Documents
Instructions
Updated: 2/2023
Purpose
This form is used to:
- inform the member of personal costs with the requested Minor Home Modification (MHM) or Adaptive Aids (AA);
- authorize the requested MHM or AA;
- document the amount authorized for the MHM or AA; and
- authorize the provider to deliver the requested MHM or AA.
Procedure
When to Prepare
The managed care organization (MCO) service coordinator completes Form 2416 when authorizing MHM or AA.
Number of Copies
The MCO service coordinator completes an original for the member or primary caregiver and copies for the provider and case file.
Transmittal
If there are no personal costs identified:
- complete Sections A, B, C and D; and
- submit an original to the member and a copy to the provider.
If personal costs are identified:
- Complete Sections A and B, with the additional information.
- Submit a copy to the member for signature. Upon return from the member:
- complete Section C and D; and
- submit the completed Form 2416 with the MCO service coordinator’s original signature to the member and a copy to the provider.
- Documentation must be on file prior to the MCO authorizing a MHM or AA that exceeds the service limit.
Form Retention
Keep a copy of the most recent form for the requested item or service for three years after the case is denied or closed.
Detailed Instructions
Section A: Individual Information
Name— Enter the member's name.
Medicaid Number— Enter the member's Medicaid number.
Parent or Guardian— Enter the name of the member's parent or guardian.
Address— Enter the member's address, including the street number and name, city, state and ZIP code.
County— Enter the member's county of residence.
Area Code and Phone No.— Enter the member's area code and telephone number.
Section B: Requested Service and Personal Costs
Service Requested— Check the box for the service requested. Select only one service: MHM or AA.
Personal Costs— Select the first box if the MCO service coordinator determines no need for personal costs for the requested MHM or AA and continue form completion in Section C.
Select the second box if the MCO service coordinator determines there are personal costs for the requested MHM or AA. If there are personal costs, provide additional information, and send a copy to the member for the member’s review, signature and date.
- Rationale for exceeding the service limit - Enter reason for exceeding the service limit.
- Cost incurred to the MCO – Enter the dollar amount the MCO will pay.
- Cost incurred to the member – Enter the dollar amount the member will pay.
Section C: Service Authorization
Individual Plan of Care (IPC) period for which service is authorized— Enter the From and To dates documented in the member's IPC.
Amount previously authorized for MHM— If applicable, enter any previously authorized MHM costs. The MCO may not authorize waiver services if the sum of previous and new costs exceeds the $7,500 lifetime limit for MHM.
Amount previously authorized for AA— If applicable, enter the amount of AA costs previously authorized for the current IPC period. The MCO may not authorize waiver services if the sum of current and new costs exceeds the $4,000 limit for AA per IPC period.
Type of Service Authorized— Select the appropriate box for the requested item or service. Specify the location, modification or item as appropriate.
For example:
- MHM — Bathroom Modification (specify modification): Tub to shower conversion; or
- AA — (specify item): Feeder seat
Based on the request and the amount of the bids submitted, MCO authorizes:— Enter the amount of the MHM or AA authorized for the requested item or service.
MCO Service Coordinator Signature and Information— The MCO service coordinator signs and dates the form and provides the area code and telephone number, address and area code and fax number.
Your service authorization is cancelled effective:— The case manager uses this section for cancellation of service authorizations. Check the box and enter the date the cancellation becomes effective.
Section D: Provider Information
Contract Number— Enter the provider’s contract number.
Name— Enter the provider’s name.
Area Code and Phone No.— Enter the provider’s area code and phone number.
Address— Enter the provider’s address, including the street number and name, city, state and ZIP code.
Area Code and Fax No.— Enter the provider’s area code and fax number.
Signature — Provider Contact and Date— The provider contact signs and dates the form.