Form 8728, ICF/IID Augmentative Communication Device (ACD) System Authorization

Instructions

Updated: 12/2009

Purpose

To provide required documentation for prior authorization of an augmentative communication device (ACD) system for an eligible Medicaid resident in the Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID) program in accordance with 40 Texas Administrative Code §9.228, Augmentative Communication Device System.

To document an assessment specific to a resident's needs for an ACD system, the assessment must be conducted by a licensed speech therapist, contain required information from the supplier and be certified as medically necessary by the resident's physician.

Note: A licensed speech therapist is a speech-language pathologist, as defined by Texas Occupations Code, Title 3, Subtitle G, Section 401.001.

To document the request for an ACD system including:

• a complete description of the specific ACD system;
• any attached accessories not included in the base price;
• any modifications to existing equipment (such as a wheelchair) that need to be made in conjunction with the operation of the ACD system; and
• retail prices for the individual components (including justification for components that would be considered modifications, customizations or adaptations).

Procedure

The applicable section of the form must be completed and:

• signed/dated by the licensed speech therapist who provided the required assessment information and documented the requirements of the requested ACD system;
• certified by the ACD system supplier; and
• certified by the resident's physician related to the medical necessity of the requested ACD system.

The completed form must be submitted by the ICF/IID provider from which the resident is receiving ICF/IID services.

The ACD system must not be purchased prior to the provider receiving authorization from the Texas Health and Human Services Commission (HHSC) and confirming the authorization through a Medicaid Eligibility Service Authorization Verification.

• All required information must be documented on the form and in the format provided in accordance with instructions for the completion of the form and policies related to the authorization process.
• Requested information in all sections must be completed prior to submission to HHSC.
• Incomplete forms will not be accepted.
• Attachment 1, Statement of Benefits, must be followed.

When to Prepare

The required information must be prepared and submitted when an ICF/IID provider will be seeking authorization and subsequent reimbursement for the purchase of an ACD system for a Medicaid-eligible resident.

Note: It is each provider's responsibility to check the resident's monthly Medicaid statement at the time each service is provided to verify eligibility. Any services provided while the resident is not eligible cannot be reimbursed by HHSC.

Form Retention

The original form must be kept by the provider for no less than five years and 90 days after purchase, or as long as the resident maintains ownership of the ACD system until all litigation, claims or audit findings are resolved, whichever is longer.

General Instructions

The form must be legible. Print or type the requested information for each part unless a signature is indicated. If any area of the form is illegible, the form will not be processed.

In any part of the form where a signature is requested, an original signature is required. Signature stamps, date stamps and electronic signatures will not be accepted. If any of the required original signatures are missing, the submission will be considered incomplete.

Documentation to support medical necessity of the service or equipment must be current, signed and dated by a physician ((Medical Doctor or Doctor of Osteopathic Medicine) before the ACD system can be considered for prior authorization.

Enter "Not Applicable" or N/A for sections that do not apply to the specific question or statement.

For help completing this form, call HHSC Institutional Policy Development and Support at 512-438-5208.

Note: Any section, statement or question on the form for which specific instructions are not provided is considered to be self-explanatory.

Complete the form and submit to HHSC by:

• faxing to:
  512-438-2180, Attn: Institutional Services — ACD Submissions; or
• mailing to:
  Institutional Services — ACD Submissions
  Mail Code W-535
  P.O. Box 149030
  Austin, TX 78714-9030

The provider must keep a copy or the original form in the provider's records.

Detailed Instructions

Is this submission a request to transfer the authorization of an ACD system to a new provider? — Check "Yes" or "No" (if "Yes," complete only Sections A, B and F and submit the form).

Section A: Resident-Related Identifying Information

www.tmhp.com/Manuals//TMPPM/Output/Frameset.html for eligibility information.

When a request for an ACD system is approved or denied, letters are sent to the resident and the person identified as the resident's legally authorized representative (LAR), using the corresponding addresses entered in this section.

The provider completes and verifies the following information in Section A:

Resident's Name — Enter the name of the resident for which the request is being made, as it appears on the resident's monthly Medicaid statement.

Resident's Medicaid No. — Enter the resident's Medicaid number as it appears on his monthly Medicaid statement.

Date of Birth — Enter the resident's date of birth as it appears on his monthly Medicaid statement.

Is resident age 21 or older? — If the resident is 21 years of age (or older) at the time the form is completed, check Yes. If the resident is under the age of 21, check No.

Resident's Address — Enter the street address of the home in which the resident lives and receives mail.

City, State, ZIP Code — Self-explanatory.

Resident's Legally Authorized Representative (LAR) Name — Enter the name of the LAR, if applicable. Note: An LAR is a person authorized by law to act on behalf of the resident and may include a legal guardian, power of attorney holder, parent of a minor or managing conservator of a minor. If the resident does not have an LAR, do not enter a name in this space.

Resident's LAR Telephone No. — Enter the LAR's area code and telephone number.

Resident's LAR Address — Enter the street address where the LAR receives mail.

City, State, ZIP Code — Self-explanatory.

Section B: ICF/IID Provider Identifying Information

The provider completes and verifies the information in Section B. The provider must designate and document a primary contact for the request.

When a request for an ACD system is denied, approved or when HHSC may need to request additional information regarding a request, letters are sent to the provider using the identified contact person and address contained in Section B.

Provider Name — Enter the name of the resident's current ICF/IID provider that is submitting the request for the ACD system.

Provider HHSC Contract No. — Enter the provider's HHSC contract number.

Provider NPI No. — Enter the provider's National Provider Identification (NPI) number.

Provider Address — Enter the mailing address that will be used by HHSC to send a letter of approval or denial of the submitted request.

City, State, ZIP Code — Self-explanatory.

Provider Primary Contact Name and Position — Enter the name and position/job title of the provider's staff who will be the point of contact for the requested ACD system.

Provider Telephone No. — Enter the area code and telephone number where the provider's staff can be reached.

Provider Fax No. — Enter the area code and fax number.

Section C: Licensed Speech Therapist Identifying Information and ACD Assessment

The licensed speech therapist, physical therapist or occupational therapist must complete the information in Section C, including the ACD assessment.

Therapist's Name and Title — Enter the name of the therapist who is administering the ACD assessment.

Therapist's Telephone No. — Self-explanatory.

Therapist's Fax No. — Self-explanatory.

Employed by the ICF/IID Provider? — Check “Yes” if the therapist administering the assessment is an employee of the provider. Check “No” if the therapist is contracted by the provider to administer the assessment.

Therapist's Employer Name — Enter the name of the provider, company or person that employs the therapist.

Mailing Address — Enter the address for the therapist's employer.

City, State, ZIP Code — Self-explanatory.

ACD Assessment (Completed by Therapist)

This section is filled out by the therapist and all parts must be complete and legible.

I. Diagnosis (DX) Relevant to the need for the ACD System — The therapist enters the International Classification of Diseases (ICD-9) Code, Brief Description and Medically Necessary (MN) Justification for the Item(s).

II. Resident Auditory Functionality Status Statement — The therapist gives a detailed statement describing the resident's current level of auditory functioning (aided and unaided).

III. Description and Name of Specific ACD System Recommended — The therapist completes A. through F. to assist in recommendations and the approval of the ACD system request. The therapist should:

1. Give the name and a complete description of the ACD system being recommended, including all components. The therapist includes the manufacturer's name and ACD model number.
2. Describe all accessories, mounting devices and/or modifications necessary for the resident's use.
3. Describe any anticipated changes, modifications or upgrades the ACD system will require and the projected time frames (short and long term).
4. Provide information on alternative ACD systems that were considered for recommendation with a comparison of capabilities.
5. Describe other types of equipment that will be used in conjunction with the ACD system (for example, wheelchair, walker, etc.).
6. Explain how the ACD system will be operated (for example, hand, chin, etc.).

IV. Description of How the ACD System Will Meet the Specific Needs of the Resident — The therapist completes A. through C. to assist in recommendations and the approval of the ACD system request. The therapist should:

1. Explain the justification of the recommended ACD system and each accessory, and include why the recommended ACD system is the most appropriate, least costly alternative and how it will benefit the resident.
2. Provide a description of the limitations of the resident's current aided and unaided modes of communication.
3. Describe the cognitive skills and physical abilities of the resident to be able to use the recommended ACD system.

V. Description of Specific Training Needs for Use of the ACD System — The therapist completes A. through F. to assist in recommendations and the approval of the ACD system request. The therapist should:

1. Describe the settings (for example, residential, vocational, educational, etc.) in which the person will be using the ACD system and how much time is spent in each setting.
2. Explain how the ACD system will be implemented and integrated into the above settings.
3. Provide a treatment plan (in the space provided or attached separately) that includes training in the basic operation of the ACD system to ensure optimal use by the resident and, if appropriate, the resident's caregiver, including a therapy schedule for the resident to gain proficiency in using the ACD system.
4. Explain the resident's speech-language goals and how the recommended ACD system will assist in achieving the goals.
5. Identify all assistance/support needed and available to the resident to use and maintain the ACD system.
6. Indicate “Yes” or “No” if a therapist from the educational/vocational setting has been involved in the assessment, if applicable, and provide the name of the therapist and telephone number.

VI. Certification by Therapist Completing the Assessment — The therapist prints his name, provides his license number, and signs and dates the form to certify the information provided is true and accurate.

Section D: Supplier and Item Information

The ACD system supplier completes all information in Section D.

Supplier's Business Name and Telephone No. — Enter the business name and telephone number with area code.

Supplier's Representative Completing Form and Fax No. — Enter the name of the person who will be the primary contact and the fax number with area code.

Address and City/State/ZIP Code — Enter the complete address for the supplier.

ACD System Name and Model Number — Enter all applicable identifying information.

Item No., Local Medicaid Code, Description of Item, Quantity, Total Price — Self-explanatory.

Supplier Certification and Acknowledgement — The supplier's representative signs and dates the form and provides the NPI number, if the supplier is a contracted Medicaid or Medicare durable medical equipment (DME) provider. If the supplier does not have an NPI, the field is left blank.

Note: The supplier does not get a copy of the decision letter for approval/denial of the ACD system from HHSC. The provider must give a copy of the full and partial approval/denial notices to the supplier so that the supplier is aware of the specific decision made by HHSC.

Section E: Physician-Related Information/Prescription

ICD-9 Code, Brief Diagnosis (DX), Describe How DX is Related to Medical Necessity for the ACD System (if applicable). — The resident's physician completes the information.

Resident Auditory Functionality Status Statement — The physician provides a statement regarding the current auditory functionality status of the resident.

Physician's Attestation of Medical Necessity for the Requested ACD System — The physician completes each field, including the:

• date the resident was last seen by the physician;
• duration of need for the ACD System (months/years);
• physician's signature and date; and
• physician's license number and Texas Provider Identification (TPI) number.

Section F: ACD System Authorization Transfer Request and Medical Professional Attestation

This section must be completed for submissions in which the:

• Yes box was checked on the top of page one indicating the submission is a request to transfer the authorization of an ACD system to a new provider; and
• original request for authorization of the ACD system was approved, but the resident has moved to a new ICF/IID provider before the ACD system could be delivered by the supplier.

I. Enter the resident's name as it appears on the resident's monthly Medicaid statement and the date of transfer to the new provider.

Printed Name of Provider's Primary Contact and Signature — Self-explanatory.

Title of Provider's Primary Contact, Telephone No. and Signature Date — Self-explanatory.

II. ACD System Medical Professional Certification — The resident's physician, occupational therapist, physical therapist or registered nurse completes each field and signs the form.

Printed Medical Professional's Name and Title — Self-explanatory.

Medical Professional's Signature and Date — Self-explanatory.

Once this section is complete, the provider must fax or mail only Page 1 and the page with Section F to HHSC by:

• faxing to:
  512-438-2180, Attn: Institutional Services — ACD Submissions; or
• mailing to:
  Institutional Services — ACD Submissions
  Mail Code W-535
  P.O. Box 149030
  Austin, TX 78714-9030

Note: Upon approval of the transfer of authorization to the new provider, only the authorization of the ACD system will be transferred to the new provider. The authorization for any assessments will remain with the provider that originally acquired the authorization for the ACD system.