Form 2358, Habilitation Coordination Authorization Request

Documents

Effective Date: 4/2020

2358.pdf

Instructions

Updated: 4/2020

Purpose

Form 2358 is used by local intellectual and developmental disability authorities (LIDDAs) to request authorization from HHSC to provide habilitation coordination to an individual.

When to Prepare

The LIDDA’s request for authorization of habilitation coordination for a one-year period, which is considered the plan year and includes twelve months. The LIDDA requests authorization for the following events:

Initial – If the initial interdisciplinary team (IDT) agrees the individual will receive habilitation coordination, the habilitation coordinator (HC) will request 12 units.
Refusal – If the individual/legally authorized representative (LAR) refuses habilitation coordination, the HC must submit a “refusal” and request one unit. The unit will allow the LIDDA to bill for the habilitation coordination service provided during the initial or annual IDT meeting.
Renewal – For an individual currently receiving habilitation coordination, to request to reauthorize for another year, 12 units.
Community Living Options – At the request of the individual/LAR who has refused habilitation coordination, the LIDDA may submit a Community Living Options (CLO) authorization request for providing CLO information support services with one unit to complete the CLO informational process at any given time after the initial CLO has been completed. CLO is typically completed every six months but can be completed more often, upon request.
Revision – After a refusal, the individual/LAR may request habilitation coordination before their annual IDT. A revision will be authorized to add the remainder of units needed to provide habilitation coordination to the individual before their next IDT meeting to renew their plan.
Termination – Completed if an individual decides to end habilitation coordination, passes away, moves to another nursing facility in the local service area of another LIDDA, or moves to the community.

Submittal

The LIDDA HC is responsible for submitting the proposed Form 2358 to HHSC.

Form Retention

Form 2358 must be kept in the person’s record until notified otherwise by HHSC Legal Services.

Detailed Instructions

Individual’s Name — LIDDA staff enters the name of the individual whose needs for habilitation coordination are being assessed.

Social Security Number — Enter the individual’s Social Security number.

Medicaid Number — Enter the individual’s Medicaid number.

Begin Date — Enter the individual’s begin date for habilitation coordination.

Initial is the date of the IDT.
Refusal is the date of the IDT.
Renewal is the date following the previous end date.
CLO is the date CLO was presented.
Revision is the date of the habilitation coordinator’s first meeting.
Termination is the date the authorization began.

End Date — Enter the individual’s end date for habilitation coordination.

Initial end date is 365 days after the begin date (366 days in a leap year).
Refusal is the date of the IDT.
Renewal end date is 365 days after the begin date (366 days in a leap year).
CLO is the date CLO was presented.
Revision end date is the last day of the month before the annual IDT is expected.
Termination end date is the date the individual will terminate services.

LIDDA Comp Code and Provider Number — Select from the drop-down menu the LIDDA Comp Code/Provider Number.

Authorization Type — Select the authorization type that describes the reason for completing Form 2358. Check only one: Initial, Refusal, Renewal, Community Living Options, Revision or Termination.

Habilitation Coordination Units — Enter the requested amount of units for habilitation coordination to be provided by the LIDDA. For initials and renewals, enter 12. For refusals, enter 1. For CLO, enter 1. For revisions, enter up to 10. For a termination, leave blank.

Authorization Type	Number of Units to be Entered
Initial	12 units
Refusal	1 unit
Renewal	12 units
CLO	1 unit
Revision	Up to 11 units
Termination	Number of units used or needed between the begin date and end date

Termination Code — If the individual is terminating habilitation coordination, select the code that best describes the reason for termination. It should be noted that Code 1 is if the individual moves to a nursing facility in a new LIDDA’s local service area, 23 is for individuals transitioning into a community program, and 29 is for individuals discharging home.

Code	Description
1	Client Leaves the LIDDA’s catchment area
2	Death of Client
5	Client Requests Service Termination
23	Transferred to Another Service
29	Discharged from Facility (Assumed to Home)
32	Hospitalized over 30 days
39	Other

Habilitation Coordinator Signature

Before electronic transmission to HHSC, an individual’s habilitation coordination authorization must be signed and dated by the required HC indicating agreement that the form meets all requirements set forth in the Habilitation Coordination Billing Guidelines Handbook.

Signature — Habilitation Coordinator — The HC signs the form.

Printed Name — Habilitation Coordinator — Enter the printed name of the HC.

Area Code and Phone Number — Enter the area code and phone number of the HC.

Date — Enter the date the HC signed the form.

Habilitation Coordinator Email Address — Enter the email address of the habilitation coordinator.

Supervisor Printed Name — Enter the printed name of the habilitation coordinator’s supervisor.

Supervisor Email Address — Enter the email address of the habilitation coordinator’s supervisor.

Bottom Section – To be used when an individual transfers to a nursing facility in the local service area of another LIDDA.

The receiving HC is responsible for:

completing the bottom portion of Form 2358 to request authorization;
sending the form to the previous providing LIDDA and request that the LIDDA complete the top portion of the form requesting to terminate the authorization and return to the receiving HC within three business days; and
notifying designated HHSC program staff at the PASRR SPA mailbox: IDD-BH_PASRRSPA@hhsc.state.tx.us, if the transferring LIDDA fails to return the form as requested within three business days.

Upon request of the receiving HC, the previous providing LIDDA is responsible for completing the top potion of Form 2358 ending the authorization and return to the receiving HC within three business days.

The two LIDDAs may use each other’s dedicated Preadmission Screening and Resident and Review (PASRR) fax line or any other coordinated secure method.

Designated HHSC program staff will assist LIDDAs when notified of problems related to beginning and ending an authorization for habilitation coordination.