Form 3617, Request for Transfer of Waiver Program Services

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Documents

Effective Date: 5/2022

Instructions

Updated: 5/2022

Purpose

Procedure

The service coordinator (SC) at the local intellectual and developmental disability authority (LIDDA) initiates Form 3617, Request for Transfer of Waiver Program Services, to:

  • transfer an individual's program services to a different contract within the same program provider's component code;
  • transfer an individual's program services to a different program provider and/or Financial Management Services Agency (FMSA); or
  • change an individual's service delivery option, meaning the delivery method of a service is changing to a different provider type (program provider or FMSA).

Transfers must be completed in accordance with the Home and Community-based Services Handbook.

It is important to complete all the fields in each section of the form. “Individual Information” and “LIDDA and Service Coordinator (SC) Information” are completed by the LIDDA service coordinator. Each provider type affected by the transfer must complete the appropriate sections of Form 3617, as described in these instructions.

If the transfer involves only FMSAs, Page 1 is not completed. If the transfer involves only program providers, Page 2 is not completed. If the transfer involves both program providers and FMSAs, Pages 1 and 2 are required. The transfer worksheet on Page 3 is always required and must be completed by a transferring program provider and/or FMSA.

The SC initiates Form 3617 and is responsible for ensuring all the appropriate pages of the form are completed and signed. The LIDDA SC is required to submit all applicable pages of the form and the transfer Individual Plan of Care (IPC) to the Texas Health and Human Services Commission (HHSC) Program Eligibility and Support (PES) unit within 10 calendar days of the transfer effective date.

If an SC has difficulty obtaining required information from any program provider or FMSA, they should notify PES within 48 hours of not receiving the required information.

Instructions for completing Page 1 – If the transfer involves only FMSAs, DO NOT complete Page 1. If the transfer involves both program providers and FMSAs, complete the applicable sections on Pages 1 and 2.

Page 2 will only be completed if an FMSA is affected by the transfer.

Transfer Effective Date — The SC enters a transfer effective date; which must be mutually agreed upon by all parties involved in the transfer. The transfer effective date must be on or before the signature dates on the IPC unless a transfer meets the criteria for an emergency transfer.

Waiver Program — The SC marks the appropriate waiver program.

CARE/Client ID — The SC enters the individual's assigned CARE identification number.

Individual (Last Name, First Name) — The SC enters the individual's name.

Printed Name — Individual or Legally Authorized Representative — The SC prints the individual's or legally authorized representative's (LAR's) name.

Signature — Individual or Legally Authorized Representative — The SC obtains the appropriate signature and date. If the individual has been appointed a legal guardian by a court system, the form must be signed by that person.

LIDDA and SC Information — To be completed by an LIDDA SC.

LIDDA Name — Enter the name of the LIDDA.

LIDDA Comp Code — Enter the LIDDA's component code.

SC’s Area Code and Phone No. — Enter the SC's area code and telephone number.

SC’s Fax No. — Enter the SC's fax number.

SC’s Email — Enter the SC's email address.

Meets the criteria for an immediate transfer — The SC checks this box if the transfer meets criteria for an emergency transfer.

Printed Name — LIDDA Service Coordinator — Enter the name of the SC.

Signature — LIDDA Service Coordinator — The SC signs the form.

Signature Date — The SC enters the date the form is signed.

Section I — Transferring Program Provider Information — To be completed by the transferring program provider’s representative.

Legal Name — Enter the transferring program provider’s legal name (do not use a “doing business as” name).

Comp Code — Enter the transferring program provider's component code.

Vendor/Contract No. — Enter the transferring program provider's vendor (contract) number.

Printed Name — Transferring Program Provider’s Representative — Enter the name of the transferring program provider's representative completing this section of the form.

Area Code and Phone No. — Enter the area code and telephone number for the transferring program provider's representative.

Fax No. — Enter the fax number for the transferring program provider's representative.

Individual's Local Case No. — Enter the local case number assigned to the individual by the transferring program provider.

Service County/Code — Enter the appropriate county code for the individual's county of service. A list of county codes is available in the HHSC data system.

Location Code — Enter the location code assigned to the individual by the transferring program provider.

Signature — Transferring Program Provider’s Representative — The transferring program provider’s representative signs the form.

Signature Date — The transferring program provider’s representative enters the date the form is signed.

Section II — Receiving Program Provider Information — To be completed by the receiving program provider’s representative.

Legal Name — Enter the receiving program provider’s legal name (do not use a DBA name).

Comp Code — Enter the receiving program provider's component code.

Vendor/Contract No. — Enter the receiving program provider's vendor (contract) number.

Printed Name — Receiving Program Provider’s Representative — Enter the name of the receiving program provider's representative completing this section of the form.

Area Code and Phone No. — Enter the area code and telephone number for the receiving program provider's representative.

Fax No. — Enter the fax number for the receiving program provider's representative.

Individual's Local Case No. — Enter the local case number assigned to the individual by the receiving program provider.

Service County/Code — Enter the appropriate county code for the individual's county of service. A list of county codes is available in the HHSC data system.

Location Code — Enter the location code assigned to the individual by the receiving program provider.

Signature — Receiving Program Provider’s Representative — The receiving program provider’s representative signs the form.

Signature Date — The receiving program provider’s representative enters date the form is signed.

Instructions for completing Page 2 — If the transfer involves only program providers, DO NOT complete Page 2. If the transfer involves both program providers and FMSAs, complete the applicable sections on Pages 1 and 2.

Transfer Effective Date — The SC enters a transfer effective date, which must be mutually agreed upon by all parties involved in the transfer. The transfer effective date must be on or before the signature dates on the IPC unless a transfer meets the criteria for an emergency transfer.

Waiver Program — The SC marks the appropriate waiver program.

CARE/Client ID — The SC enters the individual's assigned CARE identification number.
Individual (Last Name, First Name) — The SC enters the individual's name.

Printed Name — Individual or Legally Authorized Representative — The SC prints the individual's or LAR's name.

Signature — Individual or Legally Authorized Representative — The SC obtains the appropriate signature and date. If the individual has been appointed a legal guardian by a court system, the form must be signed by that person.

LIDDA and SC Information — To be completed by the LIDDA SC.

LIDDA Name — Enter the name of the LIDDA.

LIDDA Comp Code — Enter the LIDDA's component code.

SC’s Area Code and Phone No. — Enter the SC's area code and telephone number.

SC’s Fax No. — Enter the SC's fax number.

SC’s Email — Enter the SC's email address.

Printed Name — LIDDA Service Coordinator — Enter the name of the LIDDA SC.

Signature — LIDDA Service Coordinator — The LIDDA SC signs the form.

Signature Date — The LIDDA SC enters the date the form is signed.

Section III — Transferring FMSA Information — To be completed by the transferring FMSA’s representative.

Legal Name — Enter the FMSA’s legal name (do not use a DBA name).

Comp Code — Enter the transferring FMSA 's component code.

Vendor/Contract No. — Enter the transferring FMSA's vendor (contract) number.

Printed Name — Transferring FMSA’s Representative — Enter the name of the transferring FMSA 's representative completing this section of the form.

Area Code and Phone No. — Enter the area code and telephone number for the transferring FMSA's representative.

Fax No. — Enter the fax number for the transferring FMSA's representative.

Individual's Local Case No. — Enter the local case number assigned to the individual by the transferring FMSA.

Service County/Code — Enter the appropriate county code for the individual's county of service. A list of county codes is available in the HHSC data system.

Location Code — This field is pre-filled with the only location code allowed when self-directing services, Own Home/Family Home (OHFH).

Signature — Transferring FMSA’s Representative — The transferring FMSA’s representative signs the form.

Signature Date — The transferring FMSA’s representative enters date the form is signed.

Section IV — Receiving FMSA Information — To be completed by the receiving FMSA’s representative.

Legal Name — Enter the receiving FMSA’s legal name (do not use a DBA name).

Comp Code — Enter the receiving FMSA's component code.

Vendor/Contract No. — Enter the receiving FMSA's vendor (contract) number.

Printed Name — Receiving FMSA’s Representative — Enter the name of the receiving FMSA 's representative completing this section of the form.

Area Code and Phone No. — Enter the area code and telephone number for the receiving FMSA's representative.

Fax No. — Enter the fax number for the receiving FMSA's representative.

Individual's Local Case No. — Enter the local case number assigned to the individual by the receiving FMSA.

Service County/Code — Enter the appropriate county code for the individual's county of service. A list of county codes is available in the HHSC data system.

Location Code — This field is pre-filled with the only location code allowed when self-directing services, Own Home/Family Home (OHFH).

Signature — Receiving FMSA’s Representative — The receiving FMSA’s representative signs the form.

Signature Date — The receiving FMSA’s representative enters the date the form is signed.

Page 3 Transfer Worksheet

The worksheet is intended to assist the SC, program providers and FMSAs in determining the:

  • amount of units or dollars per service to be reserved for the transferring program provider or FMSA;
  • amount of service units or dollars that remain for the receiving program provider or FMSA; and
  • total amount of service units or dollars to be included on the transfer IPC.

The transferring program provider or FMSA must designate a billing representative to complete the transfer worksheet. This must be someone at their agency who has knowledge of the amount of units or dollars that have been billed for each service and the amount of units or dollars for each service that the transferring program provider or FMSA expects to provide before the transfer effective date. The designated billing representative should also be familiar with the HHSC data system. The designated billing representative should review these instructions before completing their section of the transfer worksheet.

Individual Plan of Care (IPC) Begin Date — The SC enters the IPC begin date.

IPC End Date — The SC enters the IPC end date.

Transfer Effective Date — The SC enters a transfer effective date, which must be mutually agreed upon by all parties involved in the transfer. The transfer effective date must be on or before the signature dates on the IPC unless a transfer meets the criteria for an emergency transfer.

CARE/Client ID — The SC enters the individual's assigned CARE/client identification number.

Individual (Last Name, First Name) — The SC enters the individual's name.

Column (1), Units/Dollars Claimed — The SC completes this column based on the information currently showing in the HHSC data system.

Column (2), To Be Reserved for Transferring Program Provider/FMSA — The transferring program provider or FMSA representative completes this column with the number of units/dollars provided but not yet billed, or to be provided before the transfer effective date. This is the amount that the transferring program provider or FMSA representative is requesting to reserve for billing after the transfer has been authorized. Note: Leaving the field blank next to any service in this column is regarded as a zero (0); no units/dollars will be reserved.

Reserving Units/Dollars for Transferring Provider or FMSA — At the time of the transfer, any unbilled units or dollars on an individual's IPC must be divided between the transferring and receiving providers or FMSAs. The transferring provider or FMSA must reserve any units or dollars provided but not yet billed and any units or dollars to be provided up to the transfer effective date. The LIDDA SC enters the reserved units or dollars into the CARE system as part of the transfer data entry. Any units or dollars not reserved for the transferring program provider or FMSA will automatically be allocated to the receiving program provider or FMSA. After the units or dollars are reserved on this worksheet, the transferring program provider or FMSA must not bill for the reserved units or dollars until PES has authorized the transfer in the HHSC data system. An SC, program provider or FMSA can determine if the transfer has been authorized by checking the form status in the HHSC data system. 

Column (3), Totals for Transferring Program Provider/FMSA — The SC completes this column by adding the amounts in Columns (1) and (2) for each service. This represents the total number of units or dollars available for each service to the transferring program provider or FMSA.

Column (4), To Be Provided by Receiving Program Provider/FMSA — The SC completes this column with the number of units or dollars for each service to be provided by the receiving program provider or FMSA from the transfer effective date through the IPC end date. The transfer effective date belongs to the receiving program provider.

Column (5), Total for Transfer IPC — The SC completes this column by adding Columns (3) and (4) for each service. This represents the total number of units or dollars that must be reflected on the transfer IPC.

Billing Representative Statement — The transferring program provider or FMSA’s billing representative checks the appropriate box certifying the information in Column (2) is as accurate as possible or that the transferring program provider or FMSA has no outstanding billing to be entered and no units or dollars will be reserved.

Signature — Transferring Program Provider’s or FMSA’s Billing Representative — The transferring program provider’s or FMSA’s representative signs the form.

Printed Name — The transferring program provider’s or FMSA’s billing representative prints his/her name.

Signature Date — The transferring program provider’s or FMSA’s billing representative enters date the form is signed.

Area Code and Phone Number — Enter the area code and telephone number of the billing representative.

Email address — Enter the email address of the billing representative.

Additional Information

If the transfer is being processed as an emergency transfer and the IPC was signed after the transfer effective date, the LIDDA submits the entire transfer packet, including documentation to support the emergency, to PES. PES determines if the transfer meets the criteria for an emergency based on the documentation received.

If PES agrees that the transfer meets the criteria for an emergency, PES completes the data entry in the HHSC data system for the transfer.

If the LIDDA is unable to data enter a transfer, contact PES for assistance within two business days of attempting to enter the transfer.

All user guides are published to Texas Medicaid & Healthcare Partnership’s (TMHP’s) Learning Management System (LMS). All users must create an LMS account to access the materials. 

There is a sign-up link on the LMS homepage. If you need assistance with registration, contact TMHP Training Support.