Spreadsheet: 176b8e48-ab50-4529-b2d8-0c526598c88c
Sheet: Sheet1

Unnamed: 0 | STATE OF COLORADO DEPARTMENT OF HEALTH CARE POLICY AND FINANCING | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12 | Unnamed: 13 | Unnamed: 14 | Unnamed: 15 | Unnamed: 16 | Unnamed: 17 | Unnamed: 18 | Unnamed: 19 | Unnamed: 20 | Unnamed: 21
 |  |  | REQUEST FOR ADULT HCBS PRIOR APPROVAL AND COST CONTAINMENT
 |  |  | CCT - Persons with Brain Injury Demonstration |  |  |  |  |  |  | PA Number being revised:
 |  |  |  |  |  |  |  |  |  | Revision?
 | 1. CLIENT NAME |  |  | 2. CLIENT ID |  | 3. SEX |  | 4. BIRTHDATE |  | 5. DATE OF DISCHARGE
 | 6. REQUESTING PROVIDER # |  | 7. CLIENT’S COUNTY | 8. CASE NUMBER (AGENCY USE) |  |  | 9. DATES COVERED
 |  |  |  |  |  |  | From: |  | Through:
 | STATEMENT OF REQUESTED SERVICES
 | 10.  Qualified Services Description |  |  |  | 11. Modifier | 12. [NAME]  # Units | 13. Cost Per Unit | 14. Total $ Authorized | 15. Comments:
 | S5102 Adult Day Services (UC) |  |  |  |  |  |  | 0 |  |  |  |  | NMT, [NAME]
 | T2029 Assistive Technology, per purchase  (UC) |  |  |  |  |  |  | 0 |  |  |  |  | NMT, [NAME] To and From Adult Day
 | H0025 Behavioral Programming  (UC) |  |  |  |  |  |  | 0
 | T2025 CDASS, (Cent/Unit) (UC) |  |  |  |  |  |  | 0
 | T2040 CDASS Per Member/ Per Month (PM/PM) (UC) |  |  |  |  |  |  | 0
 | H2018 Day Treatment  (UC) |  |  |  |  |  |  | 0 |  |  |  |  | NMT, [NAME]
 | S5165 Home Modifications  (UC) |  |  |  |  |  |  | 0 |  |  |  |  | NMT, [NAME] To and From Adult Day
 | T2013 Independent Living Skills Training (ILST)  (UC) |  |  |  |  |  |  | 0
 | H0004 Mental Health Counseling, Family  (UC) |  |  |  | HR |  |  | 0
 | H0004 Mental Health Counseling, Group  (UC) |  |  |  | HQ |  |  | 0
 | H0004 Mental Health Counseling, Individual  (UC) |  |  |  |  |  |  | 0 |  |  |  |  | NMT, [NAME] |  | NMT, [NAME] To and From Adult Day |  |  |  |  | NMT, [NAME] | NMT, [NAME] To and From Adult Day
 | [NAME] (NMT), Taxi (UC) |  |  |  |  |  |  | 0 |  |  |  |  | Mileage Band 1 (0-10 mi) (UC) |  | Mileage Band 1 (0-10 mi) (UC) | HB |  |  | 1 |  | HB
 | A0120 | NMT, [NAME] |  | Mileage Band 1 (0-10 mi) (UC) |  |  |  | 0 |  |  |  |  | Mileage Band 2 (11-20 mi) (UC) | TT | Mileage Band 2 (11-20 mi) (UC) | TT, HB
 | A0130 | NMT, [NAME] |  | Mileage Band 1 (0-10 mi) (UC) |  |  |  | 0 |  |  |  |  | Mileage Band 3 (over 20 mi) (UC) | TN | Mileage Band 3 (over 20 mi) (UC) | TN, HB
 | T1019 Personal Care  (UC) |  |  |  | TG |  |  | 0
 | S5160 Personal Emergency Response System (PERs), Install/Purchase  (UC) |  |  |  |  |  |  | 0 |  |  |  |  | NMT, [NAME] |  | NMT, [NAME] To and From Adult Day |  |  |  |  | NMT, [NAME] | NMT, [NAME] To and From Adult Day
 | S5161 PERs, Monitoring  (UC) |  |  |  |  |  |  | 0 |  |  |  |  | Mileage Band 1 (0-10 mi) (UC) |  | Mileage Band 1 (0-10 mi) (UC) | HB |  |  | 1 |  | HB
 | T1019 Relative Personal Care  (UC) |  |  |  | HR, TG |  |  | 0 |  |  |  |  | Mileage Band 2 (11-20 mi) (UC) | TT | Mileage Band 2 (11-20 mi) (UC) | TT, HB
 | H0045 Respite Care, NF (UC) |  |  |  |  |  |  | 0 |  |  |  |  | Mileage Band 3 (over 20 mi) (UC) | TN | Mileage Band 3 (over 20 mi) (UC) | TN, HB
 | S5150 Respite Care, In Home  (UC) |  |  |  |  |  |  | 0
 | T1006 Substance Abuse Counseling, Family  (UC) |  |  |  | HR, HF |  |  | 0
 | H0047 Substance Abuse Counseling, Group  (UC) |  |  |  | HQ, HF |  |  | 0
 | H0047 Substance Abuse Counseling, Individual (UC) |  |  |  | HF |  |  | 0
 | T2033 Supported Living Program (UC) |  |  |  |  |  |  | 0
 | T2016 Transitional Living, per day (UC) |  |  |  |  |  |  | 0
 | Demonstration Services Description
 | S5110 Caregiver Education  (UC) |  |  |  |  |  |  | 0
 | T2038 Community Transition Services, Coordinator  (UC) |  |  |  |  |  |  | 0
 | A9900 Community Transition Services, Items Purchased  (UC) |  |  |  |  |  |  | 0
 | D2999 Dental  (UC) |  |  |  |  |  |  | 0
 | T1002 Enhanced Nursing, RN  (UC) |  |  |  |  |  |  | 0
 | S5170 Home Delivered Meals  (UC) |  |  |  |  |  |  | 0
 | S5165 Home Modifications, Extended  (UC) |  |  |  | KG |  |  | 0
 | T1016 Intensive Case Management   (UC) |  |  |  |  |  |  | 0
 | H2015 Peer Mentorship  (UC) |  |  |  |  |  |  | 0
 | [NAME] Rehabilitation Services  (UC) |  |  |  |  |  |  | 0
 | V2799  Vision (UC) |  |  |  |  |  |  | 0
 | 16a.  TOTAL AUTHORIZED CCT QUALIFIED SERVICE EXPENDITURES (SUM OF QUALIFIED SERVICES) |  |  |  |  |  |  |  |  | 0 | 16c. Grand Total
 | 16b.  TOTAL AUTHORIZED CCT DEMONSTRATION SERVICE EXPENDITURES (SUM OF DEMONSTRATION SERVICES) |  |  |  |  |  |  |  |  | 0 | 0
 | 17.    PLUS TOTAL AUTHORIZED HOME HEALTH EXPENDITURES (SUM OF AUTHORIZED HOME HEALTH SERVICES DURING THE HCBS CARE PLAN PERIOD) |  |  |  |  |  |  |  |  |  | 0
 | 18.    EQUALS CLIENT’S MAXIMUM AUTHORIZED COST (CCT SERVICES EXPENDENITURES + HOME HEALTH EXPENDITURES) |  |  |  |  |  |  |  |  |  | 0
 | 19.    NUMBER OF DAYS COVERED (FROM FIELD 8 ABOVE)
 | 20.    AVERAGE COST PER DAY (Client’s maximum authorized cost divided by number of days in the care plan period) |  |  |  |  |  |  |  |  |  | 0
 | A.  Monthly State Cost Containment Amount |  |  |  |  |  |  |  |  |  | 0
 | [NAME] by 30.42 days = Daily Cost Containment Ceiling |  |  |  |  |  |  |  |  |  | 0
 | 21.  Immediately prior to CCT Services enrollment, this client lived in a:
 | 22.  CASE MANAGER [NAME] |  |  | 23.  AGENCY |  | 24. PHONE # |  | 25. EMAIL |  |  | 26.  DATE
 | 27.  CASE MANAGER’S SUPERVISOR NAME |  |  | 28.  AGENCY |  | 29. PHONE # |  | 30. EMAIL |  |  | 31.  DATE
 | DO NOT WRITE BELOW - AUTHORIZING AGENT USE ONLY
 | CASE PLAN: |  |  |  |  |  | Return for correction- Date:
 | REGULATION(S) upon which Denial or Return is based:
 | DEPARTMENT APPROVAL SIGNATURE: |  |  |  |  |  |  |  | DATE:
 | Colorado Choice Transitions (CCT) PAR Completion Instructions
 | FORM MUST BE COMPLETED ELECTRONICALLY OR IN BLUE BALLPOINT - PLEASE PRINT
 | Complete this form for Prior Authorization Requests for  CCT-BI.  Submit the PAR per the instructions listed at the bottom.
 | PAR Revisions:
 | Check "Yes" or "No" in the Revision section at the top of the form only if revising a current approved PAR. Add the number of units being requested to the original number of units approved and include all services that were approved on the original PAR.
 | Transportation:
 | A0120 [NAME] and A0130 [NAME] Transportation allocations must be calculated based on the total anticipated number of trips taken within specified mileage bands. Utilizing the address information from clients and providers, use a mapping tool to calculate the number of miles per one-way trip, which will correspond to one of the mileage band drop down options on the PAR. Enter the total number of trips for that specific mileage band into Column 12. No rounding is necessary when determining mileage bands. For example, a trip that is 10.1 miles in length would go into [NAME] 2, which is 11-20 miles.
 | Complete the following required fields:
 | 1 | Client Name: Enter the client's name.
 | 2 | Client ID: Enter the client's Medical Assistance Program ID number.
 | 3 | Sex:  Check M or F.
 | 4 | Birthdate:  Enter the client's date of birth.
 | 5 | Date of Discharge: Enter the client’s date of discharge from qualified facility.
 | 6 | Requesting Provider #: Enter the requesting provider's Medical Assistance Program provider number.
 | 7 | Client's County:  Enter the client's county of residence.
 | 8 | Case Number (for Agency use) - Optional:  Enter the agency's case number for this PAR.
 | 9 | [NAME] (From and Through):  Enter the PAR start date and PAR end date.
 | 10 | Description:  List of approved procedure codes of Qualified and Demonstration services.
 | 11 | [NAME]:  The alphanumeric values in this column are standard and static and cannot be changed.
 | 12 | [NAME] # [NAME]:  Enter the number of units next to the services for which reimbursement is being requested.
 | 13 | Cost Per Unit:  Enter the cost per unit of service.
 | 14 | Total $ Authorized:  The total dollar amount automatically populates.
 | 15 | Comments - Optional:  Enter any additional useful information. For example, if a service is authorized for different dates than in Box 8, please include the HCPC and date span here.
 | 16a. | Total Authorized CCT Qualified Services Expenditures:  Total automatically populates.
 | 16b. | Total Authorized CCT Demonstration Service Expenditures:  Total automatically populates.
 | 16c. | Grand Total of CCT Qualified and Demonstration Services: Subtotal automatically populates.
 | 17 | Plus Total Authorized Home Health Expenditures  (Sum of Authorized Home Health Services during the HCBS Care Plan Period): Enter the total Authorized Home Health expenditures.
 | 18 | Equals Client's Maximum Authorized Cost: The CCT Expenditures + Home Health Expenditures automatically populates.
 | 19 | Number of Days Covered: The number of days covered automatically populates.
 | 20 | Average Cost Per Day:  The client's maximum authorized cost divided by number of days in the care plan period automatically populates.
 | 20a. | Monthly State Cost Containment Amount: Enter the monthly state cost containment amount for the relevant level of care.
 | 20b. | Divided by 30.42 days = Daily Cost Containment Ceiling: The daily cost containment ceiling automatically populates.
 | 21 | Immediately prior to CCT enrollment, this client lived in a:  Check the appropriate facility type.
 | 22 | Case Manager Name:  Enter the name of the Case Manager.
 | 23 | Agency:  Enter the name of the agency.
 | 24 | Phone #: Enter the phone number of the Case Manager.
 | 25 | [NAME]: Enter the email address of the Case Manager.
 | 26 | Date:  Enter the date completed.
 | 27 | Case Manager Supervisors Name: Enter the name of the Case Manager's Supervisor.
 | 28 | Agency:  Enter the name of the agency.
 | 29 | Phone #: Enter the phone number of the Case Manager's Supervisor.
 | 30 | [NAME]: Enter the email address of the Case Manager's Supervisor.
 | 31 | Date:  Enter the date completed.
 | “DO NOT WRITE BELOW - AUTHORIZING AGENT USE ONLY”. This is for Department use only.
 | Send only New, Continued Stay Review (CSR), and [NAME] PARs to:
 |  | Encrypted Email: |  | Fax: |  |  |  | Mail:
 |  | [EMAIL] |  | [PHONE] |  |  |  | The Colorado Department of Health Care Policy and Financing Attn: Long Term Services and Supports Division 1570 Grant St. Denver, CO 80203-1818
 | Note: Any PAR for the CCT Demonstration Project sent directly to the fiscal agent for the Colorado Medical Assistance Program will be returned to the case manager.