Form 8611, Pre-Enrollment MHM Authorization Request

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Documents

Effective Date: 11/2015

Instructions

Updated: 11/2015

Procedure

In the Home and Community-based Services (HCS) waiver program, the Pre-Enrollment Minor Home Modification (MHM) Authorization Request must be completed to obtain approval for the procurement of a pre-enrollment MHM prior to the effective date of an individual's enrollment. The HCS service coordinator is required to submit Form 8611 to the Texas Health and Human Services Commission (HHSC) Program Enrollment/Utilization Review Unit for review during the pre-enrollment process when the applicant's service planning team determines the need for procurement of an MHM is indicated prior to the applicant being able to receive services in the program. Form 8611 must be accompanied by applicable clinical assessments and a minimum of three bids for the requested pre-enrollment MHM, when required in accordance to the HCS procurement process for MHM in the HCS Program Billing Guidelines. The total cost of the pre-enrollment MHM and the pre-enrollment MHM assessments will be included on this form in the items section.

Discussion prompts included in these instructions are provided as an optional resource to guide the individual's service planning team through the discussion of needed MHM types and amounts:

  • What are the applicant's conditions/limitations that can be addressed through provision of an MHM?
  • Are these conditions/limitations a barrier for the applicant's movement into the community if they are not addressed prior to the applicant's planned move?
  • Has a licensed therapist/professional indicated a possible medical or therapeutic need for a pre-enrollment MHM assessment and/or a pre-enrollment MHM? Will the MHM assist or increase the individual's ability to perform activities of daily living?
  • Will the MHM assist the individual to perceive, control or communicate with the environment?
  • Is the MHM available through Medicaid or another third-party resource?

Detailed Instructions

The HCS program provider is responsible for providing all needed information for the completion of Form 8611 and applicable supporting documentation to the HCS service coordinator for submitting the request to HHSC for review.

Check the box of planned residential environment upon discharge from the facility — Check the box that applies: Own home/family home, 3-person home, 4-person home or Host home/companion care.

HCS Provider Name — Enter the name of the program provider.

Component Code — Enter the program provider component code.

Contract No. — Enter the program provider contract number.

HCS Provider Contact — Enter the name of the person who will act as the contact for the program provider. The program provider contact should be someone who can answer questions about the services being requested.

Area Code and Telephone No. — Enter the area code and telephone number for the person who will act as the contact for the program provider.

Area Code and Fax No. — Enter the fax area code and telephone number for the person who will act as the contact for the program provider.

Email Address — Enter the email address of the program provider contact.

LIDDA Name — Enter the name of the Local Intellectual and Developmental Disability Authority (LIDDA).

Component Code — Enter the LIDDA component code.

LIDDA Service Coordinator — Enter the name of the service coordinator who will act as the contact for the LIDDA.

Area Code and Telephone No. — Enter the area code and telephone number of the service coordinator.

Area Code and Fax No. — Enter the fax area code and telephone number for the service coordinator.

Email Address — Enter the email address of the LIDDA service coordinator.

Individual Information

Individual Name (Last) — Enter the individual's last name.

Individual Name (First) — Enter the individual's first name.

Client Assignment and Registration (CARE) System ID No. — Enter the individual's CARE identification number.

Medicaid No. — Enter the individual's Medicaid number (if available).

Date of Birth — Enter the individual's date of birth.

Planned Community Address — Enter the planned community address.

Location Code — Enter the location code.

List of Requested Pre-Enrollment MHM and Assessments  — Enter a description of the item or items requested, the amount of each item requested and the cost of the assessment.

HHSC Use Only

Check the box if HHSC agrees to pay and the items requested are authorized for purchase.

Check the box if HHSC does not agree to pay and the items requested are not authorized for purchase.

HHSC Reviewer — Enter the name of the HHSC reviewer who reviewed the request.

Signature – HHSC Reviewer — The HHSC reviewer signs the request.

Date — Enter the date the HHSC reviewer completed the review of the exception request.

Instructions to Program Provider and LIDDA

The copy of the completed Form 8611 indicating HHSC review results will be sent by HHSC to both the program provider and service coordinator. The program provider and the service coordinator must maintain a copy of the request in the individual's record.