Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet

Effective Date
11/2019
Document
Document
3621-T.pdf (299.42 KB)

 

Instructions

Updated: 5/2015

 

Purpose

The Individual Plan of Care (IPC) Service Delivery Transfer Worksheet documents the total number of service units and costs for the Community Living Assistance and Support Services (CLASS)/Community First Choice (CFC) individual's service plan year and the total number of service units and costs appropriate for each agency providing services to the individual transferring to another CLASS/CFC provider agency.

 

Procedure

When to Prepare

The case manager completes the form at the time of the IPC transfer request, except when the individual's transfer effective date coincides with the renewal IPC effective date. The purpose of the form is not to change existing services. The form should reflect the totals (unit/dollar) of each service category on the most recently authorized IPC.

Number of Copies

The case manager completes the form. One copy each is given to the transferring and receiving agencies and a copy is provided to the CLASS/CFC individual.

Transmittal

The case manager keeps the original(s) in the individual's record and copies are sent to each provider agency as appropriate. Copies that include all parties’ signatures are sent to HHSC CLASS/CFC program staff for authorization.

Form Retention

Keep this form according to record retention requirements documented in the CLASS Provider Manual.

 

Detailed Instructions

Enter the individual's name and other identifying information.

IPC Effective Period — Enter the IPC service plan dates. 

Transfer Type — Enter the type of transfer. More than one type of transfer may apply.

Transfer Effective Date — Enter the date the transfer is effective. 

Case Management Agency (CMA) — If applicable, enter the transferring and receiving case management agencies' vendor numbers and the total number of service units appropriate for each agency.

The transferring agency's total number of service units provided before the effective date of the transfer is the sum of the number of service units:

  • provided and paid,
  • provided that have been billed but not yet paid, and
  • to be provided until the transfer effective date.

The receiving agency's total number of service units is the number of service units to be provided from the transfer effective date until the end of the IPC effective period.

Direct Services Agency (DSA) — If applicable, enter the transferring and receiving direct service agencies' vendor numbers and the total number of service units appropriate for each agency.

The transferring agency's total number of service units provided before the effective date of the transfer is the sum of the number of service units:

  • provided and paid,
  • provided that have been billed but not yet paid, and
  • to be provided until the transfer effective date.

The receiving agency's total number of service units is the number of service units to be provided from the transfer effective date until the end of the IPC effective period.

Financial Management Services Agency (FMSA) — If applicable, enter the transferring and receiving FMSA’s vendor numbers and the number of service units appropriate for each agency. IMPORTANT: For services delivered, units are expressed in dollars.

The transferring agency's total number of service dollars expended before the effective date of the transfer is the sum of the dollars expended for services:

  • provided and paid,
  • provided that have been billed but not yet paid, and
  • to be provided until the transfer effective date.

To obtain the number of units used prior to the transfer, divide the total funds expended by the unit rate.

The receiving agency's total number of service units is the number of service units (calculated by the total remaining funds divided by the unit rate) to be provided from the transfer effective date until the end of the IPC effective period.

Support Family Services Agency (SFSA) — If applicable, enter the transferring and receiving SFSA’s vendor numbers and the number of service units appropriate for each agency.

The transferring agency's total number of service units provided before the effective date of the transfer is the sum of the number of service units:

  • provided and paid,
  • provided that have been billed but not yet paid, and
  • to be provided until the transfer effective date.

The receiving agency's total number of service units is the number of service units to be provided from the transfer effective date until the end of the IPC effective period.

Total Unit Column  — The total unit column is the total number of service units assigned to both the transferring and receiving agency. This sum must equal the number of service units entered on the most recently authorized IPC.

Total Cost Column — The total cost column is the total costs assigned to both the transferring and receiving agency. This sum must equal the total cost entered on the most recently authorized IPC.

Signatures — The CLASS/CFC individual receiving services or their legally authorized representative must sign the form.

Representatives of both transferring and receiving agencies must sign the form. These signatures indicate the agencies' agreement with the number of service units and costs entered on the form.