AUTHORIZATION FOR ADDITIONAL BILLING FOR OPWDD INTENSIVE OR EXTENDED SEMP Billing Codes

Transcription

1 AUTHORIZATION FOR ADDITIONAL BILLING FOR OPWDD INTENSIVE OR EXTENDED SEMP Billing Codes Check One: The person has a job and additional hours are required in Extended SEMP (Complete Section 1 only) The person does not have a job and additional Intensive SEMP hours are requested (Complete Section 2 only) SEMP Agency Requesting Extension: SEMP Agency Provider Code: SEMP Program Code: DDRO: Name of Individual: TABS #: Date of SEMP Enrollment: Self Directed Services: Yes No Date Extended SEMP billing started (always July 1, 2015 or after): For OPWDD only Approved: Number of Hours Approved: Approval Number: Date Billing May Begin: Intensive Extended Reason: Best Interest of Person Changes in Job Responsibilities To Maintain Current Job Other: SECTION 1 EXTENDED Request for additional hours above 200 within 365 days. The 365 days (year) is based on the original enrollment date, if enrolled after 7/1/15 or 7/1/15, if enrolled prior. Business Name: Address: Wage: Title: Average Number of Hours Worked Weekly: Average percentage of work hours that require job coaching on the job: Is this an Integrated Work Setting? Yes No Date Job Began: Is this a Group Placement? Yes No Is this Temporary or Seasonal? Yes No 9/8/15 Page 1 of 5

2 Are the person s services funded by State SEMP (non waiver) through Limited Exception or other? Yes No If other describe the funding type: List 4 job duties: Is employer satisfied with individual s performance? Yes No During the last 365 days, did you bill Intensive SEMP for this person? Yes No When the person was FIRST enrolled in OPWDD Extended SEMP, they obtained the job through: (check one) ACCES VR OPWDD ETP (Employment Training Program) ESEMP Agency Obtained Job (did not use ACCES VR funds) Other: (explain) Approximately, how many of the total SEMP Extended Hours were used/projected needed in the following activities: ACTUAL NUMBER PROJECTED # Activity OF HOURS PROVIDED NEEDED Job customization and analysis Job coaching/planning/training at the job site Planning/training/development of skills off the job site Communication with existing employer Meetings/communication with family Meetings/communication with other support staff Travel Training Travel Time without the individual Travel Time with the Individual Documentation of the Delivery of SEMP services Other: TOTAL Does this job meet the individual s stated career goals? Yes No What is the individual s preferred job/career? Has the individual asked for a new job to be developed? Yes No 9/8/15 Page 2 of 5

3 Have you discussed career options with this individual? Yes No Describe any accommodations and natural supports that have been developed to assist the employee in this job position. Describe what other services (residential/clinical/other services supports) you will be seeking to assist this person in achieving greater independence on the job and to address potential job retention challenges. Describe how you have coordinated with other services (day hab/prevoc/community hab) to help this individual achieve greater independence on this job and to address potential job retention challenges. SECTION 2 INTENSIVE Request for additional hours above 250 within 365 days. The 365 days (year) is based on the original enrollment date, if enrolled after 7/1/15 or 7/1/15, if enrolled prior. Date Intensive Billing Started (always July 1, 2015 or after): Is this individual ACCEPTED in ETP? Yes No (If yes, you do not need to complete this form, check with the ETP supervisor) Check any of the following that apply: Completed and ACCES VR recommended OPWDD SEMP Completed ACCES VR closed no job found Discovery has been completed and documented through Other Services Date: Service: 9/8/15 Page 3 of 5

4 Other: (explain) Current Services: Day Hab Community Pre Voc Community Habilitation SEMP Residential Respite Site Base Prevoc Other: Are the person s services self direct? Yes No If yes, which type of self directed services? Self Hire Staff Agency Purchase Previous Services: Day Hab Community Pre Voc Community Habilitation SEMP Residential Respite Site Base Prevoc Other: Total hours spent since Intensive Billing began: Itemize how many hours of the total Intensive hours were spent/projected needed in the following activities: ACTUAL NUMBER PROJECTED # Activity OF HOURS PROVIDED NEEDED Vocational Assessment Person centered employment planning Job related discovery Training and systematic instruction prior to employment Job Development Planning/training/development of skills off the job site Development of soft skills and job retention strategies Meetings/communication with family Meetings/communication with other support staff Travel Training Travel Time without the individual Travel Time with the Individual Documentation of the Delivery of SEMP services 9/8/15 Page 4 of 5

5 Please justify why additional Intensive SEMP hours should be approved, and how future job development activities will be different than during the number of service hours previously approved. ***Additional information may be requested by OPWDD including but not limited to notes, discovery report, and other documents that would justify continued job development.**** OPWDD Intensive SEMP services are primarily focused on Job Development and Intensive Job Coaching. While some Discovery type services may be provided, these services are limited (unless other authorization is given) as OPWDD offers other services such as and Community Pre Voc where the focus is on preemployment activities and preparation for employment. Individuals in Intensive SEMP services are deemed to be in need of job development and intensive job coaching and NOT career exploration. The person signing this form is in agreement that the individual receiving Intensive OPWDD SEMP is not in need of significant pre employment services. Agency SEMP Manager (Printed): Phone Number: Approval Signature: Scan this form to This Form MUST be retained in your billing records/individuals file so that service hours/days above 200 hours or 250 hours within 365 days of beginning service date is AUTHORIZED by OPWDD. 9/8/15 Page 5 of 5