Attachment A provides more detailed information than is included on the Individual Program Plan (IPP) regarding proposed skilled and specialized therapies included on an Individual Plan of Care (IPC).
When to Prepare
The case manager prepares Attachment A when skilled or specialized therapy is proposed by the service planning team. Attachment A must be completed by the appropriate professional.
Attachment A must be submitted to HHSC program staff in conjunction with Form 8606, Individual Program Plan, when skilled or specialized therapies are proposed on an individual's IPC.
The case management agency (CMA) and direct services agency (DSA) must keep this form according to record retention requirements documented in the CLASS Provider Manual.
Individual's Name — Enter the name of the individual as it appears on the individual's Form 8606.
Medicaid No. — Enter the individual's nine-digit Medicaid number as it appears on the individual's Form 8606.
Case Management Agency (CMA) Agency Name — Enter the individual's nine-digit Medicaid number as it appears on the individual's Form 3621, CLASS Individual Plan of Care (IPC).
CMA Vendor No. — Enter the CMA's vendor number.
Requested Skilled or Specialized Therapy — Enter the type of therapy that is being proposed as it appears on Form 8606.
List non-waiver resources that were exhausted — List any non-CLASS resources that were accessed and exhausted for the proposed skilled or specialized therapy.
Case Manager Signature — Case manager signs the form.
Date — Enter the date the case manager signs the form.
Diagnosis — Enter the individual's diagnosis that is related to the proposed service.
Brief description of need for services — Describe the individual's need for the proposed service.
Specific qualifying conditions requiring treatment — Describe the conditions relevant to the proposed service.
Interventions — Describe or attach the interventions planned with baseline data and goals and objectives outlined in observable and measurable terms. Include a plan for implementation and the scope, duration, amount, frequency and location of service.
Can components of the requested service be delivered by someone other than a therapist? — Check the appropriate box.
If no — Describe the components that require a licensed/certified professional.
Transferring Therapy Services — Describe a plan for transferring the skilled or specialized therapeutic services to a non-therapist and changing the role of the therapist to a supervisory role with the non-therapist.
Signature of Professional and Title — Provide the signature of the appropriate professional and title.
Date — Provide the date of appropriate professional's signature.
Printed Name of Professional — Print the name of the appropriate professional who signed the form.
Area Code and Telephone No. — Provide the appropriate professional telephone number.
License No. — If applicable, provide the license number for the appropriate professional.