Form 3625, CLASS/CFC - Documentation of Services Delivered

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Documents

Effective Date: 12/2024

Instructions

Updated: 12/2024

Note: The term person when used in this form refers to an individual per 26 Texas Administrative Code (TAC) 259.5.

Purpose

This form must be used to summarize Community Living Assistance and Support Services (CLASS) services provided by the CLASS Case Management Agency (CMA) or Direct Services Agency (DSA) to a person in a calendar month.  Exceptions:

  • Adaptive aids, dental treatment and minor home modifications do not need to be summarized on this form.
  • Community First Choice Emergency Response System (CFC ERS), and Community First Choice Support Management do not need to be summarized on this form.
  • Services that require electronic visit verification (EVV) do not need to be summarized on this form:
    • In-home respite services;
    • Nursing services provided in the person’s own home/family home by a registered nurse (RN), licensed vocational nurse (LVN), specialized RN, specialized LVN;
    • Occupational therapy (OT) provided in the home;
    • Physical therapy (PT) provided in the home; and
    • Community First Choice Personal Attendant Services/Habilitation provided as a direct service to the person. This does not include a DSA representative's participation in the Service Planning Team (SPT) meeting.
  • Services provided through the Consumer Directed Services (CDS) option do not need to be summarized on this form.

Note: Own home/family home does not include Support Family Services or Continued Family Services.

The CLASS CMA or DSA timekeeper uses the form to verify the accuracy of the information on the form before submitting a claim for the service.

Funds paid to the CLASS CMA or DSA for a submitted service claim may be recouped by the Health Human Services Commission (HHSC) if:

  • Form 3625 is not completed correctly, or
  • the information documented on the form does not support the billed claim.

Procedure

Each CLASS case manager or DSA service provider will use a separate form to document the service provided to a person. Documentation requirements include:

  • Only one person receiving CLASS services per form.
  • Only one service provider per form. Hours worked by two or more different service providers must not be placed on the same form.
  • Only one service type per form. PT, for example, cannot be on the same form as nursing services.
  • Only the services provided in one calendar month per form.
  • CMA Log entries on the CLASS/Community First Choice (CFC) Documentation of Services Delivered form must be accompanied by contact notes that include the:
    • date of contact;
    • description of case management provided;
    • progress or lack of progress in achieving goals or outcomes in observable and measurable terms that directly relate to the specific goal or objective addressed;
    • person with whom the contact occurred; and
    • case manager who provided the contact.
  • DSA Log entries on the CLASS/CFC Documentation of Services Delivered form must be accompanied by supporting documentation to account for all activities performed on the shift if applicable. If a nurse completes an assessment, for example, supporting documentation is required.

Form Retention

This form and the accompanying supporting documentation must be maintained per record retention requirements documented in the CLASS Provider Manual and 26 TAC Section 52.113, whichever is greater at the time the record is created.

Detailed Instructions

Note: A timekeeper must be designated to verify that the hours recorded on the billing document were worked. The timekeeper may be the supervisor or other designated person but must not be the service provider.

Written approval must be obtained from HHSC Long-Term Support Services (LTSS) Policy if a different primary source billing document will be used instead of Form 3625 and instructions.

Section A — Person’s Information

The service provider completes this section.

1. Service Month and Year — Enter the month and year the service is provided. Only one month may be documented on each form.

2. Person’s Name — Enter the person's full name as shown on their Medicaid card, their Social Security card or the full name as provided by the person on the person's Form 3621, Individual Plan of Care. If the person's name is different on any or all documentation, use the name on the Medicaid card.

3. Medicaid No. — Enter the Medicaid number of the person receiving the CLASS program service. If the form is being completed for a pre-assessment and the person does not have a Medicaid number, enter the phrase pending waiver eligibility.

4. Social Security No. for CLASS applicants only — Enter the applicant's nine-digit Social Security number on their Social Security card. For those persons enrolled in CLASS, leave this item blank.

Section B — Provider Agency Information: Case Management Agency (CMA) or Direct Services Agency (DSA)

5. Agency Type — Check the appropriate box for CMA or DSA.

6. Agency Name — Enter the CMA or DSA name.

7. Contract No. — Enter the provider number assigned by HHSC.

Section C — Pre-Enrollment Assessment Fees: CMA or DSA

The CMA or DSA completes this section when billing for pre-enrollment assessment fees.

8. Case Management Services — Check the appropriate box if billing is being submitted for a Full Assessment or a Partial Assessment. Only one box should be checked.

  • Full Assessment — Check this box for reimbursement for a full assessment provided during the initial assessment process. Full assessment activities result in the development of an Individual Plan of Care (IPC) authorized by HHSC.
  • Submit to HHSC:
    • Completed Form 3621, CLASS/CFC – Individual Plan of Care; and
    • Completed Form 3625, CLASS/CFC – Documentation of Services Delivered.
  • Partial Assessment — Check this box for reimbursement for a partial assessment provided during the initial assessment process. This occurs when the applicant declines CLASS program services or does not meet eligibility requirements.
  • Submit to HHSC:
    • Completed Form 3657, Pre-Enrollment Assessment; and
    • Completed Form 3625.

9. DSA Services — Check the Full Assessment box if billing is being submitted to complete a DSA Pre-Enrollment Assessment.

  • Submit to HHSC a completed:
    • Form 3625, and
    • HHSC-authorized Form 8578, Intellectual Disability/Related Condition Assessment.

Section D — Case Management Services

10. Case Manager Name — Enter the name of the case manager who provided the case management service.

11. Case Management Services — Check this box to indicate that the case management services documented on the form are ongoing services. This does not apply to pre-enrollment assessments.

Section E — Direct Services

Only the DSA completes this section.

12. Method of Delivery — Check the box that represents the method services will be provided to the person.

  • Employee — Name of Employee — Check this box if the person providing the service documented on the form is an employee of the DSA. Type or use legible handwriting to print the name of the employee providing the service. The employee must sign and date Section G — Certification on the signature line Person Delivering Services:
    • If the employee is not available to sign and date Section G — Certification, the DSA must document in the Comments section the reason the employee is not available to sign.
    • The timekeeper must sign and date the form after verifying the accuracy of the information on the form.
  • Subcontractor: Check this box if the person providing the service documented on the form is not an employee of the DSA.
    • Name of Service Provider — Type or use legible handwriting to print the name of the person who is providing services as a subcontractor under a subcontract or written agreement with the DSA. This person must sign and date Section G — Certification on the Person Delivering Services signature line.
    • Name of Contract Service Provider Company — Type or use legible handwriting to print the name of the company providing services under a subcontract or written agreement with the DSA. This person must sign and date Section G — Certification on the Person Delivering Services signature line.
      • If the professional contracted by the DSA under a subcontract is not available to sign and date Form 3625, the DSA must document in the Comments section the reason the service provider is not available to sign.
      • The timekeeper must sign and date the form after verifying the accuracy of the information on the form.
  • Direct Purchase — May only be used for the following service categories:
    • Adaptive Aids — 15;
    • Minor Home Modifications — 16;  
    • Written Specifications for Adaptive Aids — 41C; and
    • Written Specifications/Inspections Fee for Minor Home Modifications — 41D. Check direct purchase if the DSA or a contractor will be making the direct purchase.
  • Direct purchase is only for service category Adaptive Aids — 15 and Minor Home Modifications — 16.
  • A representative of the vendor completing the work or DSA designated timekeeper must sign and date Form 3625.

Authorized Service — Enter only one service category and the corresponding requisition fee if applicable for each Form 3625 completed.

13. Service Category — Enter the authorized service category that billing is being submitted for, such as PT or nursing services. This service category excludes specialized therapies.

14. Service Code — Enter the service code that corresponds to the authorized service documented on the form. Service codes for each authorized CLASS service are on the person’s IPC. Additional information is on the Long-Term Care (LTC) Bill Code Crosswalk.

15. Bill Code — Enter the billing code that corresponds to the authorized service documented on the form. The billing codes for each authorized service category are listed on the LTC Bill Code Crosswalk.

16. Requisition Fee applicable to specialized therapies only — Enter the authorized requisition fee amount that corresponds to the specialized therapy documented in Field 14 if applicable, such as the requisition fee for massage therapy or music therapy.

Requisition fees must not exceed the authorized amount for the specialized therapy that is being billed.

17. Requisition Fee Service Code — Enter the requisition fee service code. Service codes for each authorized CLASS service are listed on the LTC Bill Code Crosswalk.

18. Requisition Fee Bill Code — Enter the requisition fee billing code that corresponds to Field 18. The billing codes for each authorized service category are listed on the LTC Bill Code Crosswalk.

Comments — This is a required field for therapy services delivered by telehealth (synchronous audio-visual technology). The DSA must use this field to indicate that remote delivery of the service is clinically appropriate per the rendering therapist’s professional judgment.

For case management and all other direct services, this is an optional field and additional information can be documented here at the discretion of the timekeeper or service provider. Additional information may include references such as case manager review or nursing assessment to note the type of supporting documentation available for that service event.

Entering information in this field does not replace the requirement to provide accompanying service delivery documentation when applicable. Separate case management contact notes, DSA assessments and therapeutic treatment notes are still required.

Section F — Record of Time

The service provider identified in Section D (CMA) or Section E (DSA) completes this section.

Record of Time — For each day when a service was provided, enter the time in and time out for the service provider.

Enter the time of day and include a for a.m. or p for p.m. Service providers may also document the time in and out with military time. Example: time in – 9:00p, time out – 10:30p or time in – 21:00, time out – 22:30.

Time must be recorded per the following:

Service Category 40 and 40B, Pre-Enrollment Assessment Fees —

  • Case Management Services — Full Assessment, Service Code 40 — The CMA records the time spent daily completing the pre-enrollment assessment process. The last calendar date recorded in the Record of Time section must be before the IPC effective date documented on Item 11 on Form 3621, CLASS and CFC Individual Plan of Care, Page 1.
  • Case Management Services — Partial Assessment, Service Code 40 — The CMA records the time spent daily until the date the applicant, person or legally authorized representative (LAR) informs the case manager they do not want CLASS services or it is determined the applicant is ineligible to receive CLASS services.
  • Direct Services Agency — Full Assessment, Service Code 40B — The DSA records daily the time spent completing the pre-enrollment assessment process. The last calendar date recorded in the Record of Time section must be the same date as Item 66, Date Signed by Reviewer, of Form 8578, Intellectual Disability/Related Condition Assessment, and before the IPC effective date documented on Item 11 on Form 3621, CLASS and CFC Individual Plan of Care, Page 1.

Note: HHSC enters into the Claims Management System (CMS) the last calendar day entry documented in the Record of Time section and the appropriate amount authorized for CMA and DSA pre-enrollment assessment fees.

Section G — Certification

Signature — Applicant, Person or LAR and Date (mm/dd/yyyy) — The applicant’s, person’s or LAR’s signature and date is optional. The applicant, person or LAR may sign and date Form 3625 to indicate that the services were provided and are accurate. This signature does not replace the requirement to have a timekeeper verify and approve the accuracy of the information.

Signature — Person Delivering Service/Date (mm/dd/yyyy) — The service provider who provided the service documented on the form signs and dates the form. The service provider must not sign and date the form before providing the service. For nursing services, the nurse must include credentials.

If the service provider who delivered the service is not available to sign and date the form, document the reason(s) in the Comments section. The timekeeper must sign and date the form after verifying the accuracy of the information on Form 3625. If the person delivering the service is the timekeeper, another designated timekeeper must sign and date Form 3625.

Form 3625 must not be signed or dated by the service provider before delivering the service.

Signature — Timekeeper and Date (mm/dd/yyyy) — After the service provider makes the last entry on the form, a staff person other than the service provider must sign and date the form as a timekeeper. The timekeeper’s signature verifies the accuracy of the information on the form. Verification must be completed before submitting a claim for the service.

Note: Claims must not be submitted for reimbursement before obtaining both the service provider and timekeeper signatures.

All signatures must be documented per the requirements outlined in 26 TAC 52.109.