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SHC Verification of Relative/Legal Guardian as Provider Process Decision Tree No STOP! This process is not applicable. Does the Relative/Legal Guardian.

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Presentation on theme: "SHC Verification of Relative/Legal Guardian as Provider Process Decision Tree No STOP! This process is not applicable. Does the Relative/Legal Guardian."— Presentation transcript:

1 SHC Verification of Relative/Legal Guardian as Provider Process Decision Tree No STOP! This process is not applicable. Does the Relative/Legal Guardian live in the same household as the waiver participant? No STOP! This process is not applicable. Yes STOP! This process is not applicable. The service to be provided is: Community Networking, Day Supports, Personal Care, In-Home Skill Building, In- Home Intensive Supports, and Residential Supports Yes Is relative/Legal Guardian as Provider applicable to this situation Is the Relative/Legal Guardian the: Employer of Record or Managing Employer in an agency with Choice Model, Respite Service provider, or the spouse of the waiver participant? No Yes Relative/Legal Guardian has been previously approved to provide services to the waiver participant living in the same household under this process Prior to December 1 st, Is the Waiver participant 18 years of age or older? Complete the Part B Application Complete the Part A Application NoYes

2 SHC Verification of Relative/Legal Guardian as Provider Process Part A New Employees Provider agency is unable to hire qualified staff to meet the member’s need for: Community Networking, Day Supports, Personal Care, In- Home Skill Building, In-Home Intensive Supports, and Residential Supports Provider Agency completes the Verification of Relative/Legal Guardian as Provider Part A Application Provider Agency submits the Part A Application to SHC’s Network Operations Department Application is reviewed by Network Operations Department to insure it is complete Network Operations sends the Provider Agency a Letter of Agreement Complete Met/Approved Incomplete Application is automatically denied and returned to the Provider Agency (Provider Agency is asked to resubmit a complete application) Provider Agency completes the Verification of Relative/Legal Guardian as Provider Part A Application Provider Agency has one opportunity to complete and resubmit the Verification of Relative/Legal Guardian as Provider Part A Application with additional information they feel meets the criteria Not Met/Denied Network Operations send the Provider Agency a Letter of Disagreement If the request meets the criteria the Network Management Manager will notify the SHC UM Department that the provider agency meets the criteria for the requested hours/daily units per week. The UM Department is responsible for authorization

3 SHC Verification of Relative/Legal Guardian as Provider Process Part B Existing Employees Provider agency hired relative as staff to meet the member’s need for: Community Networking, Day Supports, Personal Care, In-Home Skill Building, In-Home Intensive Supports, and Residential Supports Provider Agency submits the Part B Application to SHC’s Network Operations Department Complete Network Operations sends the Provider Agency a Letter of Agreement Met/Approved Provider Agency completes the Verification of Relative/Legal Guardian as Provider Part B Application for an initial or annual renewal determination Application is automatically denied and returned to the Provider Agency (Provider Agency is asked to resubmit a complete application) Incomplete Provider Agency completes the Verification of Relative/Legal Guardian as Provider Part B Application Correct application submitted Yes Not Met/Denied Provider Agency has one opportunity to complete and resubmit the Verification of Relative/Legal Guardian as Provider Part B Application with additional information they feel meets the criteria Application is reviewed by Network Operations Department to insure it is the correct application and is complete Network Operations send the Provider Agency a Letter of Disagreement If the request meets the criteria the Network Management Manager will notify the SHC UM Department that the provider agency meets the criteria for the requested hours/daily units per week. The UM Department is responsible for authorization

4 SHC Verification of Relative/Legal Guardian as Provider Process Part C Request to Exceed 40 Hours Provider agency is requesting for Relative/Legal Guardian to provide more than 40 hours per week or 7 daily units to meet the member’s need for: Community Networking, Day Supports, Personal Care, In-Home Skill Building, In-Home Intensive Supports, and Residential Supports Provider Agency completes the Verification of Relative/Legal Guardian as Provider Part C Application in addition to the Part A or Part B Application Provider Agency submits the Part C Application with Part A or Part B Application to SHC’s Network Operations Department Network Operations reviews the Part C Application and determines if additional hours/units will be approved Approved Part C Application is automatically denied if the Part A or Part B Application is denied Denied Provider Agency can resubmit a Part C Application with its resubmission of the Part A or Part B Application The Part C Denial is included in the Network Operations Letter of Agreement it sends to the Provider Agency Denied If the request meets the criteria the Network Management Manager will notify the SHC UM Department that the provider agency meets the criteria for the requested hours/daily units per week. The UM Department is responsible for authorization The Part C Approval is included in the Network Operations Letter of Agreement it sends to the Provider Agency Network Committee reviews - decision is final The Provider Agency has 7 days to resubmit a Part C Reconsideration Request to the Network Committee Network Operations approves or denies the Part A or Part B Application


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