A review process was established to help ensure that individuals enrolled in the waiver receive medically necessary services of the appropriate frequency, intensity, and duration. The process also helps to ensure that adequate documentation exists to justify medical necessity for Medicaid Reimbursement, ensure compliance with Medicaid regulations, and avoid Medicaid disallowance of billed services and recoupment of payments.

The review process begins when the waiver support coordinator assists the recipient and/or family in developing an annual support plan and related cost plan. The support plan and accompanying relevant documentation are submitted directly to the PSA unit for review of services that meet the current selection criteria established by the Agency for Persons with Disabilities (APD). A copy of the Prior Service Authorization Request (Form 1) and the annual support plan or support plan update are also submitted to the Area APD Office at the time the PSA request is made.

Professionals who have extensive experience providing support and services to individuals with disabilities review all requests that are received by the PSA program. These professionals include registered nurses, certified behavior analysts, qualified mental retardation specialists (QMRPs), physicians, and dentists. In addition to the lead reviewer, a physician or dentist (as appropriate) also review all determinations that result in a denial, termination or reduction of services.

The selection criteria page contains more information regarding the circumstances under which Prior Service Authorization Requests are submitted for review by the PSA unit.