S. Review and Approval Process for RSP
The RSP review process must be completed by the RRDS within four (4) weeks. This includes RRDS review, Nurse Evaluator and/or QMS review, if indicated, return of the RSP to the SC for corrections and then resubmission to the RRDS for final review, issuance of the appropriate Notice of Decision, if applicable, and sufficient time for implementation of RSP.
Upon receipt of the RSP packet, the RRDS uses the RRDS Revised Service Plan Review form (refer to Appendix B - form B.11) while reviewing the RSP to determine if:
- the individuals' health and welfare were maintained in the previous Service Plan and , if not what changes need to occur;
- the participant continues to need waiver services;
- Written verification from the Medicaid Eligibility Verification System (MEVS) regarding Medicaid coverage that supports community based long term care services is attached;
- the PRI/SCREEN is current, and reflects a nursing home level of care;
- the RSP is reasonable given the context of the participant's stated goals;
- all available informal supports and non-waiver services have been appropriately arranged and are utilized;
- waiver services are being used in a reasonable and effective manner;
- the services described in the RSP will maintain the participant's health and welfare;
- the goals and preferences described in previous Service Plans have been the focus of the activities in the last six months;
- the PPO is complete, signed and reasonable;
- the Insurance, resources and Funding Information Sheet is completed and signed;
- all other required forms (e.g. Cost Description and Projection forms, HCSS assessment form etc if applicable) are completed, signed by the participant, and attached to the Revised Service Plan; and
- the participant has signed the Revised Service Plan.
If the needs of the participant appear to be medically complex in nature, the RRDS will request additional review of the RSP by the Nurse Evaluator.
In addition, if the RSP exceeds $300/day, the RRDS must provide the RSP along with a copy of the RRDS RSP Review form to the QMS for review and recommendations. The QMS will send the recommendations to the RRDS within three (3) business days.
If there are any discrepancies in the information provided in the RSP, or if it appears that that RSP may not be approved, the RRDS discusses this with the SC. This is documented on the RRDS Revised Service Plan Review form which is sent with the RSP packet to the SC for correction. The SC discusses the issues and/or any alternative options with the participant.
Note: If at any time the RRDS feels the information provided in the ISR from any waiver service provider requires further explanation, they may request that the SC obtain and submit a copy of the Detailed Plan for that service.
The SC returns the corrected/amended RSP packet to the RRDS for re-review.
Upon approval, the RRDS signs the RSP and PPO and returns them to the SC. The SC provides a copy of the RSP and PPO to the participant, all waiver service providers included in the RSP and others as appropriate. The SC may also need to notify other key parties who may not necessarily receive a copy of the RSP.
The RRDS completes and issues the NOD- Authorization to the participant and others listed on the form. The SC distributes a copy of the NOD form to the approved waiver service providers. The NOD informs the participant of his/her rights regarding the decision, including Informal Conference and Fair Hearings (refer to Section II - Becoming a Waiver Participant).
Upon denial of the RSP the RRDS must relay this to the SC and issue the NOD- Denial of Waiver Program to the applicant and others listed on the NOD form.
The SC discusses the concerns with the participant to determine if any alternative options are available for consideration. If appropriate alternatives are not found to meet the participant's health and welfare needs, the SC communicates this to the RRDS.
If the RRDS's determination results in a denial of continued participation in the waiver, the RRDS sends the NOD - Discontinuation of Waiver Program to the participant and others designated on the form. The SC will work with the participant to establish an appropriate discharge plan.