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12VAC30-122-80

12VAC30-122-80. Waiver approval process; authorizing and accessing services.

C.6. The providers, in conjunction with the individual and the individual's family/caregiver, as appropriate, and the support coordinator shall develop a plan for supports for each service.

a. Each provider shall submit a copy of his plan for supports to the support coordinator. The plan for supports from each provider shall be incorporated into the ISP. The ISP shall also contain the steps for mitigating any identified risks.

b. The support coordinator shall review and ensure the provider-specific plan for supports meets the established service criteria for the identified needs prior to electronically submitting the plan for supports along with the results of the comprehensive assessment and a recommendation for the final determination of the need for ICF/IID level of care to DMAS or its designee for service authorization. "Comprehensive assessment" means the gathering of relevant social, psychological, medical, and level of care information by the support coordinator that are used as bases for the development of the individual support plan.

c. DMAS or its designee shall, within 10 working days of receiving all supporting documentation, review and approve, suspend for more information, or deny the individual service requests. DMAS or its designee shall communicate electronically to the support coordinator whether the recommended services have been approved and the amounts and types of services authorized or if any services have been denied. If the service request is to be denied for a service that in both type and amount is currently authorized, DMAS or it’s designee shall communicate electronically to the support coordinator that the recommended services have been approved for a period of ninety (90).  In advance of resubmitting the service request, the team shall consider if there are other alternatives and/or provide additional justification for the request.  DMAS or it’s designee shall make a final determination upon receipt of a revised service request and if the service is denied instruct the support coordinator to provide appeal rights to the individual, or family/caregiver as approapriate.