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Appendix 4320: DFPS Guidelines for Service Authorizations

CPS September 2017

Initial Service Authorization

The initial service authorization is completed within 48 hours or 2 working days. Emergency requests from CPS supervisors are processed within 1 working day.

If an authorization is completed on the first day of the month, that month is the first full month for all services. If the authorization is completed after the first day of the month, the next month is the first full month for all services.

Level of Service

Effective Date

Authorization Dates

Examples

Basic or Moderate

Date of Completion

12 months

If the initial service authorization was completed on 8/1/17, then:

  •  the effective date would be 8/1/17; and

  •  the authorization dates would be 8/1/17–7/31/18.

If the initial service authorization was completed on 8/15/17, then:

  •   the effective date would be 8/15/17; and

  •   the authorization dates would be 8/15/17–8/31/18.

Specialized, Intense, or Intense Plus

Date of Completion

3 months

If the initial service authorization was completed on 8/1/17, then:

  •   the effective date would be 8/1/17; and

  •   the authorization dates would be 8/1/17–10/31/17.

If the initial service authorization was completed on 8/15/17, then:

  •   the effective date would be 8/15/17; and

  •   the authorization dates would be 8/15/17–11/30/17.

Non-Scheduled Utilization Reviews – Out of Contract Care

If an authorization is completed on the first day of the month, that month is the first full month for all services. If the authorization is completed after the first day of the month, the next month is the first full month for all services.

Level of Service

Effective Date

Authorization Dates

Examples

Moderate

Date of Review

12 months

If the service authorization was completed on 8/1/17, then:

  •   the effective date would be 8/1/17; and

  •   the authorization dates would be 8/1/17–7/31/18.

If the service authorization was completed on 8/8/17, then:

  •   the effective date would be 8/8/17; and

  •   the authorization dates would be 8/8/17–8/31/18.

Specialized

Date of Review

3 months

If the service authorization was completed on 8/1/17, then:

  •   the effective date would be 8/1/17; and

  •   the authorization dates would be 8/1/17–10/31/17.

If the service authorization was completed on 8/8/17, then:

  •   the effective date would be 8/8/17; and

  •   the authorization dates would be 8/8/17–11/30/17.

Intense

Date of Review

3 months

If the service authorization was completed on 8/1/17, then:

  •   the effective date would be 8/1/17; and

  •   the authorization dates would be 8/1/17–10/31/17.

If the service authorization was completed on 8/8/17, then:

  •   the effective date would be 8/8/17; and

  •   the authorization dates would be 8/8/17–11/30/17.

Intense Plus

Date of Review

3 months

If the service authorization was completed on 8/1/17, then:

  •   the effective date would be 8/1/17; and

  •   the authorization dates would be 8/1/17–10/31/17.

If the service authorization was completed on 8/8/17, then:

  •   the effective date would be 8/8/17; and

  •   the authorization dates would be 8/8/17–11/30/17.

Non-Scheduled Utilization Reviews - Contract Care and a Current Authorization

For all service levels, regardless of the date an authorization is completed, the next month is the first full month for all services if the same service level is continued.

For an increase to an Intense or Intense Plus service level:

  •   If an authorization is completed on the first day of the month, that month is the first full month for all services.

  •   If the authorization is completed after the first day of the month, the effective date for services is the review date.

Level of Service

Effective Date

Authorization Dates

Examples

Moderate

1st of the next month

12 months

  •   If the effective date was 8/1/17, then the authorization dates would be 9/1/17–8/31/18.

  •   If the effective date was 8/8/17, then the authorization dates would be 9/1/17–8/31/18.

Specialized

1st of the next month

3 months

  •   If the effective date was 8/1/17, then the authorization dates would be 9/1/17–11/30/17.

  •   If the effective date was 8/8/17, then the authorization dates would be 9/1/17–11/30/17.

Intense or Intense-Plus

Date of Review

3 months

  •   If the effective date was 8/1/17, then the authorization dates would be 8/1/17–10/30/17.

  •   If the effective date was 8/8/17, then the authorization dates would be 8/8/17–11/30/17.

Utilization Reviews

Scheduled Utilization Reviews - Adjusted Services within Provider’s Contract

The effective date is the first of the month after the date the review was completed, and that month is the first full month for services, for:

  •   Moderate

  •   Specialized

  •   Continue at Intense

  •   Continue at Intense Plus

Level of Service

Effective Date

Authorization Dates

Examples

Moderate

1st of the next month

12 months

If the review occurred on 8/8/17, then:

  •   the effective date would be 9/1/17; and

  •   the authorization dates would be 9/1/17–8/31/18.

Specialized

1st of the next month

3 months

If the review occurred on 8/8/17, then:

  •   the effective date would be 9/1/17; and

  •   the authorization dates would be 9/1/17–11/30/17.

Continue at Intense or Intense Plus

1st of the next month

3 months

If the review occurred on 8/8/17, then:

  •   the effective date would be 9/1/17; and

  •   the authorization dates would be 9/1/17–11/30/17.

For an increase to Intense or Intense Plus, the effective date is the date the review was completed, and the next month is the first full month for services.

Level of Service

Effective Date

Authorization Dates

Examples

Increase to Intense or Intense Plus

Date of Review

3 months

If the review occurred on 8/8/17, then:

  •   the effective date would be 8/8/17; and

  •   the authorization dates would be 8/8/17–11/6/17.

Scheduled Utilization Reviews - Adjusted Services Not within Provider’s Contract

Review dates are on days 1–10 of the month. Service level dates are effective 31 days from the date of exit with the provider for the new service level.

Level of Service

Effective Date

Authorization Dates

Examples

Moderate

31st day from date of the review

12 months

If the review occurred on 8/8/17, then:

  •   the effective date would be 9/7/17; and

  •   the authorization dates would be 9/7/17–8/6/18.

Specialized

31st day from date of the review

3 months

If the review occurred on 8/8/17, then:

  •   the effective date would be 9/7/17; and

  •   the authorization dates would be 9/7/17–12/6/17.

Intense or Intense Plus

Date of Review

3 months

If the review occurred on 8/8/17, then:

  •   the effective date would be 8/8/17; and

  •   the authorization dates would be 8/8/17–11/6/17.

Scheduled Utilization Reviews - Adjusted Services Not within Provider’s Contract

Review dates are on days 11 through 31 of the month. The service level continues through the following month before the new service level is effective.

For an increase to Intense or Intense Plus, the effective date is the date the review was completed, and the next month is the first full month for services.

Level of Service

Effective Date

Authorization Dates

Examples

Service moves down a level (example: Specialized to Moderate)

For the new service level, the effective date is the first day of the second full month following the date of the review.

Specialized Service Level moves to Moderate Service Level (12 months)

The previous service is authorized through the end of the month following the review.

The new service is authorized beginning the following month.

If the review occurred 8/18/17 the authorization dates would be 8/18/17 through 9/30/17 for the Specialized service level, and 10/01/17 through 9/30/18 for the 12 months at the Moderate level.

Specialized

For the new service level, the effective date is the first day of the second full month following the date of the review.

Moderate service level moves to Specialized service level (3 months)

The previous service is authorized through the end of the month following the review.

The new service is authorized beginning the following month.

If the review occurred 8/18/17 the authorization dates would be 8/18/17 through 9/30/17 for the Moderate service level, and 10/01/17 through 12/31/17 for 3 months at the Specialized level.

Intense or Intense Plus

Date of Review

3 months

If the review was completed on 8/25/17, then:

  •   the effective date would be 8/25/17; and

  •   the authorization dates would be 8/25/17–11/23/17

All Utilization Reviews - Contract Care with an Expired Authorization

If the service level is the same or lower, the effective date can go back 3 months (90 days).

If the service level is higher than the previous service level, the effective date can go back one month (30 days).

Moderate Service Level can never exceed 12 months.

Level of Service

Effective Date

Authorization Dates

Examples

The service level is the same or lower than previous service level (gap 3 months or less).

Previous service level expiration date if not greater than three months.

Fix the Service Break *

Moderate service level expired 9/30/17, and the new Moderate service level is read 12/1/17. The gap is less than 3 months, so Moderate service level can cover the gap.

The service level is higher than previous service level (gap one month or less).

Previous service level expiration date if not greater than one month.

Fix the Service Break

Moderate expired 9/30/17, and Specialized service level is read 10/15/17. Specialized can cover the gap.

*Fixed moderate authorizations should never exceed a total of 12 full months.

If the child is recently placed without a current service level and within these time frames, fix the break in service only to the date of admission. See the table below for an example:

Date of Admission

Action

Authorization Dates

Reviewed 8/28/17 (admit 7/15/17)

Fix the Service Break

7/15/17–11/30/17

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