills, improve reality orientation, reduce anxiety, and increase self-esteem.

Assistive Technology – Device is any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified or customized, that is used to increase, maintain, or improve functional capabilities of a person with a disability.

Audiological services – The evaluation and treatment of disorders related to hearing and balance.

Authorized representative – The person authorized by the participant to act as their representative for rehabilitation services including applying for services, developing Individualized Treatment Plan (ITP) and Individual Written Rehabilitation Plan (IWRP), authorizing the release of confidential information, representing the participant in an appeal, and other specified needs focused on the participant rehabilitation. Completing and submitting Form 1487, Designation of Representative, designates the representative.

Behavior management – A set of coordinated services that provide a person with specialized forms of interventions designed to improve adaptive behaviors and reduce maladaptive or socially unacceptable behaviors, including violent dyscontrol, that prevent or interfere with the person's inclusion at home and in the community.

Case management – Services that help participants plan, coordinate, monitor, and evaluate the services they receive, with emphasis on the quality of care, continuity of services and cost-effectiveness.

Case manager – A case manager collaborates with the participant’s interdisciplinary team and with external entities to assess, coordinate, implement, and evaluate all of the services required to meet the participant's needs.

Certified Brain Injury Specialist (CBIS) – A person with advanced training and work experience in brain injury services. The completion of the certification process demonstrates the applicant has a high school diploma or equivalent, has had 500 hours of verifiable direct contact experience with an individual or individuals with a brain injury with formal supervision or under a professional license.

Certified professional – A professional who has the knowledge, experience, and skills to do a specific job and is paid to do the job. The person’s expertise is verified by a certificate earned by passing an exam that is accredited by an organization or association that monitors and upholds prescribed standards for the profession involved. Examples of certified professionals include a certified brain injury specialist, certified nursing assistant, certified medical assistant, certified medication aide, and certified nurse aide.

Chemical dependency services – Planned services that are structured to help a person abstain from using drugs and alcohol to restore appropriate levels of physical, psychological and social functioning. Services include identifying and changing behavior patterns that are maladaptive, destructive, or injurious to health and relate to or result from substance-related disorders.

Community Independence Supports (CIS) – Provides the participant with assistance for Activity of Daily Living Skills (ADLs), while facilitating the participant’s independence and integration in to the community. The training in skills related to ADLs may include meal preparation, phone use or other communication, grocery or household shopping, laundry, light housework, medication or therapeutic regiments, assuring health and safety needs are met and socialization, if these skills are affected by the participant’s brain injury. CIS may also promote communication, relationship-building skills, and integration into community activities. These supports may serve to reinforce skills or lessons taught by the licensed therapist for the core Post-Acute Rehabilitation Services (PARS) non-residential and must be provided to the participant, based on the individual treatment plan and goals. CIS can be provided in a facility or community setting.

Cognitive rehabilitation therapy (CRT) – A type of therapy intended to enable a person to compensate for lost cognitive functions. CRT includes reinforcing, strengthening, or re-establishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.

Comparable benefits – Benefits that are like services provided by the CRS program but are provided or paid for by another entity such as employers, Medicaid programs and waivers, Medicare, private health insurance, workers compensation or another agencies or services.

Competitive bid – An offer to contract with the state to provide specific services or products that are available for purchase through multiple dealers or distributors for the manufacturer or owner of the services.

Compliance – Adhering to the state laws, regulations, guidelines, and specifications that are outlined in this manual, CRS Standards for Providers Manual, Contracting Processes and Procedures Manual, and HHS Procurement Manual.

Core services – Services that are provided by a licensed or certified therapist in post-acute rehabilitation and are provided in residential or non-residential settings.

Dietary and nutritional services – Services that involve developing a prescribed diet to meet a participant’s basic or special therapeutic nutritional needs.

Durable medical equipment and supplies – Any equipment  that provides therapeutic benefits to a person with a medical condition.

Exploitation – The illegal or improper act or process of a caretaker, family member, or other individual who has an ongoing relationship with a person with a disability and uses the resources of the person, including the person’s Social Security number and other identifying information, without the person’s informed consent, for monetary or personal benefit, profit or gain.

Family therapy – A specialized type of psychotherapy that facilitates education, training, and support to families and caregivers to nurture healing and development.

Functional Independence Measure (FIM) – An 18-item, 7-level functional assessment designed to measure the level of a person’s disability and indicate how much assistance is required for the person to carry out the activities of daily living.

Glasgow Coma Scale (GCS) – A neurological scale which aims to give a reliable and objective way of recording the conscious state of a participant for initial discharge and six-months post-discharge. A person is assessed against the criteria of the scale and the resulting points give a score between three and 15.

Group therapy – A type of therapy that is conducted by a therapist for two or more persons who have a common therapeutic purpose or goal.

Home modification – Installing assistive or adaptive equipment or devices in a person's home to enable the person to perform household tasks. This equipment or device must be removable without causing permanent damage to the property. Examples include grab bars in bathrooms or portable ramps for persons who use wheelchairs or who have other mobility impairments.

Individual therapy – A collaborative process between a therapist and one person that is intended to facilitate change and improve the person’s quality of life.

Individualized Program Plan (IPP) – A document developed by a participant’s interdisciplinary team for the participant, based on the participant’s individual needs. At a minimum, the IPP identifies the participant’s long-term and short-term goals and objectives, the treatment modalities to be used in achieving the goals and objectives, the people responsible for each treatment modality, the target date by which each goal and objective is to be achieved and the discharge plan.

Individualized Written Rehabilitation Plan (IWRP) – A plan developed by CRS program staff members that outlines the goals, services, and other aspects of the services provided by the CRS program. A participant’s IWRP may include elements of the Individualized Program Plan developed by the provider and other members of the interdisciplinary team.

Interdisciplinary team (IDT) – A team of professionals that coordinates services intended to achieve treatment goals that minimize a participant's physical or cognitive disabilities and maximize the participant ’s ability to function.

Lawful permanent resident – Any person who is not a U.S. citizen but lives in the United States and has legally recognized and lawfully recorded documentation identifying themselves as a lawful permanent resident. A lawful permanent resident is also known as a permanent resident alien, resident alien permit holder and a green card holder.

Licensed professional – A person who has completed a prescribed program of study in a health field and who has obtained a license indicating their competence to practice in that field. Examples of licensed professionals include a registered nurse, physician and social worker.

Massage therapy – A type of therapy involving the manipulation of soft tissue by hand or through a mechanical or electrical apparatus that constitutes a health care service, if it is for therapeutic purposes.

Medical Team Conference – Also known as the interdisciplinary team meeting. Members of the interdisciplinary team meet to review treatment goals, progress or lack of progress, identify ongoing needs, address barriers to treatment as well as discharge planning. This can occur with the participant or family member present or not present.

Mental health counseling – Limited or short term psychiatric services, including treatment and psychotherapy, for mental conditions that impact the participant’s ability to progress in therapy or independence (defined as mental restoration services 40 TAC §107).

Music therapy – A type of therapy using musical or rhythmic interventions to restore, maintain, or improve a person's social or emotional functioning, mental processing or physical health.

Neglect – The failure of a caretaker or provider, through indifference or carelessness, to provide goods or services, including medical services, that are necessary to avoid physical or emotional harm or pain.

Net monthly income – Monthly take-home pay after taxes and other payroll deductions.

Neuropsychological and neuropsychiatric services – A comprehensive battery of tests to evaluate neurocognitive, behavioral, and emotional strengths and weaknesses and their relationship to normal and abnormal functioning of the central-nervous-system.

Occupational therapy – A type of therapy using evaluation and treatment to develop, recover, or maintain the daily living skills of persons who have a physical, mental, or cognitive disorder consistent with the Occupational Therapy Practice Act, Texas Occupations Code, Chapter 454.

Orthosis – A custom-fabricated or custom-fitted medical device designed to provide for the support, alignment, prevention, or correction of a neuromuscular or musculoskeletal disease, injury or deformity, consistent with the Orthotics and Prosthetics Act, Texas Occupations Code, Chapter 605.

Over-the-counter medication – Medication that can be obtained without a prescription.

Paraprofessional – A person who is responsible for an aspect of a professional task, but who is not licensed as a fully qualified professional. Paraprofessional services can be provided in all service arrays, for approved medical needs only, and are provided in the home or facility (non-residential only) when necessary to enable participant involvement. Services may include, assisting with medication or therapeutic regimens, preparing and serving meals, assuring that health and safety needs are met, assisting with activities of daily living, such as hygiene and laundry, providing supervision and other care to meet a participant’s basic needs, and ensuring evacuation in case of an emergency. For non-residential services the paraprofessional must have at least one year of experience working with people with Traumatic Brain Injury (TBI) or Traumatic Spinal Cord Injury (TSCI). The intent of using paraprofessionals is to supplement the work of the licensed provider.

Physical restoration services – Services that correct or substantially modify, within a reasonable time, a physical condition that is stable or slowly progressive.

Physical therapy – A type of therapy that prevents, identifies, corrects, or alleviates acute or prolonged movement dysfunction or pain that is anatomical or physiological origin.

Post-acute rehabilitation services – Services for post-acute brain injury and post-acute spinal cord injury.

Preauthorization – Approval by a CRS counselor before services are provided.

Prescription medication – A medicine that legally requires a medical prescription to be dispensed.

Prosthesis – A custom-fabricated or custom-fitted medical device used to replace a missing limb, appendage, or other external human body part but that is not surgically implanted, consistent with the Orthotics and Prosthetics Act, under the Texas Occupations Code, Chapter 605. Accordingly, the term includes an artificial limb, hand or foot.

Provider type – The certified professionals, licensed professionals, and paraprofessionals who contract with the CRS program to provide services.

Rancho Los Amigos Levels of Cognitive Functioning Scale – A scale developed at the Rancho Los Amigos Hospital in Downey, California, that describes the eight levels of cognitive function experienced by persons who have a post-acute brain injury. For example, at Level IV Confused/Agitated, the patient is in a heightened state of activity with severely decreased ability to process information. The patient is detached from the present and responds primarily to their own internal confusion. Behavior is frequently bizarre and not purposeful relative to the patient's immediate environment.

Recreational therapy – A type of therapy involving recreational or leisure activities that help restore, remediate, or rehabilitate a person's level of functioning and independence, promotes health and wellness, and reduces or eliminates the limitations on activities that are associated with traumatic brain injury, traumatic spinal cord injury or both.

Rehabilitation technology – Equipment or technology designed to help persons with disabilities perform tasks that would otherwise require assistance.

Representative – A participant may designate someone to serve as their representative in all or part of the rehabilitation process. The representative may be authorized to sign documents, speak on the participant’s behalf, or serve in other capacities indicated on Form 1487, Designation of Applicant or Consumer Representative.

Room and board – Shelter, facilities, and food, including the customary and usual meal plans offered in residential settings and any prescribed nutritional meals or supplements.

Service array – A set of services provided to eligible persons who have a traumatic brain injury, traumatic spinal cord injury or both. Services are based on assessed individualized rehabilitation needs. The service arrays for traumatic brain injury and traumatic spinal cord injury are outpatient therapy, inpatient comprehensive medical rehabilitation, post-acute rehabilitation, and ancillary goods and services.

Speech-language pathology (speech therapy) – The application of nonmedical principles, methods, and procedures for measurement, testing, evaluation, prediction, counseling, habilitation, rehabilitation, or instruction related to the development and disorders of communication. This includes speech, voice, language, oral pharyngeal function or cognitive processes, for the purpose of evaluating, preventing or modifying, those disorders and conditions in an individual or a group, consistent with the Orthotics and Prosthetics Act, under the Texas Occupations Code, Chapter 605.

Texas Identification Number (TIN) – A 14-digit number issued to entities (i.e., sole owner, individual recipient, partnership, corporation or other organization) billing the CRS program for goods or services. The state comptroller requires the TIN on requests from any party receiving payment from the state of Texas.

Texas resident –  A person who lives in Texas, as evidenced by one of the following unexpired documents. A Texas driver's license, an identification card with an address issued by a governmental entity, a utility bill with an address, a voter registration card, a vehicle registration receipt, or another document approved by HHSC or its successor agency.

Third-party payer – A company, organization, insurer, or government agency other than HHSC or its successor agency that pays for the goods and services provided to a participant.

Tier – A preauthorized number of hours allotted for providing core therapy services.

Transportation – Travel and related expenses.

Traumatic brain injury (TBI) – An injury to the brain that is not degenerative or congenital and is caused by an external physical force that produces a diminished or altered state of consciousness, resulting in temporary or permanent impairment of cognitive abilities or physical functioning and partial or total functional disability or psychosocial maladjustment.

Traumatic spinal cord injury (TSCI) – An acute, traumatic lesion of neural elements in the spinal canal resulting in any degree of temporary or permanent sensory or motor deficit or bladder or bowel dysfunction.

Vision services – A sequence of neurosensory and neuromuscular activities individually prescribed and monitored by a doctor to develop, rehabilitate, and enhance visual skills.

Appendix B: Post-Acute Rehabilitation Core Services Modality and Staff Qualifications

Modality and Staff Qualifications for Core Services

Code

Core Services

Service Delivery Modality

Provider Qualifications

1

Aquatic Therapy

Individual and Group

PT, PTA, OT, OTA

2

Art Therapy

Individual and Group

LPC- AT, LCSW-ATR

3

Behavior Management

Individual

Board Certified Behavior Analyst, LPC, LMSW, LCSW, Licensed Psychologist, Licensed Psychiatrist

4

Chemical Dependency

Individual and Group

LCDC, LMSW, LCSW, Licensed Psychologist, LPC, Licensed Psychiatrist

5

Cognitive Rehabilitation Therapy (CRT)

Individual and Group

OT, SLP, Licensed Psychologist, Licensed Psychiatrist

6

Family Therapy

Family

LPC, LMFT, LMSW, LCSW, Licensed Psychologist, Licensed Psychiatrist

7

Massage Therapy

Individual

PT, PTA, OT, OTA

8

Mental Health Counseling

Individual and Group

LPC, LMSW, LCSW, Licensed Psychologist, Licensed Psychiatrist

9

Music Therapy

Individual and Group

Certified Music Therapist with a LPC, LCSW, LMSW, LMFT

10

Neuropsychiatric Services

Individual and Group

Licensed Psychiatrist

11

Neuropsychological Services

Individual and Group

Licensed Psychologist

12

Occupational Therapy

Individual and Group

OT, OTA

13

Physical Therapy

Individual and Group

PT, PTA

14

Recreational Therapy

Individual and Group

Certified Recreation Therapist

15

Speech/Language Pathology (Speech Therapy)

Individual and Group

SLP, SLPA

 

Modality and Staff Qualifications PARS Non-Residential Only
Code Core Services Service Delivery Modality Provider Qualifications
16 Case Management Individual Bachelor’s degree in Social Work, Psychology or other health related field.
17 Community Independence Supports -Certified Brain Injury Specialist (CBIS) Individual Certified Brain Injury Specialist
18 Community Independence Supports -Paraprofessional Individual Paraprofessional with one year of experience treating TBI or TSCI
19 Medical team conference (with patient, family or both present) Team N/A
20 Medical team conference (patient, family or both not present) Team N/A

Appendix C: PARS Residential Base Services and Tier Structure

Base Services Include
Case Management Administrative Cost
Dietary and Nutritional Services Paraprofessional Services (services by CNA, CA)
Medical (Nursing & Physician) Services Room and Board

 

Core Services Include
Tiers Description

Copay

Residential Copay only

Base

Tier base—no billable core

Base Plus

greater than 0 but less than 1 hour

1

greater than or equal to 1 hour per day but less than 2 hours per day, not exceeding 7 hours per week

2

greater than or equal to 2 hours per day but less than 3 hours per day, not exceeding 14 hours per week

3

Greater than or equal to 3 hours per day but less than 4 hours per day, not exceeding 21 hours per week

4

greater than or equal to 4 hours per day but less than 5 hours per day, not exceeding 28 hours per week

5

greater than or equal to 5 hours per day but less than 6 hours per day, not exceeding 35 hours per week

6

greater than or equal to 6 hours per day but less than 7 hours per day, not exceeding 42 hours per week

7

greater than or equal to 7 hours per day but less than 8 hours per day, not exceeding 49 hours per week

8

greater than or equal to 8 hours per day but less than 9 hours per day, not exceeding 56 hours per week

Appendix D: Service Record for CRS Data Reporting System

For more information please refer to the Data Reporting System User Guide.

Required Information Description

Facility Name

Provider name

Facility Number

ReHabWorks/Contract number

CRS ID Case Number

CRS assigned id case number

Facility case number

Facility assigned case or medical record number. If facility does not have such a number, repeat CRS ID case number in this field

Participant First Name

Participant first name

Participant Last Name

Participant last name

Service Authorization number

(ID purchase order)

Id purchase order (same as service authorization) number

PABI Setting

Residential or Non Residential

Service Type

See Service list

Service Description

See Service List

Service Location

See Location list

Service Location Other (Specify)

If other, specify

Service Start Date

Service date of therapy

Provided by

See Provider Type List

Total Number of Therapists

Number of therapists delivering service

Number of 15 Minute Units Delivered

Number of 15 minute units delivered

Setting type – “Individual”, “Group”, or Team

Individual, Group or Team

If Group, Enter # of Participants

If group, number of participants

Forms

ES = Spanish version available.

Form Title
1487 Designation of Representative ES
3149 Comprehensive Rehabilitation Services Request for Tier Change  

Revisions

19-2, Miscellaneous Changes

Effective May 1, 2019

 

The following changes were made:

Chapter Title Change
Chapter 10 Section 4 Interdisciplinary Team Meetings Adds that Interdisciplinary Team Meeting is the same as Medical Team Conference.
Appendix A Definitions Adds Medical Team Conference.
Appendix B Post-Acute Rehabilitation Core Services Modality and Staff Qualifications

Adds Certified Music Therapist to Music Therapy under Core Services.

Adds Case Management to Modality and Staff Qualifications for PARS Non-Residential.

19-1, May 1, 2019

Effective May 1, 2019

 

The following changes were made:

Chapter Title Change
Chapter 1 CRS Program Overview Updates CRS contact information.
Chapter 1 Section 2 Referrals to CRS Adds the referral form, process and contact information.
Chapter 3 Section 2 Language Services Adds Language Services Standard for providers.
Chapter 3 Section 4 Facility Safety Protocol
  • Updates when and where to report incidents to CRS.
  • Adds substance abuse, inappropriate behavior that may have participant dismissed from facility, and elopement.
Chapter 4 Section 5 Staff Training Adds Cardiopulmonary arrest (CPR), Basic Life Support (BLS) training and Fall Prevention.
Chapter 4 Section 6 Staff Qualifications Adds qualification of Community Independence Supports (CIS).
Chapter 5 Section 1 Overview Updates when and where to report incidents to CRS.
Chapter 5 Section 3 CRS Service Number Adds ombudsman’s number and CRS email because CRS does not have a direct phone line.
Chapter 5 Section 4 Grievance Procedure Updates ombudsman’s contact information.
Chapter 6 Section 4 Invoices
  • Updates to match updated TAC §20.487.
  • Adds CRS Program responsibility.
Chapter 6 Section 5 Use of Comparable Benefits or Third Party Billing Adds amount CRS pays if a participant is using their insurance's out of network provider.
Chapter 7 Section 2 Quality Reviews Adds services that are billed and paid based on services and contracted rate.
Chapter 8 Compliance and Quality Review for Traumatic Brain Injury Changes Utilization Review to Compliance and Quality Review.
Chapter 8 Section 2 Review Types
  • Notes changes to types of review names.
  • Adds purchasing review.
Chapter 8 Section 4 Prospective Reviews Changes title to Clinical Reviews and adds detail of what a clinical review covers.
Chapter 8 Section 5 Concurrent and/or Retrospective Reviews Changes title to Purchasing Reviews and adds detail of what a clinical review covers.
Chapter 9 Section 1 Overview
  • Adds changes and updates to provider’s admission policies and procedures including that they need to be reported to CRS when complete.
  • Moves referral information to Chapter 1, Section 2.
Chapter 9 Section 2 Intake Process Adds information that providers must have participants sign an intake acknowledgement form and must place the form in the participant’s file.
Chapter 10 Section 2 Assessment
  • Adds information about discharge planning utilizing the wraparound approach.
  • Adds mental health and substance misuse needs.
Chapter 10 Section 3 Development of Individualized Service Plan Adds this section.
Chapter 10 Section 4 Interdisciplinary Team Meetings
  • Adds the professional staff who are included in the IDT team and credentialing information needed.
  • Adds IDT team process including changing meetings to every 30 days, what needs reviewing for the participant and how to notify the IDT team.
Chapter 10 Section 5 Behavior Management Plans
  • Adds information about behavior management plans and what they address.
  • Adds information about who signs the informed conformed consent.
Chapter 10 Section 6 Emergency Restrictive Procedures Adds procedure for minors who receive chemical or physical restraints more than once within 30 days.
Chapter 11 Section 2 Required Documentation Adds that PM&R physician overseeing the participant’s care while in ICMRS is a separate service requiring pre-authorization.
Chapter 11 Section 3 Assessment, Planning and Interdisciplinary Meetings Adds Assessment, Planning and Interdisciplinary Meetings section.
Chapter 11 Section 4 Billing Guidelines Updates billing guidelines and when invoices must be submitted.
Chapter 12 Section 1 Overview Clarifies what outpatient therapy services refer to and where they are referenced.
Chapter 12 Section 3 Assessment, Planning and Interdisciplinary Meetings
  • Adds Assessment, Planning and Interdisciplinary Meetings section.
  • Notes that outpatient services differ from Post-acute rehabilitation services (PARS) non-residential services.
Chapter 12 Section 4 Billing Guidelines Updates billing guidelines and when invoices must be submitted.
Chapter 13 Section 1 Overview Adds link for updated rates.
Chapter 13 Section 2 Required Documentation Adds information for providers about required documentation.
Chapter 13 Section 3 Assessment and Planning
  • Changes title to Assessment, Planning and Interdisciplinary Meetings.
  • Moves part of this section to Chapter 10, Section 2.
Chapter 13 Section 6 Item 1 Licensure and Accreditation Changes Department of Aging and Disability Services to Texas Health and Human Services.
Chapter 13 Section 6 Item 7 Utilization Review Removes this section.
Chapter 13 Section 6 Item 7 Exceptions and Limitations Updates therapeutic passes.
Chapter 13 Section 7 Non-Residential Adds post-acute rehabilitation non-residential services to also include case management, community independence supports, medical team conferences.
Chapter 13 Section 7 Item 1 Licensure and Accreditation Changes Department of Aging and Disability Services to Texas Health and Human Services.
Chapter 13 Section 7 Item 3 Billing Guidelines Adds uploading into CRS Data Reporting System.
Chapter 14 Section 1 Overview Adds information about meeting treatment goals.
Chapter 14 Section 2 Durable Medical Equipment Adds this section.
Chapter 14 Section 3 Home Modification Adds this section.
Chapter 14 Section 4 Required Documentation Adds requirements for receiving durable medical equipment.
Chapter 14 Section 5 Billing Guidelines Updates billing guideline requirements for providers for ancillary goods and services and DME.
Chapter 14 Section 6 Exceptions and Limitations Updates this section with what is covered under the CRS program as well as when competitive bids are required.
Chapter 15 Section 1 Overview Adds information about discharge planning.
Chapter 15 Section 3 Termination from Program Adds information about providers documenting attempted interventions.
Appendix A Definitions Adds the following terms:
  • Abuse
  • Ancillary services
  • Assistive Technology
  • Authorized representative
  • Certified Brain Injury Specialist (CBIS)
  • Community Independence Supports (CIS)
  • Comparable benefits
  • Competitive bid
  • Compliance
  • Glasgow Coma Scale (GCS)
  • Texas Identification Number (TIN)
Edits the following terms:
  • Mental restoration services to mental health counseling
  • Paraprofessional
Removes the following:
  • Utilization Review
Appendix B Post-Acute Rehabilitation Core Services Modality and Staff Qualifications
  • Changes code numbering.
  • Changes Mental Restoration to Mental Health Counseling.
  • Changes Modality and Staff Qualifications for PARS Non-Residential.
Appendix C Base Services and Tier Structure Changes title to PARS Residential Base Services and Tier Structure
Appendix D Service Record for CRS Data Reporting System Adds clarification text.

17-1, Chapter 13.6.2, Billing Guidelines - Tiers

Effective September 1, 2017

 

The following changes were made:

Chapter Title Change
13.6.2 Billing Guidelines - Tiers Adds based on the consumer’s need, which will be determined during the initial pre-admission assessment, the provider may request an admission tier of level 2 through level 8. This request is to be submitted in writing using Form 3149, Comprehensive Rehabilitation Services Request for Tier Change, or included in the pre-admission evaluation, which identifies services needed, frequency, duration and requested tier. Explains when submitting an invoice, Post-Acute Rehabilitation providers are required to submit a monthly summary that includes a descriptive breakdown of services provided; frequency, duration, progress, or lack of progress made towards the consumer's goals; actions to be taken; and preliminary discharge information. Providers are also required to upload service record details of daily services provided in the CRS Data Reporting System, per Chapter 13.2, Required Documentation. Providers will only be required to submit daily therapy documentation if a consumer's file is randomly selected for utilization review. The provider will receive a written request with a time frame outlining when documentation is to be returned to the CRS requestor.

Contact Us

 

For technical or accessibility issues with this handbook, please email: Editorial_Services@hhsc.state.tx.us

For questions about the Comprehensive Rehabilitation Services (CRS) Standards for Providers Handbook, email: CRS_Program@hhsc.state.tx.us