• All official communications from the Area Office to the PSA contractor concerning the review process will be in writing by e-mail, facsimile transmission (fax), or Agency mail. (Telephone communication may be used for the purpose of obtaining technical assistance or general information.)
• The PSA contractor will communicate directly with the APD Central Office (Central Office) and Area Offices, and only with the Central and Area Offices, with the exception of Notifications of Missing Information and determinations of denial of a service or services.
• The Area Office will communicate with both the Waiver Support Coordinators and the PSA contractor.
• Automated forms will be utilized whenever possible.

STEP 1

When preparing a recipient’s cost plan for either annual or initial review the WSC shall identify whether any of the requested services or the entire cost plan meets the established selection criteria. Refer to the most recent PSA Selection Criteria posted on the Agency for Persons with Disabilities website, Policies and Procedures Section at: http://apd.myflorida.com/. PSA information is also posted at: http://www.maximus.com/flpsap/.The WSC must complete the Prior Service Authorization Request (Form #1) when services on the cost plan meet the Selection Criteria. The Waiver Support Coordinator must gather all required information for the PSA Request and ensure the support plan provides sufficient justification to support the need for the requested service(s).

STEP 2

The WSC must submit the PSA Request form(s) and accompanying documentation to the PSA contractor.

NOTE: The current address for the PSA contractor is posted on the PSA website at: http://www.maximus.com/flpsap/.

As an alternate submission method, the WSC may send the request via Inter-Office mail by placing it in a drop box in Area Office. The PSA Request submitted through Interoffice mail should be enclosed in a manila envelope that states the following: To Agency for Persons with Disabilities, 4030 Esplanade Way, Tallahassee, FL 32399, Attention, MAXIMUS/ PSA Unit

A copy of the Form #1, and the annual support plan or support plan update must be submitted to the Area Office.

STEP 3

The PSA contractor completes the preliminary screening of the PSA Request for clarity and completeness of information.

If information is complete and clear, proceed to Step 6, otherwise continue to Step 4

STEP 4

Within 5 business days of receipt, the PSA contractor notifies the Area Office using Form #2, (who in turn notifies the WSC), that the review cannot be completed due to inadequate justification or missing information and mails a copy of the Form #2 to the recipient (care of the legal guardian, if applicable).

STEP 5

The Waiver Support Coordinator submits the additional information to the PSA contractor within 10 business days of notification.

Return to Step 3

NOTE: If a Notification of Missing Information (Form #2) is issued and no response is received within 60 calendar days, the PSA contractor will deny or terminate the service on the basis that medical necessity could not be established due to lack of required information.

STEP 6

The PSA contractor completes the review and makes a determination (for approval, termination or denial of service(s)) to the Area Office using Form #3. Notification of the determination will occur within 10 business days of the PSA contractor’s receipt of the PSA Request or response to a Notification of Missing Information. The Central APD Office may approve an extension to the time frame when there are unusual circumstances.

Determinations for annual cost plans with requested services of $100,000 or greater are reviewed by the Central APD Office before issuance of the notification of the determination.

When the determination is made, the PSA Contractor shall send an e-mail to the Area APD office that includes Form #3. If the determination is a denial, reduction, or termination, the e-mail notification will also include a copy of Form #3b, Form #4, and the Due Process Notification Letter.

STEP 7

The Area APD office shall verify the following:

1. The accuracy of the recipient’s and/or legal guardian’s name and address.
2. The correctness and continued appropriateness of the service or services denied, terminated, or reduced.
3. The correctness of all information contained in the notification packet.

The district legal counsel will review the determination from a legal perspective.

If the Area APD Office has questions or concerns regarding the PSA determination, it shall notify the PSA contractor within 3 business days. The PSA contractor will not issue a due process notification until the questions or concerns are addressed.

If the Area APD Office does not respond within 3 business days to the e-mail notification regarding a denial, termination, or reduction, the PSA contractor will issue the notification to the recipient or legal guardian.

All determinations of denial, termination or reduction in services will include rationale for the decision, and may include recommendations for alternative service(s) or alternative intensity or duration of a service if appropriate.A letter will accompany all service denials, terminations, or reductions addressed to the recipient or legal guardian notifying the recipient of the right to request reconsideration and the right to a Medicaid Fair Hearing.

STEP 8

The Area Office notifies the Waiver Support Coordinator regarding the PSA contractor’s determination.

Following notification of the determination of denial, termination, or reduction of services, the recipient or legal guardian has the right to request a reconsideration and Medicaid Fair Hearing. The reconsideration allows the PSA Request to be re-reviewed by a different PSA contractor professional review team. Medicaid Fair Hearing requests are submitted by the recipient and legal guardian/representative to the Area Office.

NOTE: A request for reconsideration does not affect the recipient’s right to request a Medicaid Fair Hearing or the time frames within which to request a Medicaid Fair Hearing. However, a hearing might become unnecessary if the service is approved on reconsideration.

The recipients may request both reconsideration and a Medicaid Fair Hearing if they wish. Medicaid Fair Hearings must be requested within 90 calendar days of the date of the notice of adverse action.

STEP1

The WSC assists the recipient/family/guardian with the completion of a Request for Reconsideration (Form #4). Only services that were included in the current PSA Request may be included in the Request for Reconsideration. New services or changes to services from what were included in the current PSA Request must be submitted as a new PSA Request.

The WSC must submit the Request for Reconsideration with additional supporting justification directly to the PSA contractor and submit a copy to the Area Office.

The Request for Reconsideration may be completed by the recipient, the recipient’s legal guardian or the WSC.

NOTE: The PSA contractor must receive the Request for Reconsideration within 14 business days of the date of the determination notification. Only one reconsideration review will be completed.

STEP 2

Upon receipt of the reconsideration request, the PSA contractor will assign the request to a new professional review team of a primary and peer reviewer, who will complete the reconsideration and provide notification of the determination for approval or denial of service(s) to the Area Office. Determinations for the reconsideration review must be made within 10 business days of receipt by the PSA contractor of the reconsideration request.

When the reconsideration review process is complete, the PSA contractor will send an e-mail notification to the Area APD office. The Area APD office will communicate the determination resulting from the reconsideration to the WSC who will notify the recipient and/or legal guardian.

All PSA Requests must include the following documents in the following order:

• A completed Form #1 and the items specified on Form #1 for the service(s) being reviewed. If a prescription, assessment, and/or bid is required, a legible copy must be attached to the Form #1. Requirements regarding prescriptions, assessments and bids are specified in the Handbook and are listed in the service specific requirements section of these guidelines.
  
• A copy of the current support plan which contains sufficient documentation to justify the recipient’s need for each service or assessment on the recipient’s cost plan with the exception of support coordination. When the submission includes the annual support plan for the upcoming year, an annual summary should be included in the support plan that describes the progress for each goal included in the support plan, what has been accomplished, and what still needs to be accomplished.
  
  • A complete picture of the recipient’s strengths and needs, progress made with services and the continued need for the service(s);
  • How each requested service supports the recipient’s desired outcomes;
  • The justification for each requested service sufficient to establish the recipient’s need for the service;
  • How DD Waiver and other services (i.e., school-funded services) are coordinated to avoid duplication;
  • The availability of unpaid supports and other sources of coverage. Documentation addressing the availability of other sources of coverage, includes but is not limited to, service(s) or funding provided by other programs such as the Vocational Rehabilitation Program, public school and other educational programs, Social Security Administration programs, military dependent benefits, and health insurance (including Medicaid state plan services and Medicare).

  Reference material regarding Medicaid State Plan benefits are contained in the Florida Medicaid Coverage and Limitations Handbooks. These publications can be downloaded from http://floridamedicaid.acs-inc.com/index.jsp?display=handbooks or from the AHCA website as follows: Go to http://www.myflorida.com/, locate the tab near the top of the page “Find an Agency”, and from the pull down menu select “Health Care Admin.” At the Agency’s Internet site, locate the sidebar and select “Medicaid”. On the new Internet site page select the link entitled “Medicaid Fiscal Agent” at the bottom of the page. On the new Internet site page locate and select the link entitled “Provider Handbook Library” or call the local Medicaid Area Office for a printed copy.

• Ensure that the cost plan in ABC is current and reflects all services requested with correct end and start dates.

When a recipient receives multiple services that require coordination, such as adult day training, residential habilitation and NRSS, the WSC should provide a written description (which may be included in the support plan) or a schedule of a representative week to demonstrate that services (waiver and non-waiver) are not overlapping. The WSC should work with the provider to obtain information for the description or schedule.

When a recipient receives such services as personal care assistance (PCA) or In-Home Support Services (IHSS), the WSC should provide a written description or schedule of a representative week to demonstrate that services (waiver and non-waiver) are not overlapping. This information should identify when services are delivered and show that the services provided are related to the requested service.

Initial requests to begin providing services including an assessment (such as a behavior assessment or physical therapy assessment) do not need to include implementation plans, but should include relevant information in the support plans. Service proposals from the provider should be provided, if available.

The PSA Request must include documentation specifying the anticipated benefits of providing each requested service, and explain how each requested service will meet the recipient’s support plan outcome(s).

For requests to continue providing services, the most recent nursing care plans, behavior analysis services plans, and other professional plans of care, with annual reports, must be submitted as specified in these Operational Guidelines. The PSA Request must include documentation specifying how the recipient benefits from each requested service and identify how each requested service will meet the recipient’s support plan outcome(s).

The Prior Services Authorization (PSA) contractor makes determinations based on the contents of the submitted documentation. The documentation must clearly substantiate the need for the initiation or continuation of the requested service(s).

NOTE: In accordance with Section 59G – 1.010(166)(c), Florida Administrative Code, a statement from a service provider, prescription, assessment or bid alone is not adequate to establish medical necessity for the requested service(s).

Some services require additional documentation. Examples of additional documentation requirements include prescriptions, assessments and/or bids, annual reports, care plans and other professional plans of care. PSA Requests to continue providing services that require the development of care plans or other medical treatment plans, must include a copy of the most recent annual report, care plan or treatment plan. A summary of the progress towards meeting the support plan/care plan/treatment plan goal(s) and the continued benefits of providing this service should be included in the support plan.

WSCs are responsible for ensuring all documentation requirements specific to PSA Requests are met and that the Form #1 identifies all services requested.

If continuation of service(s), the WSC should ensure the support plan contains a summary of progress towards meeting the support plan goal(s) and the continued benefits of providing this service (unless this is addressed in the annual report) and also include:

• The annual report (including progress and goals).

For all requests, indicate which ADT staffing ratio is requested:

• Standard (more than 5 consumers to 1 staff)
• 1 staff to 5 consumers
• 1 staff to 3 consumers
• 1 staff to 1 consumer

For ADT, 1 staff to 5 consumers, also include the:

• Documentation of the need for a moderate level of personal care support.
  or
• The behavior analysis services plan that will be implemented in the ADT including a plan for fading services.

For ADT, 1 staff to 3 consumers, also include the:

• Documentation of the need for an intense level of personal care support.
  or
• The behavior analysis services plan that will be implemented in the ADT including a plan for fading services.

For ADT, 1 staff to 1 consumer, also include the:

• The behavior analysis services plan that will be implemented in the ADT including a plan for fading services.
• Written documentation by the LRC Chairperson that verifies the need for this level of supervision.

• Duplicate X-rays relevant to procedure(s) made within 90 days of treatment plan development. Please do not send photocopies. Please note that these duplicate X-Rays cannot be returned
• Recipient’s dental records relevant to procedure(s).
• A second opinion/treatment plan.

• Behavior Assessment

For requests to continue providing services:

• The current behavior analysis services plan including a plan for fading of services (with a reviewed or revised date of no more than 12 months prior to the date of the Request).
• Data displays for services covering the preceding twelve (12) months, including a summary of the data and phase lines.
• Explanation and analysis of effects of variables on behavior and projected course of treatment.

• The behavior analysis services plan developed by CBA, including a plan for fading of services, the specific tasks and duties of the Behavior Assistant, and the schedule of behavior assistant services.
• Documentation of approval of the behavior assistant services by the LRC Chairperson.

For requests to continue providing services:

• Data displays reflecting the effects of interventions implemented by the behavior assistant service provider on the target behaviors.

• A prescription or assessment when applicable. Refer to the Handbook for prescription and assessment requirements for specific consumable medical supplies.

• A prescription.

For requests to continue services, also include:

• The dietary assessment.
• The dietary management plan from the provider.

• A prescription or professional assessment (e.g. P.T., O.T., physician or nurse), when applicable. Refer to the Handbook for prescription and assessment requirements for specific durable medical equipment items.

For requests for durable medical equipment costing $1,000 and over also include:

• Three competitive bids. If three bids cannot be obtained, documentation must indicate efforts made to obtain the three bids and reasons for obtaining less.

• Documentation of approval from landlord, if home is rented; or
• If the home was an existing home and was purchased by the recipient or their family, documentation of ownership of the home by the recipient or their family; or
• If the home was constructed by or for the recipient or their family, documentation of the date of purchase of the home must be provided and the date the recipient began receiving DD Waiver services must be noted in the support plan.
• Documentation for the requests specified below must demonstrate that bids are reasonable for the local community.
• For requests for environmental accessibility modifications costing under $1,000 also include: One bid.

For requests for environmental accessibility modifications costing between $1,000 and $3,499 also include.

• Two bids. If two bids cannot be obtained, documentation must indicate efforts made to obtain the bids and reasons for obtaining less.

For requests for environmental accessibility modifications costing $3,500 or more also include:

• Home accessibility assessment completed by a rehabilitation engineer or other qualified professional.
• Three competitive bids. If three bids cannot be obtained, documentation must indicate efforts made to obtain the bids and reasons for obtaining less.

• Ensure the support plan contains a summary of progress towards meeting the support plan goal(s) and the continued benefits of providing this service (unless this is addressed in the annual report), and include:
  • The annual report (including progress and goals).

• A prescription.
• An occupational therapy assessment.

For requests to continue providing services, also include:

• The occupational therapy care plan.
• Reports to show that the recipient is making progress toward the goals identified in the assessment and care plan.

• Indication whether PCA is requested at the Standard, Moderate or Intensive level.

For requests for a moderate or intensive level of personal care assistance, also include:

• Documentation of the need for a moderate or intensive level of personal care support

• A prescription.
• A physical therapy assessment.

For all requests:

• The physical therapy care plan.
• Reports to show that the recipient is making progress toward the goals identified in the assessment and care plan.

• A prescription.
• A nursing assessment.
• Location(s) where nursing services are to be provided

For requests to continue providing services, also include:

• The nursing care plan.

• Ensure the support plan contains a summary of progress towards meeting the support plan goal(s) and the continued benefits of providing this service (unless this is addressed in the annual report), and include:
• The annual report (including progress and goals).

• Behavior Assessment.

For requests to continue providing services, also:

• Ensure the support plan contains a summary of progress towards meeting the support plan goal(s) and the continued benefits of providing this service (unless this is addressed in the annual report) and include
  • A current behavior analysis services plan including a plan for fading of services (with a reviewed or revised date of no more than 12 months prior to the date of the Request).
  • Data displays for services covering the preceding twelve (12) months, including a summary of the data and phase lines.
  • Explanation and analysis of effects of variables on behavior and projected course of treatment.
  • A current (within 12 months of submission of a PSA request) completed “Recommendation of Eligibility Form” identifying the recipient as eligible for Residential Habilitation Services (behavior focus) signed by the District Behavior Analyst.
  • The annual report (including progress and goals).

• Behavior Assessment

For requests to continue providing services, also:

• Ensure the support plan contains a summary of progress towards meeting the support plan goal(s) and the continued benefits of providing this service (unless this is addressed in the annual report) and include:
  • A current behavior analysis services plan including a plan for fading of services (with a reviewed or revised date of no more than 12 months prior to the date of the Request).
  • Data displays for services covering the preceding twelve (12) months, including a summary of the data and phase lines.
  • Explanation and analysis of effects of variables on behavior and projected course of treatment.
  • A current (within 6 months of submission of a PSA request) completed “Recommendation of Eligibility Form” identifying the recipient as eligible for Residential Habilitation Services (intensive behavior) signed by the District Behavior Analyst and Senior Behavior Analyst.
  • The annual report (including progress and goals).

For requests to continue providing services, also:

• Ensure the support plan contains a summary of progress towards meeting the support plan goal(s) and the continued benefits of providing this service (unless this is addressed in the annual report), and include:
  • The annual report (including progress and goals).

• A prescription.
• A nursing assessment.
• A list of the specific duties to be performed by the nurse.
• Location(s) where nursing services are to be provided.

For requests to continue providing services, also include:

• The nursing care plan.

• A prescription.
• A respiratory therapy assessment.

For requests to continue providing services, also include:

• The respiratory therapy care plan.

• A prescription.
• A nursing assessment.
• List of the specific duties to be performed by the nurse.

For requests to continue providing services, also include:

• The nursing care plan.

• A prescription.
• A nursing assessment.
• List of the specific duties to be performed by the nurse.

For requests to continue providing services, also include:

• The nursing care plan.

• A mental health assessment by a psychiatrist, psychologist or licensed mental health professional.

For requests to continue providing services, also:

• Ensure the support plan contains a summary of progress towards meeting the implementation plan (IP) goal(s) and the continued benefits of providing this service (unless this is addressed in the annual report) and also include:
  • The mental health services treatment plan.

• A prescription.
• A speech therapy assessment.

For requests to continue providing services, also include:

• The speech therapy care plan.
• Reports to show that the recipient is making progress toward the goals identified in the assessment and care plan.

• Ensure the support plan contains a summary of progress towards meeting the support plan goal(s) and the continued benefits of providing this service (unless this is addressed in the annual report) and also include:
  • The annual report (including progress and goals).

• Ensure the support plan contains a summary of progress towards meeting the support plan goal(s) and the continued benefits of providing this service (unless this is addressed in the annual report) and also include:
  • The annual report (including progress and goals).

• A prescription.
• Massage therapist’s assessment and a summary of benefits by the therapist and prescribing physician, physician’s assistant or nurse practitioner.