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Effective Date: 
1/2017

Documents

Instructions

Updated: 1/2017

Purpose

Form 1570 is used by Texas Health and Human Services (HHS) staff, State Supported Living Centers (SSLCs), and Local Intellectual and Developmental Disability Authorities (LIDDAs) to request a Medical Needs Assessment (MNA) evaluation or verification of a Resource Utilization Group (RUG) value by an HHS nurse.

Procedure

When to Prepare

Form 1570 is completed when an LIDDA, nursing facility (NF) or SSLC determines an applicant or individual will need an MNA evaluation or verification of a RUG value to receive high medical needs support.

Note: On the date of the last Minimum Data Set (MDS) and RUG, this information is available from the NF, if applicable.  However, the information would not be available if the individual had not been in an NF prior to this placement.

Transmittal/Submission

Providers must submit the form via email to HmnServices@hhsc.state.tx.us.

Form Retention

The LIDDA or SSLC making the request must maintain a copy of the completed form in the individual's record. For questions about the form or instructions, email HmnServices@hhsc.state.tx.us.

Detailed Instructions

Name of Individual — Enter the individual's first and last name.

Date of Birth — Enter the individual's date of birth.

Medicaid Number — Enter the individual’s Medicaid number.

Date of Request — Enter the date the request is completed and sent.

Individual’s Facility Name — Enter the name of the facility in which the individual is currently receiving services.

CARE ID — Enter the individual’s identifying number as assigned in the Client Assignment and Registration (CARE) System, if applicable.

Comp Code — Enter the Component Code for the LIDDA or SSLC, if applicable.

Current or Requested Level of Need — Enter the individual’s current level of need or the requested level of need for an enrollment in an ICF/IID, if applicable.

ICAP Service Level — Enter the service level determined by the Inventory for Client and Agency Planning (ICAP), if applicable.

Nursing Frequency Code (ID/RC Item No. 40) — Enter the frequency code for nursing as recorded in Item No. 40 of Form 8578, Intellectual Disability/Related Condition Assessment.

Name of Legally Authorized Representative — Enter the name of the individual’s legally authorized representative.

Area Code and Telephone Number — Enter the area code and telephone number of the legally authorized representative.

Name of LIDDA or SSLC Making Request — Enter the name of the LIDDA or SSLC making the request.

Area Code and Telephone Number — Enter the area code and telephone number for the LIDDA or SSLC making the request.

Name and Title of Contact Person — Enter the name and title of the person HHS will contact for questions about the request, such as the LIDDA diversion coordinator, SSLC transition staff or SSLC RN.

Area Code and Telephone Number — Enter the area code and telephone number for the contact person.

Area Code and Fax Number — Enter the area code and fax number for the contact person.

Email Address — Enter the email address for the contact person.

Individual currently receives services from — Check the appropriate box for SSLC or NF.

Date of Last Minimum Data Set (MDS) — For individuals residing in an NF, enter the date of the last minimum data set assessment, if applicable.

Resource Utilization Group (RUG) Category —  For individuals residing in an NF, enter the most recent RUG category, if applicable.

Completed by Designated Nurse Conducting Assessment or Verifying RUG III Category — The designated nurse, who is either an HHS Utilization Management Review nurse or HHS field nurse, enters the date the initial contact was made, the date of the MNA, if applicable, signs and dates the form.

Completed by State Office Nurse — The State Office nurse enters the RUG category, date the RUG category is verified, frequency code verified, group number (ICF only), whether the individual meets the high medical needs criteria, signs and dates the form.