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Effective Date: 



Updated: 9/2018


To serve as the primary documentation establishing medical need and rationale for all items or services requested in the STAR+PLUS Home and Community Based Services (HCBS) program and included on Form H1700-1, Individual Service Plan (Pg.1).


When to Prepare

This form, or an alternate form of documentation that includes the same information on Form H1700-A, is prepared by the managed care organization (MCO) any time an STAR+PLUS HCBS program service has been identified as a need and/or requested by the applicant or member.

Form Retention

The MCO must keep a copy of Form H1700-A and/or any alternate document in the member's case record according to the retention requirements found in all Medicaid Uniform Managed Care Contracts (UMCC) and federal regulations. Keep all originals and electronic copies in the member's case record for five years after services are terminated.

Detailed Instructions

1. Applicant/Member Name — MCO staff enter the name of the applicant or member.

2. Medicaid No. — Enter the applicant's or member's Medicaid number, or Social Security number if a Medicaid number is not available.

3. Specify the Applicant's/Member's Diagnosis/Medical Condition and Functional Limitation — Enter specific information regarding the applicant's or member's diagnosis, medical condition and functional limitations.

4. Specify the STAR+PLUS Home and Community Based Services (HCBS) program item(s)/service(s)requested or identified — Enter the STAR+PLUS HCBS program item or service that is included on the individual service plan (ISP) that has been requested by the applicant or member or identified as a need by the MCO representative.

5. Describe why the STAR+PLUS HCBS program item/service is necessary and how the STAR+PLUS HCBS program item/service benefits the applicant/member. — The MCO representative documents why the requested STAR+PLUS HCBS program item or service is necessary and specifically how it will benefit the individual medically, functionally or in terms of rehabilitation.

Signature – MCO Representative — The MCO representative signs to certify that the medical need and rationale as listed in number 4 and number 5 has been established as per federal and state policies and rules.

Date — Enter the date the information on this form is certified.