Miscellaneous Quick Reference

 

Waiver Services: Supported Living, Residential Habilitation, Family Model Residential, Facility & Community Based Day, Supported Employment, Personal Assistance, Dental, Environmental Accessibility, Medical Residential, Individual Transportation, Behavior, PT, OT, SLP, RD, Nursing, Orientation & Mobility, and Vehicle Accessibility Mods – Vision is covered under the Arlington Waiver only

 

State-Funded Services:  Hospital Sitter, Establishment, MR housing, Emergency Housing, Other Health Medical, etc.

 

Circle of Support: consists of the person, his/her conservator, if applicable, and family members the person chooses to have there – There really should not be any “paid” providers in a circle of support, only those who are there for the person and not for a job.

 

Planning Team: consists of the entire circle of support plus any paid providers who work with the person.

 

Appeals:  TNCare Appeals – Once you receive a denial, you have 30 days to complete TNCare appeal form with information needed and make sure you justify why person needs the service.  Attach any information that may help you justify the service as well.  Send the form and the documentation into the office email. It will be faxed into TNCare.  TNCare has 21 days to review the appeal and make a decision. 

                DMRS Waiver Appeals – Once a service plan has come back denied, you ask person/family/conservator if they want to appeal.  They have 30 days to appeal once they received the denial letter.  If they do want to appeal, you complete the DMRS appeal form with all appropriate information and as much justification as you can.  Attach any documentation that may help get the denial overturned.  Send the appeal form and any documentation into the office email.  Your QA mentor will review it.  Once completed, they will get it to the service plan department so that it is processed.  The appeal is sent to DMRS, who in turn, also sends it to TNCare.  Once DMRS has it, they will review it again and have the opportunity to overturn their previous denial.  If they choose to uphold the original denial, they send a letter indicating that and TNCare takes over.  TNCare has 21 days to work the appeal.  Once they have made a decision, they issue a letter.  If TNCare overturns the denial, DMRS has to make sure the service is provided within 5 days.  If TNCare agrees with the denial, it will automatically be sent to the next level.  The person/family/conservator then has to decide if they want to carry it further.  They can stop the appeal process at any time.  That next level is the Administrative Law Judge.  This is a court hearing in front of a judge and the decision the Judge makes is final. 

(More detailed information about appeals can be found in the Provider Manual, Chapter 2, starting on Section 2:16.)

 

Delay In Service: Type 1 – Person needs a service and a provider can’t be found.  You have tried every listed provider and no one can provide the service for the person in that area.  For this, you must submit a service request to ask for the service.  You justify the need for the service in the amendment and fill in as much of the service plan page as you can (service needed, units needed, etc.)  The rest is left blank (ie. provider name, site name, etc.).  It is submitted to the Regional Office.  Upon approval, the Regional Office automatically files a delay in service on this. 

                             Type 2 – Person has been receiving a service and the provider can no longer continue providing it for whatever reason (ie. therapist or PA quits and the agency doesn’t have another person to replace them).  Once the provider stops providing the service that is approved on the person’s service plan, you must immediately complete the Delay In Service form.  That is sent to the Regional Office and the delay process is initiated.  YOU DO NOT SUBMIT TO END A SERVICE, IN THIS CASE, UNTIL A NEW PROVIDER HAS BEEN LOCATED!!

 

Timelines: Drafts, Extra Pages, & Medication Listings should be sent in 10 calendar days prior to the meeting.

                   Final ISP’s should be sent into the office no more than 7 calendar days after the meeting.

                   Amendments should be completed within 3 days of receiving request for service change.

                   FF and PR notes are due in every Monday for the previous week.

                   All remaining notes are due in by the 1st of the following month.          

 

Title VI Coordinator: Lori T.                                                     Complaint Resolution:  Julie V.