Effective Date: 
7/2017

Documents

Instructions

Updated: 5/2015

 

Purpose

The Individual Plan of Care (IPC) Service Delivery Transfer Worksheet documents the total number of service units and costs for the Deaf Blind with Multiple Disabilities (DBMD)/Community First Choice (CFC) individual's service plan year and the total number of service units and costs appropriate for each agency providing services to the individual transferring to another DBMD/CFC provider agency.

 

Procedure

When to Prepare

The case manager completes Form 6500-T at the time of the request to transfer except when the individual's transfer effective date coincides with the renewal IPC effective period.

Number of Copies

The current case manager completes an original of Form 6500-T. One copy is given to the transferring and receiving agencies and a copy is provided to the individual receiving DBMD/CFC services. The copy that is maintained by each provider agency in the individual's record should include signatures from the transferring provider, receiving provider, individual/legally authorized representative (LAR) and the Texas Health and Human Services Commission (HHSC) DBMD Program specialist. This may be a faxed copy as long as it includes all of the signatures.

Transmittal

The case manager should keep a copy of Form 6500-T in the individual's record that includes all necessary signatures. A copy of that same document should be sent to each provider agency as appropriate. The copy that is maintained by each provider agency in the individual’s record should include signatures from the transferring provider, receiving provider, individual and the HHSC DBMD Program specialist.

A copy including all signatures is also sent to the HHSC DBMD Program specialist for authorization, with a copy of the last IPC approved by HHSC.

Form Retention

The current and receiving case manager keep Form 6500-T according to the record retention requirements in Texas Administrative Code, Chapter 49 (related to Contracting for Community Care Services).

 

Detailed Instructions

Individual's Name, Social Security No., Medicaid No. — Enter the individual's name, social security number and Medicaid number.

IPC Effective Period — Enter the IPC service plan dates, as reflected on Form 6500, Individual Plan of Care (IPC) – DBMD.

Transfer Type — Enter the type of transfer. More than one type of transfer may apply (Provider or Financial Management Services Agency (FMSA) transfer).

Transfer Effective Date — Enter the date the transfer is effective.

Provider Agency/CFC Services Provider — If applicable, enter the transferring and receiving provider agencies' vendor numbers and the total number of service units appropriate for each agency.

The transferring agency's total number of service units provided before the effective date of the transfer is the sum of the number of service units:

  • provided and paid,
  • provided that have been billed but not yet paid, and
  • to be provided until the transfer effective date.

If units have not been used and will not be used before the transfer effective date, a zero should be placed in the units column for the transferring provider. The remaining units should be carried over to the receiving provider's vendor number.

The receiving agency's total number of service units is the number of service units to be provided from the transfer effective date until the end of the IPC effective period.

Financial Management Services Agency (FMSA)/CFC FMSA Provider — If applicable, enter the transferring and receiving FMSAs vendor numbers and the number of service units appropriate for each agency.

The transferring agency's total number of service units provided before the effective date of the transfer is the sum of the number of service units:

  • provided and paid,
  • provided that have been billed but not yet paid, and
  • to be provided until the transfer effective date.

The receiving agency's total number of service units is the number of service units to be provided from the transfer effective date until the end of the IPC effective period.

Total Units Column — The total units column is the total number of service units assigned to both the transferring and receiving agency. This sum must equal the number of service units entered on the last IPC approved by HHSC.

Total Cost Column — The total cost column is the total costs assigned to both the transferring and receiving agency. This sum must equal the total cost entered on the last IPC approved by HHSC. Under both columns, include the estimated cost totals, even if there were not any units used. Make sure to total each column under the Total Estimated Cost for both vendor numbers.

Signatures — The individual receiving DBMD/CFC services or their Legally Authorized Representative (LAR) must sign Form 6500-T. The document that is maintained in the individual's record should also include signatures from the following:

  • transferring provider representative,
  • receiving provider representative,
  • individual/LAR and;
  • HHSC DBMD/CFC Program Consultant.

Representatives of both the transferring and receiving agencies must sign Form 6500-T. These signatures indicate the agencies' agreement with the number of service units.

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