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Effective Date: 
5/2016

Documents

Instructions

Updated: 5/2016

Procedure

In the Intermediate Care Facilities/Intellectual Disability (ICF/ID) and Home and Community-based Services (HCS) waiver program, the program provider must submit Form 8603 and a packet of justification documentation to the Texas Health and Human Services Commission (HHSC), Access and Intake, Utilization Management and Review, Intellectual and Developmental Disability (IDD), Waivers Program Enrollment/Utilization Review (PE/UR) for review when the provider is requesting a change in an individual's LON assignment. Because there are no LON increases allowed in the Texas Home Living (TxHmL) waiver program, HHSC typically authorizes the LON associated with the Inventory for Client and Agency Planning Assessment score when an LON increase is submitted for a TxHmL individual.

Detailed Instructions

The program provider will complete all the information on the form.

Date Submitted — Enter the date the program provider submitted the form and review packet to PE/UR.

Program Type: (check one) — Mark the appropriate box to indicate the type of program.

Provider Name — Enter the name of the program provider.

Component Code — Enter the program provider component code.

Contract No. — Enter the contract number for the program provider.

Provider Contact Information

Provider Contact — Enter the name of the person who will act as the contact for the program provider. The provider contact should be someone who can answer questions about the action being requested.

Area Code and Telephone No. — Enter the area code and telephone number for the person who will act as the contact for the program provider.

Fax Area Code and Telephone No. — Enter the fax area code and telephone number for the person who will act as the contact for the program provider.

Email Address — Enter the email address of the program provider contact.

Local Intellectual and Developmental Disability Authority (LIDDA) (applicable for HCS only)

LIDDA Name — Enter the name of the LIDDA.

Component Code — Enter the LIDDA component code.

LIDDA Service Coordinator Contact Information

LIDDA Service Coordinator — Enter the name of the service coordinator.

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

Fax Area Code and Telephone No. — Enter the fax area code and telephone number for the service coordinator.

Email Address — Enter the email address of the service coordinator.

Individual Information

Individual Name (Last) — Enter the last name of the individual for whom the LON increase is being requested.

Individual Name (First) — Enter the first name of the individual for whom the LON increase is being requested.

CARE ID No. — Enter the individual's Client Assignment and REgistration (CARE) system identification number.

Medicaid No. — Enter the individual's Medicaid number.

Does any correspondence sent to the Legally Authorized Representative (LAR) or individual need to be translated to another language? — Check the appropriate box and indicate the language needed, if other than English.

Initial LON Increase Requested — Enter the individual's current LON and the LON being requested (From/To).

Due To — Mark the applicable box(es) indicating the reason the LON change is being requested (due to an Inventory for Client and Agency Planning [ICAP] change, behavior increase, LON 9 or medical increase).

Instructions to Provider

The program provider will:

  • document the need for the LON increase;
  • submit an LON packet to HHSC PE/UR that includes the Form 8603 justification for the LON increase and additional supporting documentation;
  • data enter the Intellectual Disability/Related Condition Assessment in the CARE system before submitting the LON packet to PE/UR;
  • maintain the individual's and LAR's contact information current in the CARE screens C12 and C20; and
  • check CARE screen C68 (HCS/TxHmL) or 1168 (ICF/ID) to view the LON authorization.

HHSC PE/UR Action

HHSC PE/UR will:

  • review the documentation submitted by the program provider;
  • request additional information from the program provider, if necessary;
  • approve or deny the requested LON;
  • authorize an LON in the CARE system after reviewing the reconsideration documentation or after the time period for the submission of reconsideration has passed with no response from the program provider; and
  • if the LON is denied, mail a certified letter to the individual or LAR. Copies of the letter will also be sent to the program provider and the service coordinator for HCS and TxHmL.