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Effective Date: 
5/2017

Documents

 

Instructions

Updated: 5/2017

Procedure

In the Home and Community-based Services (HCS) waiver program, the Intellectual/Developmental Disability Eligibility and Support (IDD PES) staff and the Local Intellectual and Developmental Disability Authority (LIDDA) use the Level of Care (LOC) Redetermination Cover Sheet to share information and documentation regarding an individual’s LOC redetermination desk review.

Detailed Instructions

Section I — This section is to be completed by IDD PES when sending a request for LOC redetermination to the LIDDA.


LIDDA Contact Name: — Enter the name of the LIDDA contact who will be receiving the request.

Phone: — Enter the phone number for the LIDDA contact who will be receiving the request.

Fax: — Enter the fax number for the LIDDA contact who will be receiving the request.

LIDDA Name: — Enter the name of the LIDDA.

LIDDA Component Code: — Enter the LIDDA's component code.

Individual's Name: — Enter the name of the individual.

Medicaid No.: — Enter the individual’s Medicaid number.

CARE ID: — Enter the individual’s Client Assignment and REgistration (CARE) Identification number.

The LIDDA must complete a new LOC assessment  for the individual listed and using this fax cover sheet, submit a new Determination of Intellectual Disability (DID) and any other pertinent information regarding the individual's LOC to IDD PES within 30 days from the date on this notification.

Signature: — The IDD PES contact signs the form.

Date: — Enter the date the IDD PES contact signed the form and submitted the request to the LIDDA.


Section II —This section is to be completed by the LIDDA when submitting the new DID and other pertinent information to IDD PES.

Legal Name of Provider: — Enter the legal name of the individual’s assigned HCS provider.

Provider Comp: — Enter the provider’s component code.

Provider Contact Name: — Enter the name of the provider’s contact.

Phone: — Enter the phone number for the provider’s contact.

Fax: — Enter the fax number for the provider’s contact.

LIDDA Comments: — The LIDDA may enter comments, if applicable.

Signature: — The LIDDA contact signs the form.

Date: — Enter the date the LIDDA contact signed the form and submitted the documentation to IDD PES.

Section III —This section is to be completed by IDD PES when notifying the LIDDA and provider contacts listed of the LOC redetermination review results.

Meets LOC Criteria: — Mark this box if HCS LOC criteria is met.

Does Not Meet LOC Criteria: — Mark this box if HCS LOC criteria is not met.

IDD PES Reviewer Name: — Enter the name of the IDD PES reviewer.

Phone: — Enter the phone number for the IDD PES reviewer.

Fax: — Enter the fax number for the IDD PES reviewer.

Comments: — Enter comments, if applicable.

Signature: — The IDD PES contact signs the form.

Date: — Enter the date the IDD PES reviewer contact signed the form and notified the LIDDA and provider contacts of the review results.