VIII. Service Authorization and Prior Approval

Helping Families. Supporting Communities. Empowering Individuals.

General Requirements

DHS must authorize all waiver services. Waiver services may not be initiated for an individual before an award letter or written authorization from the DHS Division of Developmental Disabilities is received. The Department is not financially liable for services prior to the effective date of the award letter/written authorization, including meeting all of the terms and conditions stated in the award letter.

Providers must submit the application information packets to the PAS/ISSA agency. PAS/ISSA agencies must submit application packets for the requested services to the Region Facilitator when requesting service authorization. Providers and PAS/ISSA agencies should address questions about service authorization to the Region Facilitators and Representatives.

The application packets include:

Providers electronically transmit the following additional information to DHS Central Office prior to service authorization:

  • The PAS/ISSA agency must transmit the determination that the individual meets the waiver eligibility criteria. The effective date on the Reporting of Community Services (ROCS) system is the date the determination was made as documented on the Determination of Developmental Disability and Associated Treatment Needs (DDPAS-5).

    Note: DHS will not process fee-for-service bills for payment unless this information is transmitted timely, the SSN is correct and the effective date of the service authorization is on or before the service date on the bill.

  • Providers must complete and transmit client case information in the Reporting of Community Services (ROCS) system.

    Note: The provider must transmit acceptable client case information in ROCS before any fee-for-service programs may be paid.

Providers must complete the following forms at the time of initial service authorization and maintain them in the individual's file:

Prior Approval Requirements by Service Type

Some waiver services (Supported Employment, Adult Day Care, At Home Day Program, Other Day Program, Temporary Intensive Staffing, Occupational Therapy, Physical Therapy, Speech Therapy, Adaptive Equipment, Assistive Technology, Vehicle Modifications and Home Accessibility Modifications, and Crisis Services) have additional prior approval requirements. Prior approval requirements for each of these service types are detailed below and on the DHS web site, please see Becoming New Developmental Disability Provider

The Department will mail an award letter or a denial letter with appeal rights with the results of its consideration of the prior approval request. The letters are sent to the participant, case manager/Service Facilitator, and ISSA agency.

  1. Supported Employment

    Participants in the Adult Waiver seeking waiver Supported Employment Program funding must first apply at the local district office of the DHS Division of Rehabilitation Services (DRS) to determine if they qualify for federal Vocational Rehabilitation (VR) funding. At the time of formal application for Vocational Rehabilitation funding, individuals should provide the VR counselor with documentation of their developmental disability, including the functional limitations caused by their disability.

    If approved by the DRS counselor, the federal Vocational Rehabilitation program funds necessary short-term supported employment services. Only individuals for whom federal Vocational Rehabilitation funding is not available and individuals who have exhausted Vocational Rehabilitation funding for Supported Employment may request waiver funding for needed Supported Employment services.

    Requests for waiver Supported Employment Program (SEP) funding must be submitted to Network staff and must include documentation that Vocational Rehabilitation funding for the individual is not available. Documentation may take one of two forms:

    • Documentation from the DRS counselor that the individual is denied Vocational Rehabilitation services.
    • Documentation from the DRS counselor that the individual needs to transition from short-term Vocational Rehabilitation-funded services to extended/long term services and that short-term Vocational Rehabilitation-funded services are being terminated.
  2. Adult Day Care, At Home Day Program and Other Day Program

    Requests for prior approval for Adult Day Care, At Home Day program, and Other Day programs must be submitted to Region staff. The prior approval requests must include:

    1. An explanation of why the individual is appropriate for and needs these services, including diagnoses, age, health/medical issues and behavioral issues, if any.
    2. An explanation of why Developmental Training, Supported Employment or Regular Work/Sheltered Employment program options are not appropriate, including the individual's special needs that cannot be met by a traditional day program.
    3. Names of providers that were contacted and the reasons that each provider gave for declining to serve the individual. If applicable, include reasons why the individual or the individual's guardian rejected day programs.
    4. For At Home Day Program, an individual program plan that describes the services the individual will receive. The plan should provide a detailed weekly schedule that includes the time staff are directly working with the individual. If the individual has been rejected for or refuses to attend traditional day services, the plan should include goals that would transition the individual into an appropriate day program.
    5. For Other Day Program, the identity of the service provider, a general program plan, a description of the services to be provided to the individual and the qualifications of the entity providing the services.
    6. Statement of support for the request from the PAS/ISSA agency.
  3. Temporary Intensive Staffing

    Prior approval requests submitted to the Region Facilitator must include documentation of the individual's behavioral or medical needs for which Temporary Intensive Staffing is required.

  4. Physical Therapy, Occupational Therapy and Speech Therapy

    The Medicaid State Plan covers some therapy services for Medicaid beneficiaries. These services typically include assessments and short-term restorative services.

    Adult Waiver participants may be eligible to receive additional long-term habilitative therapy services under the Waiver when prior approved. Therapy authorizations under the waiver are generally continued across state fiscal years as long as the individual needs and is receiving the service.

    1. Therapy Services Received Under the Medicaid State Plan

      The Medicaid State Plan, in addition to the Waiver Program, covers the following therapy services for Medicaid beneficiaries of all ages:

      • Therapy evaluations as needed for individuals who are enrolled in Medicaid without prior approval. The Medicaid State Plan enrolled therapist does the evaluation and submits the bill directly to the Department of Healthcare and Family Services (HFS) according to HFS procedures.
      • Ongoing therapy services that are restorative in nature, such as those needed after an injury or hospitalization or other specific cause to restore the individual to a previous level of functioning. Prior approval from the HFS Bureau of Comprehensive Health Services is required before the Department of Healthcare and Family Services (HFS) will pay bills for ongoing physical therapy, occupational therapy and speech therapy services.

      Questions about HFS Medicaid State Plan requirements and procedures should be directed to the HFS Bureau of Comprehensive Health Services at (217) 782-5565 or on the HFS website. Copies of the manuals for therapists that contain instructions and sample forms are available upon request from the HFS Provider Participation Unit at (217) 782-0538.

    2. Prior Approval Requirements for Therapy Services Received Under the Adult DD Waiver

      Waiver-funded physical therapy, occupational therapy and speech therapy services require prior approval from the Division of DD. The provider must submit the prior approval request to the Network Facilitator.

      The provider may not initiate waiver-funded physical therapy, occupational therapy or speech therapy services for an individual before receiving written confirmation of service authorization. Questions about Division of DD service authorization should be directed to the Region Facilitators or Region Representatives.

      A waiver prior approval request for up to 26 hours of therapy per state fiscal year must include:

      1. A completed and signed copy of the Medicaid Waiver Therapy Prior Approval Request form.
      2. A signed and dated evaluation completed by a licensed physical therapist, occupational therapist or speech therapist. The evaluation must identify needed services and the reasons the individual needs the services because of chronic conditions related to his/her developmental disability. If HFS is terminating the individual from HFS-funded restorative services because the individual is making no further progress, the evaluation should include this information and a copy of the HFS denial of further services should be attached.
      3. A copy of the physician's therapy order.
      4. A HFS denial, only if the Division initially denied the requested therapy services as restorative and referred the individual to HFS. In such cases, the therapist may resubmit prior approval requests with documentation that the HFS has denied the services under the Medicaid State Plan.

      A waiver prior approval request for up to 52 hours of therapy per state fiscal year must include:

      1. A completed and signed copy of the Medicaid Waiver Therapy Prior Approval Request form.
      2. A signed and dated evaluation completed by a licensed physical therapist, occupational therapist or speech therapist. The evaluation must identify needed services and the reasons the individual needs the services because of chronic conditions related to his/her developmental disability. If HFS is terminating the individual from HFS-funded restorative services because the individual is making no further progress, the evaluation should include this information and a HFS denial of further services should be attached.
      3. A letter from the physician describing the individual's needs and expected improvement due to the additional hours to justify why 26 hours of therapy are insufficient.
      4. A Department of Healthcare and Family Services (HFS) denial, only if the Division initially denied the requested therapy services as restorative and referred the individual to HFS. In such cases, the therapist may resubmit prior approval requests with documentation that the HFS has denied the services under the Medicaid State Plan.
      5. A copy of the current, complete, signed and dated individual service plan.
    3. Adaptive Equipment, Assistive Technology, Vehicle Modifications and Home Accessibility Modifications

      Waiver coverage for adaptive equipment, assistive technology, vehicle modifications and home accessibility modifications require prior approval. Equipment should not be purchased and work should not begin until an award letter has been received. The Department is not liable for any financial obligation for items purchased without an award letter or for funding beyond the amount in the award letter or from a vendor or contractor that is not enrolled as a Medicaid waiver provider.

      The Department is a possible source of funding, but the Department is not a party to the contract for services between the participant, guardian and family and the vendor. Therefore, Department is not responsible for accepting the equipment or modifications from the vendor or contractor, nor is the Department responsible for enforcement of any warranty or the quality of workmanship provided by a contractor or vendor.

      1. Prior Approval Criteria

        1. General Approval Criteria

          Adaptive equipment, assistive technology, vehicle modifications and home accessibility modifications must meet general criteria for prior approval. Requested equipment or modifications must:

          • Be essential to address needs caused by the developmental disability and must be for direct benefit of the individual.
          • Be necessary to prevent institutional placement, to deinstitutionalize an individual or to enable the individual to participate in specialized habilitative services for individuals with developmental disabilities. Quality of life enhancements that are not essential are not covered.
          • Increase independence and decrease reliance on supports and services provided by either paid or unpaid workers.
          • Be usable by the individual throughout the year and may not be for back-up or secondary use, except for back-up generators if necessary to ensure continuous operation of disability-related electrical equipment.
          • Be the most cost effective way to address the developmental disability-related needs of the individual.
          • Be recommended as part of the individual service plan and be approved by the planning team.

          General utility items or items perceived by the general taxpaying public as a luxury are excluded from coverage. See Section III.E for examples of items that are not covered.

        2. Additional Adaptive Equipment and Assistive Technology Approval Criteria

          In addition to the above general criteria, approval for adaptive equipment or assistive technology is also subject to the below criteria. Adaptive equipment and assistive technology must:

          • Not be covered under the State Medicaid Plan. Waiver adaptive equipment is not available to meet medical needs such as requests related to diabetes, allergies, obesity or respiratory problems requiring oxygen and special medical equipment or supplies.
          • Be based on an assessment by a physician, physical therapist, occupational therapist or speech therapist, as appropriate to the disability, if DHS requests assessment information.
          • Be the property of the individual or the individual's family and be for the individual's use.
        3. Additional Home Accessibility Modifications Approval Criteria

          In addition to the above general criteria, approval for home accessibility modifications is also subject to the following criteria:

          • Modifications must be in accordance with state or local building codes.
          • For CILA homes, modifications must comply with the requirements of the CILA Start-Up Guidelines.
          • Homes must be the primary residence of the individual and the individual is expected to live in the home for a period of at least one year.
          • For rented or leased homes, individuals must have written permission of the landlord to make the modifications.
        4. Additional Vehicle Modifications Approval Criteria

          In addition to the above general criteria, approval for vehicle modifications is also subject to the following criteria:

          • The vehicle must be the property of the individual or the individual's family and be for the individual's use.
          • The vehicle must be the individual's primary vehicle for basic transportation.
          • Vehicles that are five or more years old must have sufficient remaining useful life to justify the investment of the requested modifications.
          • Vehicle modifications will not be funded more than once in a five-year period. Replacement or repair of broken or worn out individual components of a lift mechanism may be considered on a case-by-case basis within the five-year period when not covered by a warranty or insurance.

          Vehicle modifications do not include necessary general vehicle repairs, such as struts, shock absorbers, electrical system, tires, engine, transmission, muffler or, brakes or body work.

      2. Prior Approval Request Submission Requirements

        1. General Prior Approval Request Submission Requirements

          The prior approval request must be submitted to your Region Facilitator and must include all of the following:

          A completed and signed copy of Adaptive Equipment / Assistive Technology / Home and Vehicle Modification Request Cover Sheet

          A detailed description of the adaptive equipment, assistive technology, home accessibility modifications or vehicle modification and the reason they are necessary and related to the developmental disability. The description must address both specific and general criteria set forth above.

          Two detailed cost estimates. Itemized costs must be given for all items requested or for each part of the modifications. For example, separate or itemize the costs for a roll-in shower, door widening and grab bars, as opposed to providing one estimate for bathroom accessibility remodeling.

          Documentation that the responsible case manager or Service Facilitator and the Individual Service and Support Advocate (ISSA) have reviewed and recommend approval of the item.

          A completed and signed copy of Adaptive Equipment / Assistive Technology / Home and Vehicle Modification Request Cover Sheet

          A detailed description of the adaptive equipment, assistive technology, home accessibility modifications or vehicle modification and the reason they are necessary and related to the developmental disability. The description must address both specific and general criteria set forth above.

          Two detailed cost estimates. Itemized costs must be given for all items requested or for each part of the modifications. For example, separate or itemize the costs for a roll-in shower, door widening and grab bars, as opposed to providing one estimate for bathroom accessibility remodeling.

          Documentation that the responsible case manager or Service Facilitator and the Individual Service and Support Advocate (ISSA) have reviewed and recommend approval of the item.

          • A completed and signed copy of Adaptive Equipment / Assistive Technology / Home and Vehicle Modification Request Cover Sheet
          • A detailed description of the adaptive equipment, assistive technology, home accessibility modifications or vehicle modification and the reason they are necessary and related to the developmental disability. The description must address both specific and general criteria set forth above.
          • Two detailed cost estimates. Itemized costs must be given for all items requested or for each part of the modifications. For example, separate or itemize the costs for a roll-in shower, door widening and grab bars, as opposed to providing one estimate for bathroom accessibility remodeling.
          • Documentation that the responsible case manager or Service Facilitator and the Individual Service and Support Advocate (ISSA) have reviewed and recommend approval of the item.
          • A Medicaid waiver enrollment packet for the equipment vendor or contractor, if not already enrolled. If the vendor or contractor is not yet known, the enrollment packet may be submitted after the award letter is received.

            Note: Payment will not be made until the provider has completed the waiver enrollment process and HFS has processed the enrollment form.

          • Payee Designation/Authorization Form, if a payee agency will transmit bills using ROCS. If the vendor or contractor is not yet known, the payee designation form may be submitted after the award letter is received, but before the payee agency submits bills.
          • If approved, the Department will specify the lowest bid and least expensive option available. Please refer to Section VIII for additional information on purchasing more expensive items or modifications.
        2. Additional Prior Approval Submission Requirements for Adaptive Equipment, Assistive Technology or Vehicle Modifications

          In addition to the general submission requirements above, prior approval requests for adaptive equipment, assistive technology or vehicle modifications must also include:

          • Information on whether the item is to be purchased, rented or repaired, and whether it is a new item or a replacement for a currently owned item.
          • Vehicle modification requests on vehicles that five or more years old must include an evaluation by a mechanic that determines the estimated remaining useful life of the vehicle.
          • A written denial from the Department of Healthcare and Family Services (HFS) for communication devices and wheelchairs. DHS may also require a written denial from HFS for other adaptive equipment or assistive technology.
          • A physician's order or an assessment by a physical therapist, occupational therapist or speech therapist, as appropriate to the disability and the item, if requested by DHS.
        3. Additional Prior Approval Submission Requirements for Home Accessibility Modifications

          In addition to the general submission requirements above, prior approval requests for home accessibility modifications must also include:

          • Information on whether the individual owns, rents or leases the home.
          • Information on whether the modification is being done to an existing structure or if the home is all new construction.
          • Written permission from the landlord. The written permission must include a statement that the landlord understands the modifications are permanent and that the Department bears no responsibility for the home modification or for returning the building to its previous condition. The permission should also stipulate that the landlord will not change the rent due to the modifications.
          • Proof of home ownership if the home modification request exceeds $5,000. For agency-owned or controlled homes, see the CILA Start-Up Guidelines for additional information.
    4. Temporary Assistance

      Prior approval requests must describe the reasons for the temporary absence or incapacity of the persons who normally provide unpaid care. Absence or incapacity of the primary care giver must be due to a temporary cause, such as hospitalization, illness, injury, or other emergency situation. Temporary Assistance is not available for care giver absences for vacations, educational or employment-related reasons, or other non-emergency reasons.