Form 2101, Authorization for Community Care Services

Instructions

Updated: 6/2024

Procedure

When to Prepare

The Community Care Services Eligibility (CCSE) caseworker or regional nurse completes this form when:

• referring an applicant for Primary Home Care (PHC), Community Attendant Services (CAS) or Day Activity and Health Services (DAHS);
• authorizing or reauthorizing CCSE services;
• authorizing changes to CCSE services;
• authorizing Consumer Directed Services (CDS); and
• terminating CCSE services.

All authorizations must be completed in the Service Authorization System Online (SASO) Wizards.

Initial PHC

For initial PHC cases, the caseworker generates Form 2101 using the SASO Authorization Wizard to complete a Referral by setting the service authorization status to Pending. Then they send the form to the provider to begin pre-initiation activities. After the practitioner's statement is received and all eligibility requirements are met, the regional nurse generates a Form 2101, changing the authorization status to Authorize.

Initial CAS, PHC, and DAHS

For initial CAS, PHC and DAHS referrals, the caseworker generates Form 2101 using the SASO Authorization Wizards to complete a Referral by setting the service authorization status to Pending. Then they send the form to the provider or facility to begin the approval process. For these cases, eligibility is pending until the  regional nurse gives final approval. The regional nurse:

• awaits receipt of the proper forms and documentation from the provider;
• makes an approval determination;
• if approval is granted, makes SASO entries that populate Items 1, 4 and 29-38; and
• changes the referral to an authorization by processing the Authorization Wizard and setting the authorization status to Authorize.

For Title XX Services

The caseworker processes the Authorization Wizard and sets the service authorization status to Authorize. A separate Form 2101 is generated for each service the person is determined eligible to receive.

For the CDS Option For PHC, CAS or Family Care (FC)

For Family Care, the caseworker generates Form 2101 using the appropriate service code for CDS in the specific program. The caseworker also generates a second Form 2101 for the CDS Financial Management Service (FMS) fee.

For CAS or PHC, the regional nurse generates Form 2101 using the appropriate service code for CDS in the specific program. The regional nurse also generates a second Form 2101 for the CDS Financial Management Service (FMS) fee.

Number of Copies

Print an adequate number of copies of Form 2101 for program requirements.

Transmittal

The caseworker keeps a copy in the person's case record and sends copies to the provider as required by the program. Review Community Care Services Eligibility Handbook, Appendix XIII, Content of Referral Packets, for requirements.

For all services except CAS, PHC and DAHS initial authorizations, the provider keeps a copy, completes the provider portion of the form or uses some other form of notification of service initiation. They return it to the caseworker within 14 days of the service initiation.

For CAS, PHC and DAHS initial authorizations, the provider sends the regional nurse a copy of the Referral Form 2101 with the referral packet. The regional nurse authorizes or denies service and sends a copy of the Authorization Form 2101 to the provider and the caseworker.

Detailed Instructions

1. Date — Enter the date (month, day and year) the form is prepared. The date entered must also be the date the form is mailed.

2. Contract No. — Enter the nine-digit number assigned by HHSC to the contracted provider.

3. Type of Authorization — Inform the provider agency as to the type of authorization contained in the referral packet by checking the appropriate authorization (case action). Check one of the following:

1 – New, for initial authorizations/referrals in SASO;
2 – Update, for changes in the service plan or CAS annual reassessment; or
3 – Terminate, for terminations of service authorizations in SASO.

4. Begin Date —

Referrals

For the referral to provider/facility, leave the begin date blank for:

• initial PHC;
• initial DAHS;
• initial CAS; and
• annual reassessments of CAS, if there are no changes.

Title XX-funded services do not require a referral for pre-initiation activities and only the authorization process is used.

Authorizations

The begin date is the day the person is authorized for services after being determined eligible. This date is the same as the date in Item 1 (mail date) or the negotiated date.

For CAS, PHC and DAHS initial authorizations and CAS annual reassessments with no changes, the  regional nurse enters the begin date in the Service Authorization record.

Coverage Dates for Ongoing Services Plan Changes

• For service increases, the begin date is seven calendar days from the Item 1 (mail) date.
• For service decreases, the begin date is 12 calendar days from the Item 1 (mail) date (unless a weekend or a legal holiday). See the Community Care Services Eligibility Handbook, Appendix XVIII, Time Calculation.
• For immediate increases, the begin date is the date the caseworker verbally negotiated as the date the increase is to be effective.

5. End Date — Leave the end date blank for initial authorizations. For terminations, enter the last date the contracted provider is authorized to deliver service.

6. Term Code — Enter the appropriate termination codes to terminate the service authorization screen in SAS. Reminder: Termination of a person's enrollment requires a separate entry in the Enrollment Termination screen.

Terminate the Client Enrollment in SASO only if the person is not going to receive any other community care service.

7. Individual Name — Enter the person's last name, first name and middle initial.

8. Individual No. — Enter the person’s permanent nine-digit number. If a permanent individual number has not yet been assigned, enter person’s information into SASO to get an individual number.

9. 2060 Score —Enter the functional assessment score, if one is required for service eligibility.

10. Priority — For personal attendant servers (PAS) only, enter whether or not the person has priority status by entering:

• 1 for non-priority; or
• 2 for priority.

Leave blank for all other services.

11. County — Enter the county code where the person resides.

12. Agency — Pre-populated on Form 2101 as agency code 324.

13. Provider Address — Enter the name and address of the contracted provider.

14. RUG — Resource Utilization Group. (Not used in CCSE services).

15. Fund Code — Enter 20 for Medicaid people  eligible for FC. This item is also used for forced payments.

16. Group — Pre-populated on Form 2101 as Service Group 7, Community Care.

17. Code —

18. Units — Enter the number of units. Caseworkers may enter half units. For PHC, CAS or FC, half units must not exceed one digit. For example, if 16½ hours of PHC/CAS/FC are authorized, enter: 016.5. If the units are fewer than three digits, enter zeros in front of the units. For emergency response services always enter 001.0. For residential care, enter 001.0.

For CDS – Enter the total dollar amount of the Annualized Service Plan.

19. Unit Type — Enter the appropriate unit type based on the services being purchased.

1 – Week — PHC, CAS, FC, DAHS, Home Delivered Meals (HDM), SSPD, SSPD-Adult Day Care, CMPAS
2 – Month — ERS
3 – Year — CDS
4 – Per Authorization — IHFSP
5 – Daily — Adult Foster Care (AFC), Residential Care (RC), RC-Emergency Care

COPAYMENT — This item must be completed if the authorized service is RC. Leave blank for other services.

20. Initial Amt. — Enter the assessed person’s copayment amount for the first calendar month of the authorized period. If there is no individual copayment, enter zeros. The initial copayment amount will always correspond to the first calendar month reflected in the begin date.

21. Ongoing Amt. — Enter the assessed person’s copayment amount beginning with the second calendar month of the authorized period. The indicated copayment amount should continue indefinitely unless an increase or decrease occurs.

22. % CMPAS Only — The regional contract manager completes this item for CMPAS cases. Enter the percentage copayment amount as determined by the CMPAS contract and appropriate information letter.

23a. For PAS — Check the appropriate box to indicate whether the person is receiving CAS, PHC or FC.

23b. For DAHS — Check the appropriate box to indicate whether the person is receiving Title XIX or Title XX DAHS.

24. Service Items — For initial referrals and reassessments sent to providers, mark all tasks being purchased for CAS, PHC and FC.

25. Comments — The caseworker must use this item to document the number of days a PAS person is requesting services based on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Example: Person requests "a five-day plan" or "seven-day plan."

This item is also used to document information or communicate to the provider any applicable comments or circumstances which may include but are not limited to:

• Verbal negotiations between caseworker and provider. Include the date the caseworker contacted the provider, the name of the provider representative the caseworker contacted for the negotiation, and the specific agreements made during the negotiation.
• People who should not be hired as the paid attendant.
• People who require a special schedule based on health or safety concerns.
• Priority status changes.
• Name of companion case.
• Other CCSE services a person receives.
• CAS annual reassessments with no change in services. Document "No Changes."
• DAHS facility-initiated referrals.
• CMPAS voucher individuals only – include the budget amount.
• CDS – enter weekly hours of service, the hourly rate, the Annual Service Plan (ASP) annualized hours, and the total ASP amount.
• Retroactive Reimbursement Case for PHC, including:
  • approval for the retroactive period, but not for the ongoing period; and
  • date the caseworker notified the provider that the person is eligible for only the retroactive period (ineligible for ongoing PHC/CAS) and the termination date.

Authorizing Agents:

Enter all appropriate authorizing agents.

26. Case Manager — Enter the caseworker’s name for all applicable cases.

27. Phone No. — Enter caseworker’s phone number including the area code and extension.

28. Mail Code — Enter caseworker’s mail code.

29. BJN — Enter caseworker’s budgeted job number (BJN).

30. Case Manager Address — Enter caseworker’s address.

31. Practitioner — The regional nurse enters the practitioner's name for initial CAS, PHC and DAHS.

32. Phone No. — Enter the practitioner’s phone number, including the area code and extension. The regional nurse completes this item for initial CAS, PHC and DAHS.

33. License No. — Enter the practitioner’s license number. For initial CAS, PHC and DAHS, the regional nurse must enter the license number. .

34. Date of Order — The regional nurse enters the date as provided by Form 3055, Physician's Orders, (for DAHS) or Form 3052, Practitioner's Statement of Medical Need, (for CAS and PHC).

35. Nurse — Enter the name of the regional nurse who is authorizing services for CAS, PHC or DAHS.

36. Phone No. — Regional nurse enters phone number.

37. Mail Code — Regional nurse enters mail code.

38. BJN — Regional nurse enters BJN.

39. Nurse Address — Regional nurse enters address.

40. Diagnosis — Regional nurse enters the diagnosis or diagnoses from Form 3055 (for DAHS). This includes diagnosis of AIDS or HIV infection.

Contracted Agency May Complete This Section and Return a Copy to HHSC

For AFC, PHC, CAS, ERS, FC and RC, the contracted agency may complete and return the bottom portion of this form. However, the agency is not required to complete and return Form 2101.

For PHC, CAS and FC, based on 40 Texas Administrative Code Section 47. 61(b), the provider must notify the caseworker of service initiation. It is up to the provider if Form 2101 is used or if another written document is used for the notification.

For DAHS and HDM, the contracted agency must complete Form 2101 and return to the caseworker.

If completion is required, the contracted agency enters the following:

Service Initiation Date — The contracted agency enters the date services are initiated.

Schedule — Self-explanatory. The contracted agency may complete this section for initial referrals for applicable community care services. Do not complete for AFC, RC or ERS.

Agency Contact Person — The contracted agency enters the name of the person the HHSC caseworker should contact regarding the recipient.

Phone No. — The contracted agency enters the phone number of the provider contact person.

Comments — The contracted agency may enter this information including the name(s) of the attendant(s) delivering services to the person, but it is not required. Add other comments as needed.

Signature – Agency Representative — Self-explanatory.

Date — Enter the date this form is mailed to the referring HHSC caseworker.