Form 1589, Consumer Directed Services Revision Worksheet

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Documents

Effective Date: 1/2016

Instructions

Updated: 1/2016

Procedure

When to Prepare

The case manager (CM) initiates Form 1589 to revise an annual service plan (ASP) for an individual using the Consumer Directed Services (CDS) option for a Community Care Services Eligibility (CCSE) program, including:

  • a transfer to a different Financial Management Services Agency (FMSA);
  • an increase or decrease of authorized CCSE service units; or
  • a rate change.

This form is not required for individuals initially beginning the CDS option.

The CM and FMSA must complete their designated sections of Page 1 of the form. Page 2 includes a guide to assist the CM in completing the revision calculation.

The CM initiates Form 1589 and is responsible for sending Page 1 to the applicable FMSA for completion.

Detailed Instructions

Page 1 of Form 1589 is intended to assist an FMSA and CM in determining the hours/dollars:

  • that have been used by the FMSA from the original ASP amount; and
  • to be reserved for an FMSA from the original ASP amount.

The CM should follow the instructions in the Case Manager Community Care Eligibility Services (CCSE) Handbook, Section 6333.3, Circumstances That Necessitate a Revised Annual Service Plan (ASP), to complete the entire calculation for determining the total amount of hours/dollars to be included for the revised ASP. The CM can use Page 2 to assist in completing the rest of the revision calculation.

The CM completes the individual identifying information and Column 1. The CM then requests information from the FMSA. The FMSA may either be an individual’s current FMSA, if the individual is receiving an increase/decrease in service units or a rate change, or an individual’s transferring (or “losing”) FMSA if the individual is requesting a transfer to a new FMSA. In the instance of an FMSA transfer, the new (or “gaining”) FMSA is not required to complete any section of this form. The FMSA must designate a billing representative to complete the revision worksheet. This must be someone at the FMSA who has knowledge of which services have been billed and which services are expected to be provided before the transfer effective date. The FMSA billing representative should review these instructions before completing the FMSA section of the revision worksheet.

The FMSA will complete:

  • Column 2, indicating how many hours/dollars have been used by the individual; and
  • Column 3, indicating hours/dollars to be reserved for the FMSA.

Note for FMSA Reserving Hours/Dollars: At the time of revision, any unbilled hours/dollars on an individual's ASP must be divided between the current ASP and the revised ASP. The FMSA must reserve any hours/dollars provided but not yet billed and any hours/dollars to be provided up to the revision effective date. Any hours/dollars not reserved for the FMSA will automatically be allocated to the newly revised ASP.

The CM will add the amounts from Columns 2 and 3 and enter this total in Column 4. This total represents the hours already billed or available for billing by the FMSA from the current ASP begin date up to the revised ASP effective date.

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

Individual No. — The CM enters the individual's assigned identification number.

Annual Service Plan (ASP) Begin Date — The CM enters the original ASP begin date.

ASP End Date — The CM enters the original ASP end date.

Revision Effective Date — The CM enters the date that all parties have mutually agreed upon for the revised ASP effective date.

Authorized Hours — The CM enters the authorized hours.

Case Manager (CM) Name — The CM enters his/her name.

CM Area Code and Phone No. — The CM enters his/her area code and phone number.

CM Area Code and Fax No. — The CM enters the area code and fax number.

Column 1, Original ASP Amount  — The CM enters the original ASP amount from the current Form 2101, Authorization for Community Care Services, for Community Attendant Services (17DV), Primary Home Care (17V) or Family Care (17CV).

Column 2, Hours and Dollars Used — To capture hours already billed for by the FMSA, the CM requests the FMSA to complete this section of the worksheet with the hours and dollars of service which the FMSA has documentation for use by the individual.

Column 3, Hours and Dollars Reserved for FMSA — The FMSA billing representative enters the number of hours/dollars that need to be reserved for billing for services that were provided and not yet claimed and for services that will be provided up to the revision effective date. If the FMSA has no outstanding billing to be entered, the representative enters 0 for the appropriate program in Column 3. Any service field left empty will result in no hours/dollars being reserved for the FMSA.

Example: An individual's ASP has a begin date of January 1, and he will transfer to a different FMSA on July 16. The transferring/losing FMSA has billed for January through June. The individual is receiving 20 hours of Community Attendant Services per week. In this example, the transferring/losing FMSA will request 40 hours be reserved by entering 40 in the appropriate row of Column 3 (20 hours of Community Attendant Services to be provided July 1-16 for two weeks). The FMSA will multiply the 40 hours by the rate of pay for the attendant services to get the dollar amount to enter in Column 3.  

Column 4, Totals Available for FMSA — The CM adds the amounts in Columns 2 and 3 and enters the total in the appropriate row of Column 4.

Billing Representative Statements — The FMSA billing representative must check:

  • Box 1, certifying that the information in Column 2 is accurate.
  • The appropriate Box  2, certifying the information in Column 3 is accurate or that the FMSA has no outstanding billing to be entered and no hours/dollars will be reserved.

Signature – Billing Representative — The FMSA billing representative signs to indicate agreement with the hours/dollars entered in Columns 2 and 3.

Printed Name — The FMSA billing representative who signed the form prints his/her name.

Date — The FMSA billing representative enters the date the form is completed and signed.

Billing Representative Area Code and Telephone No. — The FMSA billing representative enters his/her area code and telephone number.

Billing Representative Area Code and Fax No. — The FMSA billing representative enters his/her area code and fax number.

Signature – Case Manager — The CM signs to indicate receipt of the information from the FMSA, and confirmation of the original ASP amount and totals available for the FMSA.

Date — The CM enters the date the form is signed and completed.

Page 2, Consumer Directed Services Supplemental Calculation Worksheet
The supplemental calculation worksheet is intended to assist the CM in calculating the new ASP authorization amount, by using the total amount in Column 4 from Page 1, and by following instructions in the CCSE Handbook, Section 6333.3.

FMSA Transfer — If the individual is transferring to a new FMSA, complete this section and follow instructions to input the authorization into the Service Authorization System (SAS), in accordance with CCSE Handbook, Section 6333.3.1, Provider Transfer.

Calculation of New ASP — If the individual receives an increase or decrease in authorized service hours, or there is a change in the rate, complete this section to determine the amount of weeks left in the individual’s ASP.

Increase or Decrease — If the individual has received an increase or decrease in hours, complete this section and follow instructions to input the authorization into SAS, in accordance with CCSE Handbook, Section 6333.3.3, Increase in Service Units, and Section 6333.3.4, Decrease in Service Units.

Rate Change — If a rate change has occurred, complete this section and follow instructions to input the authorization into SAS in accordance with CCSE Handbook, Section 6333.3.2, Rate Change.