This form must be used to summarize Community Living Assistance and Support Services (CLASS) services provided to an individual 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 do not need to be summarized on this form:
- In-Home Respite Services; and
- Community First Choice Personal Attendant Services/Habilitation provided as a direct service to the individual. This does not include DSA 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
The CLASS CMA or DSA timekeeper uses the form to demonstrate verification of the accuracy of the information on the form prior to submitting a claim for the service.
Funds paid to the CLASS CMA or DSA for a submitted service claim may be recouped by HHSC if Form 3625 is not completed correctly or if the information documented on the form does not support the billed claim.
Each CLASS case manager or DSA service provider will use a separate form to document the service provided to an individual.
- Only one individual receiving CLASS services per form.
- Only one service provider per form - hours worked by two or more different service providers should not be placed on the same form.
- Only one service type per form – for example, physical therapy 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/CFC Documentation of Services Delivered form must be accompanied by contact notes that include:
- the date of contact;
- the description of case management provided;
- the 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;
- the person with whom the contact occurred; and
- the 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 – for example, if a nurse completes an assessment.
This form and the accompanying supporting documentation must be maintained per record retention requirements documented in the CLASS Provider Manual and 40 TAC Section 49.307, whichever is greater at the time the record is created.
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 provider of the service.
Written approval must be obtained from HHSC LTSS Policy if a different primary source billing document is to be used instead of Form 3625 and instructions.
Section A — Individual’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. Individual’s Name — Enter the individual's full name as shown on their Medicaid card, their Social Security card, or the full name as provided by the individual on the individual's Form 3621, Individual Plan of Care. If the individual's name is different on any or all documentation, use the name as shown on the Medicaid card.
3. Medicaid No. — Enter the Medicaid number of the individual receiving the CLASS program service. If the form is being completed for a pre-assessment and the individual 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 as it appears on their Social Security card. For enrolled CLASS individuals, leave this item blank.
Section B — Provider Agency Information: Case Management Agency (CMA)/Direct Services Agency (DSA)
5. Agency Type — Check the appropriate box for Case Management Agency (CMA) or Direct Services Agency (DSA).
6. Agency Name — Enter the name of the case management agency or direct services agency.
7. Contract No. — Enter the provider number assigned by the Texas Health and Human Services Commission (HHSC).
Section C — Pre-Enrollment Assessment Fees: CMA or DSA
This section is to be completed by the CMA or DSA 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 IPC that is authorized by HHSC.
- Submit to HHSC the completed Form 3621, CLASS/CFC – Individual Plan of Care, along with a 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 the completed Form 3657, Pre-Enrollment Assessment, which should be submitted with the completed Form 3625.
9. DSA Services — Check the Full Assessment box if billing is being submitted for the completion of a DSA Pre-Enrollment Assessment.
Submit to HHSC the completed Form 3625 along with completed 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 applies to all case management services excluding pre-enrollment assessments.
Section E — Direct Services
This section is to be completed by the DSA only.
12. Method of Delivery (Check only one) — Check the box that represents the method by which services will be provided to the individual.
- Employee — Name of Employee — Check the box marked "employee" 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 the reason why the employee is not available to sign in the "Comments" section. The timekeeper must sign and date the form after verifying the accuracy of the information on Form 3625.
- Subcontractor: Check the box marked “Subcontractor” if the person who is 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 signature line "Person Delivering Services."
- Name of 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 signature line "Person Delivering Services."
- If the professional contracted by the DSA under a subcontract is not available to sign and date Form 3625, the DSA must document the reason why the service provider is not available to sign in the "Comments" section. The timekeeper must sign and date the form after verifying the accuracy of the information on Form 3625.
- Direct Purchase — May only be used for 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, excluding specialized therapies. For example, Physical Therapy or Nursing services.
14. For Service Code 42 A-F, name specialized therapy – Enter the specialized therapy that billing is being submitted for. For example, Massage Therapy or Music Therapy.
15. Service Code — Enter the service code that corresponds to the authorized service documented on the form. Service codes for each authorized CLASS service are listed on the Individual’s IPC. Additional information is listed on the LTC Bill Code Crosswalk.
16. 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.
17. Requisition Fee (if applicable to services documented in box 14) — Enter the authorized requisition fee amount that corresponds to the specialized therapy documented in Field 14, if applicable. For example, 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.
18. 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.
19. 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
This section is to be completed by the service provider identified in Section D(CMA) or Section E (DSA).
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 by using military time. Example: time in – 9:00p, time out – 10:30p or time in – 21:00, time out – 22:30.
Time should be recorded in accordance with 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, individual or legally authorized representative (LAR) informs the case manager they do not want CLASS services or the applicant is determined 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, Individual or LAR and Date (mm/dd/yyyy) — The applicant’s, individual’s or LAR’s signature and date is OPTIONAL. The applicant, individual 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 prior to 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, then another designated timekeeper must sign and date Form 3625.
Form 3625 must not be signed or dated by the service provider prior to 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 as verification of the accuracy of the information on the form. Verification must be completed prior to submitting a claim for the service.
Note: Claims must not be submitted for reimbursement prior to obtaining both the service provider and timekeeper signature.
All signatures must be documented in accordance with the requirements outlined in 40 TAC 49.305.