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Effective Date: 
7/2019

Documents

 

Instructions

Updated 7/2019

 

Purpose

Form 1047 is used by the local intellectual and developmental disability authority (LIDDA) Diversion coordinator to request a targeted nursing facility (NF) diversion slot for Home and Community-based Services (HCS).

 

When to Prepare

Form 1047 is completed by the LIDDA Diversion coordinator to request an HCS targeted NF diversion slot for a person at imminent risk of a long-term stay in an NF, and who currently resides in the community.

 

Transmittal

LIDDA staff must scan the completed form, along with any supporting documentation, and send by secure email to HHSC at LIDDARequests@hhsc.state.tx.us. The subject line should read “Request for HCS Targeted NF Diversion Slot.”

 

Detailed Instructions

Date of Request — Enter the date the request is being submitted to HHSC.

LIDDA Name — Enter the name of the LIDDA requesting the adult NF diversion slot for HCS.

Comp Code — Enter the requesting LIDDA’s designated component code.

LIDDA Diversion Coordinator — Enter the name of the Diversion coordinator submitting the request.

LIDDA Diversion Coordinator Email Address — Enter the email address of the LIDDA Diversion coordinator.

Area Code and Telephone No. — Enter the area code and telephone number for the LIDDA Diversion coordinator.

Person’s Name — Enter the first and last name of the person for whom the request is being made.

CARE ID — Enter the person’s Client Assignment and Registration (CARE) identification number.

Name of Legally Authorized Representative — Enter the first and last name of the legally authorized representative, if applicable. If not applicable, check the Not Applicable box.

Medicaid Number — Enter the person’s Medicaid number for whom the request is being made.

Date of Birth — Enter the person’s date of birth.

Intermediate Care Facility (ICF) Level of Care (LOC) I or ICF LOC VIII — If the LIDDA determines the person meets the criteria for ICF Level of Care (LOC) I, the LIDDA checks the box labeled “ICF LOC I.” If the person does not meet the criteria for ICF LOC I, then the LIDDA checks the box labeled “ICF LOC VIII.”

By submitting this form to HHSC, the LIDDA attests that the request is for a person who meets the following criteria:

  • The person is at imminent risk of a long-term stay in an NF;
  • The person’s current PASRR Evaluation (PE) indicates the person has IDD and is appropriate for the community placement;
  • The Long-Term Care online portal indicates the person meets medical necessity;
  • The person’s diagnosis meets HCS diagnostic eligibility criteria, including ICF LOC I or ICF LOC VIII; and
  • Other adequate and appropriate community resources, as described in Diversion from Nursing Facility Admission in the IDD PASRR Handbook, are unavailable to meet the person’s needs.

Comments — Enter any relevant information. This is not a required field, but helpful in communicating with HHSC.

Diversion Coordinator Signature and Date — The Diversion coordinator signs the form and enters the date.

 

The last section is for HHSC use only.

Date and time request is received — HHSC staff enters the date and time.

Reviewer Signature and Date — The reviewer signs the form and enters the date.