Effective Date: 
4/2016

Documents

Instructions

Updated: 4/2016

Purpose

Form 8490 must be used in the Home and Community-based Services (HCS) Program when submitting a request for a medical level of need (LON) increase to the Texas Health and Human Services Commission (HHSC). The form must be completed by the registered nurse (RN) or licensed vocational nurse (LVN) providing HCS program services to the individual and include information about the individual's medical condition(s) requiring 181 minutes or more of face-to-face nursing services per week.

Procedure

The completed form and required supporting documentation must be mailed or faxed by the RN or LVN to:

Texas Health and Human Services Commission
Access and Intake – IDD Waivers Program Enrollment/Utilization Review
P.O. Box 149030, Mail Code W-551
Austin, TX 78714-9030
Fax: 512-438-4249

Supporting documentation in excess of 50 pages must be mailed.

To obtain approval for an LON increase, HHSC must receive the completed form and supporting documentation within seven days after the date the intellectual disability/related condition (ID/RC) assessment, showing a frequency code 6 on Item 40 on the Client Assignment and Registration (CARE) screen C23, is submitted.

Detailed Instructions

Name of Individual — Enter the individual’s full name. Do not use nicknames.

Age — Enter the individual’s age.

CARE ID — Enter the individual’s CARE ID.

Program Provider — Enter the legal name of the HCS program provider who provides HCS program services to the individual.

Comp Code — Enter the component code for the HCS program provider who provides HCS program services to the individual.

Contract No. — Enter the HCS program provider’s contract number for the contract under which the individual is enrolled.

Name of Nurse Completing Form — Enter the name of the nurse completing the form and providing HCS program services to the individual, and who will serve as a resource if clarification is needed by the Program Enrollment/Utilization Review (PE/UR) reviewer regarding the content of the form or if there are questions about the individual’s medical condition.

Title — Enter the title of the RN or LVN completing the form.

No. of Face-to-Face Nursing Minutes Per Week — Enter the total minutes of face-to-face nursing services per week the individual needs.

Area Code and Telephone No. — Enter the area code and telephone number of the nurse completing the form.

Date Completed — Enter the date the form was completed.

List the ongoing medical condition(s) requiring 181 minutes or more of face-to-face nursing services per week — Enter the name(s) of the individual’s medical diagnoses for which the nurse is providing face-to-face nursing services.

List the treatments the individual needs — Mark the boxes for the treatment(s) the nurse is providing to the individual. Mark “Other” for any treatments not listed and describe in the space provided.

Face-to-Face Nursing Tasks Performed by a Nurse — Describe the specific task being performed by the nurse.

Frequency — Enter how often the nursing task is performed.

Total Minutes Per Week — Enter the total number of minutes spent per week to perform the face-to-face nursing task.

List extenuating factors necessitating 181 or more minutes of face-to-face nursing services per week — Describe any circumstances that may contribute to the individual’s need for the provision of face-to-face nursing services.

Check the documentation included with this form — Mark the boxes for each type of documentation being submitted with the completed form. Mark “Other” for any documents not listed and describe those documents in the space provided.

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