Page 1 – Recommendation of Action, DTR 05/2017

Notice of Recommendation for Action Denial, Termination, or Reduction (DTR) for Waiver Services Instructions

General Instructions: • Notice of Recommendation for Action (DTR) for Waiver Services Form must be used to

communicate to SCHA a denial, termination, or reduction of the following services: - SeniorCare Complete and MSC+ Members: ALL Elderly Waiver services including Home

Care Services - Home Health Aide, Skilled Nursing, Private Duty Nursing (PDN), Personal Care Assistant (PCA) services

Any time a screening document is closed in MMIS, you MUST complete the Notice of Recommendation for Action (DTR) prior to closing Elderly Waiver services. Examples: Member enters a nursing home and stay is planned for longer than 30 days. Member losses their Medicaid eligibility. Member moves out of the SCHA service area.

- AbilityCare Members: CAC, CADI, TBI, or DD waiver home care services including skilled nurse, and home health aide

- PMAP Members: CAC, CADI, TBI, or DD waiver home care services including skilled nurse, home health aide, private duty nursing (PDN), and personal care assistant (PCA) services

• All fields MUST be completed or form will be sent back to the Care Coordinator/ Case Manager for completion. If form is sent back it MUST be returned within 1 business day.

• Care Coordinator/ Waiver Case Managers must notify SCHA within one business day of the discussion they had with the member about a denial, termination, or reduction of the service.

• Waiver services cannot be changed until SCHA sends the DTR determination letter to member and Care Coordinator/Case Manager

Item Instructions Member Information 1. Date Date the form was completed.

2. Member Name First and last name of the member.

3. SCHA ID Member’s health plan identification number.

4. Member Address Member’s address including street address, city and zip code.

5. SCHA Product Product the member is enrolled. Examples include SeniorCare Complete, AbilityCare, MSC+ or PMAP).

6. Date of Birth Member’s Date of Birth.

7. PMI The DHS assigned “Person Master Index (PMI) Number” used in MMIS, also known as Member ID or Client ID.

8. Parent/Guardian Name and Address

Name of the Parent/Guardian and the address of the Parent/Guardian including street address, city, and zip code

9. MMIS Service Agreement Authorization #

If the service is currently authorized in MMIS, enter the service agreement authorization number. If the service is not currently authorized enter N/A.

10. Date(s) of Service

Enter the date(s) of service that are being denied, terminated or reduced. If currently authorized enter the date of services that are being denied, terminated or reduced.

Page 2 – Recommendation of Action, DTR 05/2017

Notice of Recommendation for Action Denial, Termination, or Reduction (DTR) for Waiver Services Instructions

Care Coordinator/Case Manager Information 11. Care Coordinator/ Case Manager Enter the name of the Care Coordinator/Case Manager.

12. Primary Care Physician Enter the full name of the member’s Primary Care Provider (i.e. Dr. John Smith)

13. Care Coordinator/ Case Manager Phone Number

Enter the direct phone number of the Care Coordinator/ Case Manager

14. Primary Care Clinic Enter the full name of the member’s Primary Care Clinic

15.Care Coordinator/ Case Manager Fax Number

Enter the fax number for the Care Coordinator/ Case Manager

16. PCP Fax Number Enter the fax number for the member’s Primary Care Provider

Recommendation for DTR Information 17. Recommended Date of Action Enter the date that you are recommend the service be denied,

terminated, or reduced. 18. Recommended Action Check the appropriate box as to what action you are recommending

denial, termination, or reduction.

19, 21, 23, 25, 27. Service Provider(s) Name and Address

Enter the service provider’s name and the address of the service provider’s office. If multiple enter all.

20, 22, 24, 26, 28. Service Provider (s) Fax Number

Enter the fax number for the service provider. If multiple enter all.

29. Date of discussion with Member or Legal Representative regarding potential denial, termination, or reduction of service

It is required that the Care Coordinator/Case Manager have a discussion with the Member/Guardian/Authorized Representative regarding the recommended action. Enter the date of that discussion.

30. Describe the recommended action and reasons why it is being recommended

Enter the description of the service being recommended for denial, termination or reduction and describe the reason why the action is being recommended.

31. Service Code Check the box for the correct service(s) that is being recommended to be denied, terminated or reduced. (For a full termination of services, ensure that Elderly Waiver (EW) - Eligibility and EW - Case Management/EW - Case Management - paraprofessional are checked)

32. Reason Code Check the box for the most appropriate reason as to why the service is being recommended to be denied, terminated or reduced.