Revision 24-3; Effective July 1, 2024
For a concurrent review with findings for Primary Home Care (PHC) or Community Attendant Services (CAS) cases, the Utilization Review (UR) nurse contacts the caseworker and requests the documentation for review. The caseworker provides the documentation within seven calendar days of the request. Depending on available information, the UR nurse may make a home visit or a Home and Community Support Services agency visit in addition to a desk review.
If a concurrent UR results in a recommendation to decrease, increase or deny services, or identifies a policy compliance or quality of care issue, the UR nurse manager reviews the case. If the UR nurse manager concurs, they email the UR tool to the regional director (RD) of the region where the person lives. If the RD has a designee, only the baseline information and the findings are sent.
The RD or designee reviews the case and contacts the UR nurse manager, state office UR manager, or both for any additional information needed. UR staff immediately provide the RD with the requested information.
The RD has seven business days after receiving the information from the UR manager to respond to the UR finding. During this time, the RD may:
- agree with the UR finding and direct regional staff to implement the finding;
- discuss the finding with the UR manager through an informal exception process; or
- file a formal exception to the findings with state office.
If the RD attempts to phone the UR nurse manager to discuss the findings in an informal exception process for a concurrent UR, and the UR nurse manager is unavailable. In that case, the UR nurse manager or designee returns the contact within two business days. If a discussion or informal exception process between the UR nurse manager and the RD results in changes to the UR finding, the UR nurse manager makes the changes to the electronic version of the UR tool and emails the final copy of the revised tool to the RD and caseworker.
If the UR finding is not changed through the informal exception process and the RD disagrees with the final findings, the region can either:
- note the disagreement and direct regional staff to implement the finding, if indicated; or
- file a formal exception with state office. If a formal exception is filed, the RD will notify the UR nurse manager via phone or email of the date the exception is filed.
If the RD agrees with the UR recommendation, the RD will notify the UR unit of the agreement and direct the caseworker to implement the UR finding within one HHSC business day.
If no formal exception is filed and the UR finding recommends a change to the existing service plan, the RD’s seven-business-day time frame is part of the 14-calendar-day time frame that a caseworker has to complete a change request.
5310 Implementation of Utilization Review Findings
Revision 24-3; Effective July 1, 2024
The regional director (RD) or designee notifies the caseworker to implement the Utilization Review (UR) findings. They will provide the date for completion and any specific instructions regarding the UR findings. The caseworker files a copy of the findings page(s) and all service planning documents completed by the UR nurse in the case record to support justification for the changes made to the person’s services. Under no circumstances should the entire UR tool be filed in the case record.
The caseworker follows the time frames and procedures below to implement the UR findings.
The UR findings for concurrent reviews must be implemented within 14 calendar days of:
- the date the UR manager notifies the RD of the UR findings unless a formal exception is made; or
- the date state office issues a decision on a formal exception.
To implement the UR findings, the caseworker may be required to increase, decrease, add or terminate services. The caseworker follows the current policy for changing service authorizations. This includes:
- discussing the UR Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, tasks and allocated time changes with the person for UR recommended changes to Personal Assistance Services (PAS);
- documenting the discussion with the person in the case record;
- completing Form 2065-A, Notification of Community Care Services, documenting the action taken;
- registering the change in the Service Authorization System Online (SASO), as applicable;
- sending a copy of Form 2065-A to the person; and
- sending Form 2101, Authorization for Community Care Services, to the service provider.
The caseworker must ensure that all service criteria is met when completing the changes. The caseworker must also ensure that the most current Form 2060 is entered in the SASO Functional Wizard and maintained in the case record.
5320 Individual Agreement or Disagreement with the Change
Revision 24-3; Effective July 1, 2024
The person may agree or disagree with the Utilization Review (UR) findings when the case- worker reviews the change request with the person. The caseworker completes the change action using the following guidelines if the person:
- agrees with the addition, increase, termination, or decrease of services, the caseworker implements the change.
- disagrees with the addition, increase, termination, or decrease of services, the caseworker does not implement the change. The caseworker must document why the change was not implemented in the case record and on the UR tool.
- makes a decision placing their health or welfare at risk, the caseworker, in consultation with the regional nurse, must review the UR findings with the person or primary caregiver to ensure the person made an informed choice. The caseworker must follow procedures in HB section 2550, Identifying People at Risk, and HB section 2551, Caseworker Actions for People at Risk.
- does not agree with the termination or decrease, the caseworker must implement the UR findings. An exception to implementing the termination or decrease from the UR findings is allowed if the person has experienced a condition or environmental change since the UR visit, and the change would jeopardize the client’s health or safety. The caseworker must conduct an interdisciplinary team (IDT) meeting to review service needs and follow procedures for people at-risk .
There may be instances where the person’s condition or circumstances have changed, without a threat to the person’s health and safety, since the UR visit and the person’s service plan must be revised to meet the person’s needs. The case-worker takes appropriate action to address the current needs, including reviewing personal assistance services hours or making a referral to the provider agency for additional services.
Advance notice must be given for any decisions that reduce or terminate the client's current services. The case-worker documents the decision based on no unmet need for services or decreased need for service as appropriate to the change. Refer to Form 2065-A, Notification of Community Care Services, instructions, and Attachment A for denial reasons and relevant comments.
5330 Provider Implementation of the Change
Revision 24-3; Effective July 1, 2024
When Form 2101, Authorization for Community Care Services is received from the caseworker, the provider agency follows established procedures to implement the change request.
If the provider agency has concerns about meeting a person’s needs based on the new service plan, they follow the procedures outlined in:
- Provider Information Letter (IL) 09-30, Implementation of Regional and Local Services (RLS) Utilization Review Program, dated Dec. 23, 2009; and
- IL 2007-06, Clarification of Licensing Rules and Contract Requirements Regarding Accepting Individuals with Complex Needs for Service, dated June 20, 2007.
Caseworkers follow current program enrollment policies. This includes conducting an interdisciplinary team (IDT) meeting if needed and helping the person transfer to another provider agency when necessary.