Long Term Care Online Portal Reference Guide. Waiver Programs Staff. for DADS Community Services. v

Transcription

1 Long Term Care Online Portal Reference Guide for DADS Community Services Waiver Programs Staff v

2 Contents General Security Information...4 Links to additional information...4 Accessing the LTC Online Portal...5 Power Search...6 Power Search by Type of Form...7 Power Search by Document Locator Number...10 Power Search by Client (i.e., Individual) First Name/Last Name...11 Power Search by Social Security Number...12 Saved Searches (Creating a Worklist)...15 Search Limitations...15 My Saved Searches...16 Assessment Status...17 Common Statuses...17 Internal to External Status Crosswalk...18 Letters...19 Letter Types...19 Client Letters to the Individual...19 Letters to the Physician...19 Letter Search...20 Performing a Letter Search...20 Community Services Workflow...22 Community Services Workflow Tasks...23 Locating Assessments in the CS Workflow...23 Using Power Search...23 Using My Searches...24 Workflow Buttons...25 Workflow System Actions...25 Utilization Review Assessments v

3 Criteria...26 How to Submit a Utilization Review Assessment...26 System Actions...29 Limitations...30 Locating UR Assessments...30 Corrections...32 Criteria for Making Corrections...32 How to Submit a Correction...32 System Actions...33 Inactivations...35 Criteria for When an Inactivation Can Be Performed...35 How to Inactivate an Assessment...35 System Actions...35 Appendix...37 Client Pending Denial Letter (CBA) Example...38 Client Overturn Final Approval Letter (CBA) Example...39 Client Final Denial Letter (CBA) Example...40 Doctor Pending Denial Letter (CBA) Example...41 Doctor Overturn Final Approval Letter (CBA) Example...42 Doctor Final Denial Letter (CBA) Example...43 v

4 General Security Information Security clearance and access to needed Long Term Care (LTC) Online Portal functions are based on the role of the worker, allowing them to complete the tasks associated with job performance. Workers receive the security profile which their job requires. The options available on the blue navigational bar are based on the security profile assigned to each user. Some options on the blue navigational bar may not be available for all users. Refer to the LTC Online Portal General Security Permissions Guide for more information. Links to additional information The following links provide additional information about the LTC Online Portal and assessments. LTC Community Services Waiver Programs Workshop User Guide Medical Necessity and Level of Care Assessment (MN/LOC) Item by Item Guide 4 v

5 Accessing the LTC Online Portal To access the LTC Online Portal: 1. Open Internet Explorer or preferred web browser. 2. Enter in the address field. 3. Click the Enter button. The LTC Online Portal page will display the Power Search screen initially. v

6 Power Search Once the worker has accessed the LTC Online Portal, they will be taken to the Power Search screen. This is an internal (Texas Medicaid & Healthcare Partnership [TMHP] and state) screen that can be used to search all forms and assessments, regardless of their status. Note: Providers may use the Form Status Inquiry (FSI) tool for monitoring the status of assessments that have been successfully submitted. Refer to the LTC Community Services Waiver Programs User Guide at Materials/LTC%20Waiver%20Programs/30%20LTC%20Waivers%20Online%20Portal%20User%20Manual.pdf for additional information regarding FSI. The Power Search can be performed in a number of ways. By Type of Form (must include a date range) By document locator number (DLN) only (no other information needed) By Client (i.e., Individual) name (must include a date range) By Social Security number ([SSN] must include a date range) By Medicaid number (must include a date range) 6 v

7 Power Search by Type of Form From the Power Search screen: 1. Choose the assessment type from the Type of Form drop-down box (e.g., Waiver 2.0: Medical Necessity and Level of Care Assessment, Waiver 3.0: Medical Necessity and Level of Care Assessment, etc.). 2. The information on the screen changes based on the type of assessment chosen. 3. Enter a From Date and To Date. These are required fields (as indicated by the red dots). Enter the date manually or click the calendar icon to choose the date. The date must be entered in the MM/DD/YYYY format. v

8 4. To narrow the search results, enter specific client (i.e., individual) or vendor information. Information does not have to be entered into all fields. Note: The screen shot below shows the client and vendor entry fields when Waiver 3.0: Medical Necessity and Level of Care Assessment is chosen from the Type of Form drop-down box. 5. You can choose additional criteria to narrow the search results. This is an optional step. Click the box next to the applicable criteria in the Additional Criteria area of the screen Note: The screen shot below shows the available criteria when Waiver 3.0: Medical Necessity and Level of Care Assessment is chosen from the Type of Form drop-down box. 8 v

9 6. Click the Search button at the bottom of the screen. 7. A list of results is shown at the bottom of the screen. To sort the results by a particular column, click the column header. Note: If only one assessment result is found, the assessment will be displayed on the screen. A results list will not be displayed. 8. To display the details of an assessment, click a number in the DLN column. v

10 Power Search by Document Locator Number From the Power Search screen: 1. Enter the DLN in the DLN field. 2. Click the Search button at the bottom of the screen. 3. Once the search is complete the document will display at the bottom of the screen. 10 v

11 Power Search by Client (i.e., Individual) First Name/Last Name From the Power Search screen: LTC Online Portal Reference Guide 1. Optionally, you can choose to search the assessment type from the Type of Form drop-down box. This will limit the search results to only that assessment. Leave the Type of Form box blank to list all assessments for the client (i.e., individual). If you leave the Type of Form drop-down box blank, you will be required to enter a contract number. 2. If you choose an assessment type in Step 1, the information on the screen changes based on the type of assessment chosen. 3. Enter the From Date and To Date. These are required fields (as indicated by the red dots). Enter the date manually or click the calendar icon to choose the date. The date must be entered in the MM/DD/YYYY format. 4. Enter the client s (i.e., individual s) last name in the Last Name field. 5. Enter the client s (i.e., individual s) first name in the First Name field. 6. You can choose additional criteria to narrow the search results. This is an optional step. Click the box next to the applicable criteria in the Additional Criteria area of the screen. 7. Click the Search button at the bottom of the screen. v

12 8. A list of results is shown at the bottom of the screen. To sort the results by a particular column, click the column header. Note: If only one assessment result is found, the assessment will be displayed on the screen. A results list will not be displayed. 9. To display the details of an assessment, click a number in the DLN column. Power Search by Social Security Number From the Power Search screen: 1. Optionally, you can choose the assessment from the Type of Form drop-down box. If you choose an assessment, the search results will be limited to only that assessment. Leave the Type of Form drop-down box blank to search for all forms. 2. The information on the screen changes based on the type of assessment chosen. 3. Enter the From Date and To Date. These are required fields (as indicated by the red dots). Enter the date manually or click the calendar icon to choose the date. The date must be entered in the MM/DD/YYYY format. 12 v

13 4. Enter the client s (i.e., individual s) Social Security number (SSN) in the SSN field. LTC Online Portal Reference Guide 5. You can select any of the options in the Additional Criteria area of the screen by clicking the box next to the criterion name. Selecting from the Additional Criteria options will limit the search results. v

14 6. Click the Search button at the left side of the bottom of the screen. 7. A list of results is shown at the bottom of the screen. To sort the results by a particular column heading, click the column header link. Note: If only one assessment result is found, the assessment will be displayed on the screen. A results list will not be displayed. 8. To display the document for one of the results, click a number in the DLN column. 14 v

15 Saved Searches (Creating a Worklist) LTC Online Portal Reference Guide Instead of having to recreate searches, workers can create a work list with the search criteria that they will be using on a regular basis. From the Power Search screen: 1. To search for an assessment type, choose from the Type of Form drop-down box. 2. The information on the screen changes based on the type of assessment. 3. Enter a From Date and a To Date. These are required fields (as indicated by the red dots). Enter the date manually or click the calendar icon format. to choose the date. The date must be entered in the MM/DD/YYYY 4. To narrow the search results, enter client (i.e., individual s) or vendor information. Information does not have to be entered into all fields. Required fields are indicated with red dots. 5. Click to check the box next to the applicable criteria in the Additional Criteria area of the screen. 6. In the Search Options section of the screen, enter a search name in the Search Name: field. 7. Click the Save Search button at the bottom of the screen. Search Limitations There are search limitations to be aware of, these include: From Date and To Date are required fields. Search results are limited to 250 rows. Data is stored on the LTC Online Portal for seven years. v

16 My Saved Searches The My Searches feature provides a way to access and use previously saved and defined searches which were created by the system administrator. 1. Click the My Searches link on the blue navigational bar. 2. The My Searches screen opens. The Defined Searches are listed first. The searches you have saved are listed under the My Saved Searches heading. 3. Click the Open link to open the predefined Power Search screen. The fields on the Power Search screen will contain the information saved when the search was created. 4. Click the Work Results link to open the first document to be worked. The next document to be worked will display once you have completed the current document or you have skipped the current document. 16 v

17 Assessment Status LTC Online Portal Reference Guide Assessment Status denotes the current status of the assessment in the workflow. Common Statuses While there are many different statuses an assessment can have, there are some statuses that are more common than others. Below are the common statuses seen by Claims Management System (CMS) Coordinators, Case Managers, and Department of Disability and Aging Services (DADS) nurses. Community Services (CS) Processed/Complete Issues resolved, process and complete the assessment. Pending More Info More information is needed in order for TMHP to approve the assessment. Pending Denial The assessment has been reviewed for Medical Necessity (MN) by a TMHP RN. The information did not support MN. The provider has up to 21 calendar days to supply additional information. Invalid/Complete Review assessment, determine invalid. Escalated Needs Review The assessment has been escalated to a DADS case manager for review. Submitted to CS Assessment has been submitted for manual review. v

18 Internal to External Status Crosswalk The status message of an assessment seen by TMHP and DADS staff can be different from the status the provider sees. Below is a table showing what the internal System Facing status is compared to the corresponding external Provider Facing status. Note: This listing includes only those statuses applicable to Waiver 3.0 forms. System Facing (Internal) Status Name Appealed Doctor Review Corrected CS Processed/Complete CS Provider Action Required Denial Inventory Doctor Overturn Denied Escalated Needs Review Fair Hearing (FH) Appeal Denied FH Doctor Appeal Denied Form Inactivated Identification (ID) Invalid Invalid/Complete Med ID Check Inactive Medicaid ID Pending Medical Necessity (MN) Approved MN Denied Out-of-State Medical Doctor (MD)/Doctor of Osteopathy(OD) License Invalid Out-of-State RN License Invalid Overturn Doctor Review Expired Overturned Doctor Review Pending Denial Pending Doctor Review Pending Fair Hearing Pending MD/DO License Verification Pending More Info Pending Nurse Review Pending RN License Verification Processed/Complete Service Authorization System (SAS) Request Pending Submitted to CS Provider Facing (External) Status Name Appealed Corrected Processed/Complete Provider Action Required Pending Denial (need more information) Denied Escalated Needs Review Denied Appealed Form Inactivated ID Invalid Invalid/Complete Med ID Check Inactive Medicaid ID Pending Approved Denied Out-of-State MD/DO License Invalid Out-of-State Registered Nurse (RN) License Invalid Denied Overturned Doctor Review Pending Denial (need more information) Pending Denial (need more information) Appealed Pending MD/DO License Verification Pending More Info Pending Review Pending RN License Verification Processed/Complete SAS Request Pending Submitted to manual workflow 18 v

19 Letters Letter Types There are several different letters which are automatically generated by the LTC Online Portal as a result of a status change. Examples of the letters generated by the LTC Online Portal are available in the Appendix of this job aid. Client Letters to the Individual The following letters are automatically sent to the client (i.e., individual) based on the status change listed for each letter. Client Denial Letter Pending Doctor Review set to status MN Denied status. Client Overturn Denial Letter MN Denied set to status Overturn Doctor Review Expired. Doctor Overturn Denied set to status Overturn Doctor Review Expired. Client Overturn Approval Letter MN Denied set to status MN Approved. Doctor Overturn Denied set to status MN Approved. Overturned Doctor Review set to status MN Approved. Appealed Doctor Review set to status MN Approved. Pending Fair Hearing set to status MN Approved. Letters to the Physician The following letters are automatically sent to the physician based on the status change listed for each letter. Physician Denial Letter Pending Doctor Review set to status MN Denied. Physician Overturn Denial Letter MN Denied set to status Overturn Doctor Review Expired. Doctor Overturn Denied set to status Overturn Doctor Review Expired. Physician Overturn Approval Letter MN Denied set to status MN Approved. Doctor Overturn Denied set to status MN Approved. Overturned Doctor Review set to status MN Approved. Appealed Doctor Review set to status MN Approved. Pending Fair Hearing set to status MN Approved. v

20 Letter Search The Letters feature provides a way to find letters which have been created for a client (i.e., individual) and the client s (i.e., individual s) physician. Note: Only users with the necessary security profile have access to the Letter Search function. Performing a Letter Search 1. Click the Letters link on the blue navigational bar to open the Letter Search Page. 2. Enter information in the fields on the page. There are no required fields, but the more information entered for the search, the more specific the results will be. You can also search by the DLN to access a particular letter. If you choose to search by DLN, only the DLN must be entered. The date field does not need to be entered for a search by DLN. 20 v

21 3. Enter a From Date or To Date. Enter the date manually or click the calendar icon to choose the date. The date must be entered in the MM/DD/YYYY format. 4. Click the Search button at the bottom of the screen. 5. The results of the search are shown at the bottom of the screen. The results display is limited to 100 records. If there are more than 100 records found, only the first 100 records are displayed. If the record being searched for is not displayed in the first 100 records, then enter additional search criteria to further limit the search. If there are no results, the No Results Found message is displayed. Note: If only one letter is found or a DLN was used, the letter will be displayed on the screen. A results list will not be displayed. 6. To view the details of an individual letter, click the View Letter link in the first column of the results. v

22 Community Services Workflow At the point a form reaches the Community Services (CS) workflow, a number of circumstances could have taken place such as: After the original assessment has processed to the Service Authorization System (SAS) a request for inactivation was submitted. CMS Synch Error status was returned from SAS (any form type). All forms in the transitional status of Reject by SAS will be submitted to the CS Manual Workflow for review and determination. The CS worker will access their workflow through the Power Search. This screen will allow staff to work through any forms in a status that require their manual intervention. They will have the option to either select one of the four available actions, or to skip the form. Skipped forms will remain in the work list until someone takes action on them. Once a form is placed in the CS workflow, the CS worker has five possible actions: 1. Processed/Complete: Resolve issue and update status to Processed/Complete. 2. Pending More Information: Work form until a point where more information is needed. 3. Invalid/Complete: Review form and determine the form sent is invalid. 4. Resubmit to SAS: Resolve issue related to form (such as out of synch with CMS) and update status to continue submission to SAS. 5. Escalated Needs Review: The assessment has been escalated to a DADS case manager for review. 22 v

23 Community Services Workflow Tasks 1. Once a CS worker resolves the issue, the assessment can be updated on the necessary subsystems and SAS by the CS worker manually. When the CS worker has completed the manual changes, the CS worker will click the Processed/Complete button and the assessment will be updated on the LTC Online Portal. Once in a Processed/Completed status, no further action is required. 2. When an assessment is in the CS Workflow and the CS worker determines more information is needed, the CS Worker can click the Pending More Info button. An assessment will remain in Pending More Info status for up to 15 calendar days while awaiting additional information. If the information is not received, it will be automatically set to status Escalated/Needs Review. If more information is received within the 15-day period, CS workers are able to update the status as appropriate. 3. When a CS worker reviews an assessment and determines it should not have been submitted (e.g., an assessment that is not allowed or is submitted beyond an appropriate timeframe) and no updates need to be made, they can click the Invalid/Complete button. The status will be updated in the LTC Online Portal. 4. Once the CS worker resolves the issue by modifying the record(s) that are causing the form to be rejected by SAS, they can click the Resubmit to SAS button to have the LTC Online Portal send the information to SAS again. At this point SAS will process the assessment based on form type and reason. 5. If an assessment is placed in a status inaccurately, CS workers are able to change the status to Escalated-Needs Review. This action can take place on an assessment that is inaccurately placed in a status of Processed/Complete or Invalid/Complete. Once the status is escalated, the CS worker has the ability to update the assessment and return it to the correct status. The CS worker can change the status to Processed/Complete if worker resolves the issues with the assessment. The CS worker can change the status to Invalid/Complete if the assessment is determined to be invalid (e.g., if the individual already has another valid assessment). The CS worker can resolve the issues with the assessment and set to status Submit to SAS to allow the assessment to continue to process in SAS normally (e.g., if an overlapping record exists in SAS). 6. The same options as in number 5 above are available in the Pending More Information status. There is no time restriction here and no further escalation process. Locating Assessments in the CS Workflow Using Power Search 1. Choose the Type of Form from the drop-down box. 2. Enter the From Date and the To Date. 3. Enter any client (i.e., individual) or vendor information to narrow the search. 4. Enter any additional criteria. v

24 5. Click the Work List button at the center of the screen. 6. The LTC Online Portal starts building a list of assessments for the work list. 7. Once the next assessment is located, the assessment is displayed on the screen. Using My Searches Workers can also access the workflow list using the My Searches feature. My Searches allows you to save commonly used search queries. For detailed information on how to create and save searches to My Searches, refer to the My Searches section of this document. 1. Open the LTC Online Portal. 2. Click the My Searches link on the blue navigational bar. 3. From the My Searches screen, click the Work Results link. 24 v

25 Workflow Buttons LTC Online Portal Reference Guide When the assessment opens, several workflow buttons are available in the yellow Form Actions bar: Processed/Complete Pending more information Invalid/Complete Resubmit to SAS Workflow System Actions The following system actions occur for each of the workflow buttons. Processed/Complete The assessment is updated in SAS. Once in a Processed/Complete status, nothing else needs to happen. Pending more information Assessment remains in status Pending more information for up to 15 calendar days. If information is not received, the status automatically changes to Escalated/Needs Review. If more information is received, the assessment is put back into the workflow. Invalid/Complete Once this status is selected, the status is updated on the LTC Online Portal and no further action needs to be taken. Resubmit to SAS This action sends the assessment back to SAS to be reprocessed. SAS will then reprocess the assessment based on assessment type and reason. v

26 Utilization Review Assessments The DADS Utilization Review (UR) nurses may complete and submit the purpose code 1, Utilization Review assessments. Only a UR nurse has the ability to submit UR assessments and corrections to UR assessments. When a UR nurse submits a UR assessment, the data from the original (parent) assessment is copied to the new (child) assessment and the nurse is able to update fields. Criteria The criteria for performing a UR assessment are listed below: All UR assessments require: User must have UR nurse security profile Must be within 365 days of: MN approved date MN denied date MN denied statuses Entry into Pending Denial status Limited to MN/LOC Assessments with reason: Initial assessment Significant change in status assessment Annual assessment Form status must be: Processed/Complete CS Processed/Complete Service Group must be 3 or 18 Note: Service Group 3 is Community Based Alternatives (CBA); Service Group 18 is Medically Dependant Children s Program (MDCP). How to Submit a Utilization Review Assessment 1. Use Power Search to locate the desired assessment for the UR. For information on how to use Power Search, see the Power Search section in this document. 2. Once the search is complete, select the desired assessment from the search results by clicking a number in the DLN column. 3. The assessment is displayed on the screen. 26 v

27 4. Click the UR Review Form button on the yellow Form Actions bar. 5. The UR assessment is created as a child assessment. The parent assessment is changed to Corrected status and the child assessment is assigned a new DLN. The child assessment does not have a status until it is submitted. The parent DLN is shown at the top of the child assessment and a different Resource Utilization Group (RUG) may be assigned. The field, S2f (Purpose Code), is changed automatically to 1. Utilization Review. 6. The following fields must be entered before the UR assessment form can be submitted. Section A A Assessment Date Section Z Z Signature of RN Completing Assessment Section LTCMI S5d - DADS RN Last Name S5e - DADS RN License# S5f - DADS RN License State S5g DADS RN Signature Date 7. Once the assessment is completed and the fields listed above have been completed, click the Submit Form button in the bottom right corner of the screen. v

28 If the assessment is submitted successfully, a DLN is assigned and the following message is displayed. If the assessment did not submit successfully, an error message box is shown at the top of the form. Each error message explains why the error occurred. Click the error message links to go to the specific box on the form which is causing the error. If the link is for a section, click the section link. Once in the correct section, an error message explaining the exact error in the section is displayed. 28 v

29 System Actions Disabled Fields on Child Assessment Some fields are disabled on the UR (child) assessment. The following is a list of fields disabled (non-editable) on the UR assessment. A0500C Legal Name of Individual Last Name A0600A Social Security Number A0600B Medicare Number A0700 Medicaid Number A0310A Reason for Assessment Z0500B Date Assessment Completed S2a DADS Vendor/Site ID Number S2b Contract/Provider Number S2c Service Group S2d NPI Number S5a HHA RN Last Name S5b HHA RN License # S5c HHA RN License State S5h PACE RN Last Name S5i PACE RN License # S5j PACE RN License State S5k HMO RN Last Name S5l HMO RN License # S5m HMO RN License State Fields Cleared on Parent Assessment The Certification fields in the LTCMI section of the parent assessment are cleared when the child assessment is created. The following fields are cleared from the parent assessment. S5d DADS RN Last Name S5e DADS RN License # S5f DADS RN State S5g DADS RN Signature Date Notes Added to UR Assessment When a UR Review is submitted, a note is added to the UR assessment containing the following information: Time Date Parent DLN v

30 Notes Added to Parent Assessment When a UR assessment is submitted, a note is added to the parent assessment with the following information: Time Date User name UR assessment DLN Limitations A subsequent UR assessment can be performed on a UR assessment by a user with a UR nurse security profile. Locating UR Assessments From the Power Search link: 1. Use the Type of Form drop-down box to choose the Waiver 3.0 Medical Necessity and Level of Care Assessment or Waiver 2.0 Medical Necessity and Level of Care Assessment. 2. The information on the screen changes based on the type of assessment chosen. 3. Enter the From Date and To Date. These are required fields (as indicated by the red dots). Enter the date manually or click the calendar icon to choose the date. The date must be entered in the MM/DD/YYYY format. 4. To narrow the search results, enter client (i.e., individual s) or vendor information in the fields provided. 5. In the Additional Criteria Area of the screen, click the checkbox next to 1. Utilization Review under Purpose Code. 30 v

31 6. Select any of the options in the Additional Criteria area of the screen by clicking the box next to the criterion name. The screen shot below shows the available options when the Waiver 3.0: Medical Necessity and Level of Care Assessment form is chosen. 7. Click the Search button at the bottom of the screen. 8. A list of results is shown at the bottom of the screen. To sort the results by a particular column header, click the column header link. Note: If only one assessment result is found, the assessment will be displayed on the screen. A results list will not be displayed. 9. To display the assessment for one of the results, click a number in the DLN column. v

32 Corrections If incorrect data is submitted on the MN/LOC Assessment, an internal user with a security profile associated with a Vendor/Contract number can submit a correction within 14 calendar days of the original submission by clicking the Correct this form button. Within 14 calendar days an unlimited number of corrections can be made. However, not all fields are correctable (see a list of disabled fields that cannot be corrected in the System Actions section for UR assessments). Examples of incorrect data include: Individual is listed as a male, but is actually a female. Individual s diagnosis indicates diabetes, but the individual actually has hypoglycemia. Criteria for Making Corrections Must be made within 14 days from the date TMHP received the original (parent) assessment Exception: Corrections to UR assessments do not have any time limit The assessment must not be in any of the following statuses: Corrected Form Inactivated SAS Request Pending Invalid/Complete How to Submit a Correction 1. Locate the desired document using the Power Search feature. 2. Click the View Detail link. 3. Click the Correct this form button. 4. Complete only the fields that need correction. 5. Click the Submit Form button. 32 v

33 System Actions When corrections are made to an assessment, the original assessment (parent) is set to status Corrected and a new assessment (child) DLN is assigned, creating the parent/child DLN relationship. The information in the parent (original) assessment is copied to the child assessment. The child assessment has a unique DLN number. The parent DLN is shown on the child assessment. The new child assessment replaces the parent assessment. The parent assessment is also updated to reflect a correction has been made to the assessment. v

34 Notes Added to Assessment When an assessment is corrected, a note is added to the parent assessment containing the following information: Time Date User name Child DLN 34 v

35 Inactivations Assessments may need to be inactivated when a document needs to stop being processed in the workflow, or when incorrect information has been entered into a field that cannot be corrected (e.g., Medicaid Number, Individual Name). MN/LOC Assessments can be inactivated through the LTC Online Portal by first retrieving the assessment using the Power Search feature. Criteria for When an Inactivation Can Be Performed MN/LOC 3.0 Assessments and UR assessments No time limit. Only original submitter can inactivate the form unless the DADS user has internal submitter rights associated with a Vendor/Contract number. Form must have been previously submitted. Forms with the following statuses cannot be inactivated: Form Inactivated Corrected SAS Request Pending How to Inactivate an Assessment 1. Find the document using the Power Search feature. 2. Click the View Detail link. 3. Click the Inactivate Form button. 4. When the dialog box that displays Are you sure you want to Inactivate this form? appears: a. Click the OK button to inactivate the assessment. or b. Click the Cancel button if you do not want to inactivate the assessment. System Actions Once the assessment is inactivated, it will set to status Form Inactivated. The assessment cannot be reactivated; however, it can still be used as a template. v

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37 Appendix v

38 Client Pending Denial Letter (CBA) Example Long Term Care Unit P.O. Box Austin, TX CBA CLIENT PENDING DENIAL LTR Revised 4/09 «prntdate» «rfname» «rlname» «rstreet» «rcity», «rstate» «rzip» DLN: «DLN» Dear «rfname» «rlname», Recently, you applied for the Community Based Alternatives (CBA) Waiver program through the Texas Department of Aging and Disability Services (DADS). Texas Medicaid & Healthcare Partnership (TMHP), under contract with Health and Human Services Commission (HHSC), determines medical necessity for these waiver programs. Based on review of the assessment and medical information submitted to TMHP on your behalf, TMHP has determined that you do not need the services of a licensed nurse on a regular basis; therefore, you do not meet the medical necessity criteria for the CBA Waiver program. You have the right to submit more information to support your need for the services of a licensed nurse on a regular basis. If you feel your doctor or a different doctor may have more medical information that supports your need, ask your doctor to send the information to TMHP explaining your medical condition(s) and the nursing or in-home services you need related to it. Please have them fax this information directly to TMHP at within 14 business days from the date of this letter. If we do not receive information that supports the need for a licensed nurse, your case may be denied. You will receive separate notification from your DADS CBA Case Manager telling you about the final eligibility decision for the waiver program you applied for. Sincerely, TMHP LTC Unit If you believe you have been discriminated against because of race, color, national origin, age, sex, disability, political beliefs, or religion, you may lodge a complaint by writing immediately to the Civil Rights Office, Texas Health and Human Services Commission, 701 West 51 st Street, Suite 104W, Austin, TX v

39 Client Overturn Final Approval Letter (CBA) Example Long Term Care Unit P.O. Box Austin, TX CBA CLIENT OVERTURN FINAL APPROVAL LTR Revised 4/09 «prntdate» «rfname» «rlname» «rstreet» «rcity», «rstate» «rzip» DLN: «DLN» Dear «rfname» «rlname», Texas Medicaid & Healthcare Partnership (TMHP) has reviewed the additional medical information recently submitted on your behalf and has determined that it supports your need for the services of a licensed nurse on a regular basis. The former notification of pending denial for medical necessity has been overturned and you have been granted a medical approval to pursue available benefits through the waiver program that you applied for, specifically, the Community Based Alternatives (CBA) Waiver program. A CBA Case Manager will be contacting you regarding your waiver program eligibility process. Sincerely, TMHP LTC Unit NOTE: If you requested a Fair Hearing and you want to request a withdrawal from the Fair Hearing, please contact your Department of Aging and Disability Services (DADS) case manager as soon as possible. If you believe you have been discriminated against because of race, color, national origin, age, sex, disability, political beliefs, or religion, you may lodge a complaint by writing immediately to the Civil Rights Office, Texas Health and Human Services Commission, 701 West 51 st Street, Suite 104W, Austin, TX v

40 Client Final Denial Letter (CBA) Example Long Term Care Unit P.O. Box Austin, TX CBA CLIENT FINAL DENIAL LTR Revised 4/09 «prntdate» «rfname» «rlname» «rstreet» «rcity», «rstate» «rzip» DLN: «DLN» Dear «rfname» «rlname», Texas Medicaid & Healthcare Partnership (TMHP) has reviewed the medical information submitted on your behalf and has determined that the services of a licensed nurse are not needed on a regular basis. As you were previously notified, you do not need the services of a licensed nurse on a regular basis; therefore, you do not meet the medical necessity criteria for the Community Based Alternatives (CBA) Waiver program. This decision does not affect your eligibility for other Medicaid benefits. You will receive separate notification from your Department of Aging and Disability Services (DADS) CBA case manager telling you about the final eligibility decision for this waiver program. Sincerely, TMHP LTC Unit If you believe you have been discriminated against because of race, color, national origin, age, sex, disability, political beliefs, or religion, you may lodge a complaint by writing immediately to the Civil Rights Office, Texas Health and Human Services Commission, 701 West 51 st Street, Suite 104W, Austin, TX v

41 Doctor Pending Denial Letter (CBA) Example Long Term Care Unit P.O. Box Austin, TX CBA DOCTOR PENDING DENIAL LTR Revised 4/09 «prntdate» Dr. «dfname» «dlname» «dstreet» «dcity», «dstate» «dzip» «rfname» «rlname» DLN: «DLN» Dear Dr. «dfname» «dlname», Recently, your patient applied for the Community Based Alternatives (CBA) Waiver program through the Texas Department of Aging and Disability Services (DADS). Texas Medicaid & Healthcare Partnership (TMHP), under contract with Health and Human Services Commission (HHSC), determines medical necessity for these waiver programs. Based on review of the assessment and medical information submitted to TMHP on your patient s behalf, TMHP has determined that your patient does not need the services of a licensed nurse on a regular basis. If you have more medical information that supports your patient s need for the services of a licensed nurse on a regular basis, send the information to TMHP explaining your patient s medical condition(s) and the need for nursing or in-home services. Assistance with performing activities of daily living alone is not sufficient to qualify for this program. Please fax this information directly to TMHP at within 14 business days from the date of this letter. If we do not receive information that supports the need for a licensed nurse, your patient s case may be denied. If you have questions regarding the criteria for medical necessity or the CBA program, you may contact TMHP at and select option 2. Sincerely, TMHP LTC Unit If you believe you have been discriminated against because of race, color, national origin, age, sex, disability, political beliefs, or religion, you may lodge a complaint by writing immediately to the Civil Rights Department, Health and Human Services Commission, 701 West 51 st Street, Suite 104W, Austin, TX v

42 Doctor Overturn Final Approval Letter (CBA) Example Long Term Care Unit P.O. Box Austin, TX CBA & ICM DOCTOR OVERTURN FINAL APPROVAL LTR Revised 4/09 «prntdate» Dr. «dfname» «dlname» «dstreet» «dcity», «dstate» «dzip» DLN: «DLN» Dear Dr. «dfname» «dlname», Based on the medical information you recently submitted for your patient, «rfname» «rlname», we have determined that the need for skilled nursing services is medically necessary. The former notification of pending denial for medical necessity has been overturned and your patient has been granted a medical approval to pursue available benefits through the Community Based Alternatives Waiver Program or the Integrated Care Management Waiver program for which your patient applied. If you have any further questions, please contact Texas Medicaid & Healthcare Partnership (TMHP) at the telephone number listed above. Sincerely, TMHP LTC Unit If you believe you have been discriminated against because of race, color, national origin, age, sex, disability, political beliefs, or relig ion, you m ay lodge a com plaint by writing im mediately to the Civil Rights Department, Health and Human Services Commission, 701 West 51 st Street, Suite 104W, Austin, TX v

43 Doctor Final Denial Letter (CBA) Example Long Term Care Unit P.O. Box Austin, TX CBA & ICM DOCTOR FINAL DENIAL LTR Revised 4/09 «prntdate» Dr. «dfname» «dlname» «dstreet» «dcity», «dstate» «dzip» DLN: «DLN» Dear Dr. «dfname» «dlname», In considering the medical information you recently submitted for your patient, «rfname» «rlname», we have determined that the need for skilled nursing services is not medically necessary; therefore, we are unable to approve your patient for the Community Based Alternatives Waiver program or the Integrated Care Management Waiver program. This information was reviewed by a Texas Medicaid & Healthcare Partnership (TMHP) physician. Sincerely, TMHP LTC Unit If you believe you have been discriminated against because of race, color, national origin, age, sex, disability, political beliefs, or religion, you may lodge a com plaint by writing immediately to the Civil Rights Department, Health and Human Services Commission, 701 West 51 st Street, Suite 104W, Austin, TX v

44 The LTC Online Portal Job Aid for DADS Community Services Waiver Programs Staff is produced by TMHP Training Services. Contents are current as of the time of publishing and are subject to change.