• All CARE fields must be completed by the provider. (Note: Waiver program providers do not complete the "Physician's Evaluation and Recommendation" section.)

  • For Item #22, the age at date of onset must be before age 18 if an individual has a diagnosis of an intellectual disability, and must be before age 22 if an individual has a diagnosis of a related condition.

  • All diagnosis codes (Item #s 20, 24, 27), entered must be valid ICD codes. Diagnostic codes with three characters are included in the ICD as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided. A valid code is one that is subdivided down to the greatest specificity and has the correct amount of alphanumeric characters.

  • Do not use decimal points in diagnosis code entries.

  • Diagnosis codes entered in Psychiatric Diagnosis (Item # 27) must reflect the version of the DSM, as represented in Field 28, Version 5. If you have difficulties inputting ICD-10 codes in field 27, make sure that they are codes recognized in the DSM-5.

  • IQ (Item #29) must be 69 or below to qualify for a Texas Medicaid program based on a diagnosis of intellectual disability.

  • IQ (Item #29) must be 75 or below with a diagnosis of a related condition to qualify for a Texas Medicaid waiver program under LOC 1 criterion. (Individuals enrolled under OBRA before Sept. 1, 2003, are exempt.)

  • Inventory for Client and Agency Planning (ICAP) Service Level (Item #33) and Recommended Level of Need (LON) (Item #18) must correlate, unless requesting a behavioral increase (or a Medical increase for individuals enrolled in the Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions [ICF/IID] program).

  • Recommended Level of Care (LOC) (Item #17) must be either 1 or 8, depending on the diagnosis.

  • A "Y" as a response to Behavior Program (Item #34) does not mean that a "1" or "2" is necessary in any of Item #s 35-38.

  • If any one of Item #s 35-38 contain a "1" or "2," item #34 MUST be answered "Y."

  • A "1" in any of Item #s 35-38 indicates a request for increase of LON and will force the LON to next higher LON (Item #18), except for LON 6.

  • A "2" in any of Item #s 35-38 indicates a request for a LON 9 and will force any recommended LON (Item #18) to a "9."

  • A physician's evaluation and recommendation is not required for waiver programs (Item #s 48-55). However, if any items in this section have information entered, all items must be completed.

  • For ICF/IID programs, or if the provider does put a physician's signature on the waiver ID/RC:

    • Physician's responses on Item #s 48-51 MUST be "Y, N, Y, Y" — in that order — or the individual is not eligible for services.

    • The initial ID/RC must be signed by an M.D. (this includes psychiatrists) or a D.O. For admission to an ICF/IID, the M.D./D.O.'s signature is required. Signature by designee is allowed for subsequent ID/RC assessments. Renewals may be delegated to an advance practice nurse/physician assistant. When delegated, both license numbers are required. The ID/RC must include the physician's license number and the date signed.

  • The physician's evaluation and recommendation section is still required for ICF/IIDs, except when submitting a Purpose Code 4.