Spreadsheet: d802a010-e436-4ad1-a448-0fa6dd540040
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | STATE OF COLORADO DEPARTMENT OF HEALTH CARE POLICY AND FINANCING | 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 HOME AND COMMUNITY BASED SERVICES (HCBS) PRIOR APPROVAL AND COST CONTAINMENT |  |  |  |  |  |  | BI - U6
 |  |  |  | HCBS - Persons with a Brain Injury (BI) Waiver |  |  |  |  |  |  | PA Number being revised:
 |  |  |  |  |  |  |  |  |  |  | Revision?
 | 1. CLIENT NAME |  |  |  | 2. CLIENT ID |  |  | 3. SEX |  | 4. BIRTHDATE
 | 5. REQUESTING PROVIDER # |  |  | 6. CLIENT’S COUNTY | 7. CASE NUMBER (AGENCY USE) |  |  | 8. DATES COVERED
 |  |  |  |  |  |  |  | From: |  |  | Through:
 | STATEMENT OF REQUESTED SERVICES
 | 9. Description |  |  |  | 10. Provider | 11. Modifier | 12. [NAME]  # Units | 13. Cost Per Unit |  | 14. Total $ Authorized | 15. Comments
 | S5102 Adult Day Services (U6) |  |  |  |  |  |  |  |  | 0
 | T2029 Assistive Technology, Per Purchase (U6) |  |  |  |  |  |  |  |  | 0 |  |  |  | A0120 NMT, [NAME], |  | A0120 NMT, [NAME] To and From Adult Day |  | A0130 NMT, [NAME], |  | A0130 NMT, [NAME] to and From Adult Day,
 | H0025 Behavioral Programming (U6) |  |  |  |  |  |  |  |  | 0 |  |  |  | Mileage Band 1 (0-10 miles) (U6) |  | Mileage Band 1 (0-10 miles) (U6) | HB | Mileage Band 1 (0-10 miles) (U6) |  | Mileage Band 1 (0-10 miles) (U6) | HB
 | H2018 Day Treatment (U6) |  |  |  |  |  |  |  |  | 0 |  |  |  | Mileage Band 2 (11-20 miles) (U6) | TT | Mileage Band 2 (11-20 miles) (U6) | TT, HB | Mileage Band 2 (11-20 miles) (U6) | TT | Mileage Band 2 (11-20 miles) (U6) | TT, HB
 | S5165 Home Modifications (U6) |  |  |  |  |  |  |  |  | 0 |  |  |  | Mileage Band 3 (over 20 miles) (U6) | TN | Mileage Band 3 (over 20 miles) (U6) | TN, HB | Mileage Band 3 (over 20 miles) (U6) | TN | Mileage Band 3 (over 20 miles) (U6) | TN, HB
 | T2013 Independent Living Skills Training (ILST) (U6) |  |  |  |  |  |  |  |  | 0
 | H0004 Mental Health Counseling, Family  (U6) |  |  |  |  | HR |  |  |  | 0
 | H0004 Mental Health Counseling, Group  (U6) |  |  |  |  | HQ |  |  |  | 0 |  |  |  | S5102 Adult Day Services (U6)
 | H0004 Mental Health Counseling, Individual  (U6) |  |  |  |  |  |  |  |  | 0 |  |  |  | T2029 Assistive Technology, Per Purchase (U6)
 | [NAME] (NMT), Taxi (U6) |  |  |  |  |  |  |  |  | 0 |  |  |  | H0025 Behavioral Programming (U6)
 | A0120 NMT, [NAME] |  |  | Mileage Band 3 (over 20 miles) (U6) |  | TN |  |  |  | 0 |  |  |  | H2018 Day Treatment (U6)
 | A0120 NMT, [NAME] To and From Adult Day |  |  | Mileage Band 1 (0-10 miles) (U6) |  | HB |  |  |  | 0 |  |  |  | S5165 Home Modifications (U6)
 | A0130 NMT, [NAME] |  |  | Mileage Band 1 (0-10 miles) (U6) |  |  |  |  |  | 0 |  |  |  | T2013 Independent Living Skills Training (ILST) (U6)
 | A0130 NMT, [NAME] to and From Adult Day |  |  | Mileage Band 1 (0-10 miles) (U6) |  | HB |  |  |  | 0 |  |  |  | H0004 Mental Health Counseling, Family  (U6)
 | T1019 Personal Care (U6) |  |  |  |  |  |  |  |  | 0 |  |  |  | H0004 Mental Health Counseling, Group  (U6)
 | T1019 Personal Care, Relative (U6) |  |  |  |  | HR |  |  |  | 0 |  |  |  | H0004 Mental Health Counseling, Individual  (U6)
 | S5160 Personal Emergency Response System (PERs) Install/Purchase (U6) |  |  |  |  |  |  |  |  | 0 |  |  |  | [NAME] (NMT), Taxi (U6)
 | S5161 PERs, Monitoring (U6) |  |  |  |  |  |  |  |  | 0 |  |  |  | A0120 NMT, [NAME], Mileage Band 1 (0-10 miles) (U6) | -
 | S5150 Respite Care, In Home (U6) |  |  |  |  |  |  |  |  | 0 |  |  |  | A0120 NMT, [NAME], Mileage Band 2 (11-20 miles) (U6) | TT
 | H0045 Respite Care, NF (U6) |  |  |  |  |  |  |  |  | 0 |  |  |  | A0120 NMT, [NAME], Mileage Band 3 (over 20 miles) (U6) | TN
 | T1006 Substance Abuse Counseling, Family (U6) |  |  |  |  | HR, HF |  |  |  | 0 |  |  |  | A0120 NMT, [NAME] To and From Adult Day, [NAME] 1 (0-10 miles) (U6) | HB
 | H0047 Substance Abuse Counseling, Group (U6) |  |  |  |  | HQ, HF |  |  |  | 0 |  |  |  | A0120 NMT, [NAME] To and From Adult Day, [NAME] 2 (11-20 miles) (U6) | TT, HB
 | H0047 Substance Abuse Counseling, Individual (U6) |  |  |  |  | HF |  |  |  | 0 |  |  |  | A0120 NMT, [NAME] To and From Adult Day, [NAME] 3 (over 20 miles) (U6) | TN, HB
 | T2033 Supported Living Program, (U6) |  |  |  |  |  |  |  |  | 0 |  |  |  | A0130 NMT, [NAME], Mileage Band 1 (0-10 miles) (U6) | -
 | T2016 Transitional Living, Per Day (U6) |  |  |  |  |  |  |  |  | 0 |  |  |  | A0130 NMT, [NAME], Mileage Band 2 (11-20 miles) (U6) | TT
 | A |  |  |  |  |  |  |  |  | 0 |  |  |  | A0130 NMT, [NAME], [NAME] 3 (over 20 miles) (U6) | TN
 | B |  |  |  |  |  |  |  |  | 0 |  |  |  | A0130 NMT, [NAME] to and From Adult Day,  [NAME] 1 (0-10 miles) (U6) | HB
 | C |  |  |  |  |  |  |  |  | 0 |  |  |  | A0130 NMT, [NAME] to and From Adult Day,  [NAME] 2 (11-20 miles) (U6) | TT, HB
 | D |  |  |  |  |  |  |  |  | 0 |  |  |  | A0130 NMT, [NAME] to and From Adult Day,  [NAME] 3 (over 20 miles) (U6) | TN, HB
 | E |  |  |  |  |  |  |  |  | 0 |  |  |  | T1019 Personal Care (U6) | -
 | F |  |  |  |  |  |  |  |  | 0 |  |  |  | T1019 Personal Care, Relative (U6) | HR
 | G |  |  |  |  |  |  |  |  | 0 |  |  |  | S5160 Personal Emergency Response System (PERs) Install/Purchase (U6) | -
 | H |  |  |  |  |  |  |  |  | 0 |  |  |  | S5161 PERs, Monitoring (U6) | -
 | 16.  TOTAL AUTHORIZED HCBS EXPENDITURES (SUM OF AMOUNTS IN COLUMN 14 ABOVE) |  |  |  |  |  |  |  |  |  | 0 |  |  | S5150 Respite Care, In Home (U6) | -
 | 17.  PLUS TOTAL AUTHORIZED HOME HEALTH EXPENDITURES (SUM OF AUTHORIZED HOME HEALTH SERVICES DURING THE HCBS CARE PLAN PERIOD)- Excludes In-Home Support Services amounts |  |  |  |  |  |  |  |  |  |  | 0 |  | H0045 Respite Care, NF (U6) | -
 | 18.  EQUALS CLIENT’S MAXIMUM AUTHORIZED COST (HCBS EXPENDENITURES + HOME HEALTH EXPENDITURES) |  |  |  |  |  |  |  |  |  |  | 0 |  | T1006 Substance Abuse Counseling, Family (U6) | HR, HF
 | 19.  NUMBER OF DAYS COVERED (FROM FIELD 8 ABOVE) |  |  |  |  |  |  |  |  |  |  |  |  | H0047 Substance Abuse Counseling, Group (U6) | HQ, HF
 | 20.  AVERAGE COST PER DAY (Client’s maximum authorized cost divided by number of days in the care plan period) |  |  |  |  |  |  |  |  |  |  | 0 |  | H0047 Substance Abuse Counseling, Individual (U6) | HF
 | A.  Monthly State Cost Containment Amount |  |  |  |  |  |  |  |  |  |  | 0 |  | H0045 Substance Abuse Counseling, Family (U6) | -
 | B.  Divided by 30.42 days = Daily Cost Containment Ceiling |  |  |  |  |  |  |  |  |  |  | 0 |  | H0045 Substance Abuse Counseling, Group (U6) | HQ
 | 21. Immediately prior to HCBS enrollment, this client lived in a: |  |  |  |  |  |  |  |  |  |  |  |  | T2033 Supported Living Program, (U6) | -
 | 22.  CASE MANAGER [NAME] |  |  |  | 23.  AGENCY |  | 24. PHONE # |  | 25. EMAIL |  |  | 26.  DATE |  | T2016 Transitional Living, Per Day (U6) | -
 |  |  |  |  |  |  |  |  |  |  |  |  |  | A0120 [NAME] (U6) | -
 | 22A. CASE MANAGER SIGNATURE: |  |  |  |  |  |  |  |  |  |  |  |  | A0120 [NAME], To and From Adult Day (U6) | HB
 | 27.  CASE MANAGER’S SUPERVISOR NAME |  |  |  | 28.  AGENCY |  | 29. PHONE # |  | 30. EMAIL |  | 31.  DATE | 31.  DATE |  | A0130 [NAME] (U6) | -
 |  |  |  |  |  |  |  |  |  |  |  |  |  | A0130 [NAME], To and From Adult Day (U6) | HB
 | 27A. CASE MANAGER'S SUPERVISOR SIGNATURE: |  |  |  |  |  |  |  |  |  |  |  |  | [NAME] (U6) | -
 | DO NOT WRITE BELOW - AUTHORIZING AGENT USE ONLY |  |  |  |  |  |  |  |  |  |  |  |  | [NAME], To and From Adult Day (U6) | HB
 | 32. CASE PLAN: |  |  |  |  |  |  |  | Return for correction- Date:
 | 33. REGULATION(S) upon which Denial or Return is based:
 | 34. DEPARTMENT APPROVAL SIGNATURE: |  |  |  |  |  |  |  |  | 35.  DATE:
 | Home and Community Based Services (HCBS) PAR Completion Instructions
 | FORM MUST BE COMPLETED ELECTRONICALLY OR IN BLUE BALLPOINT- PLEASE PRINT
 | Complete this form for Prior Authorization Requests for  HCBS-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. Use one of the eight (8) lettered (A-H) dropdown fields found in the first few lines immediately following the last code in Column 9, the “Description” column when a Revision requires: 1) Additional lines of existing codes to indicate varying rates, units, etc.; or 2) The inclusion of codes for a timeframe that used codes not listed on the existing form.
 | Transportation:
 | A0120 [NAME] and A0130 [NAME] Transportation allocations must be calculated based on the total anticipated number of trips taken within specified mileage bands. Using 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. Use the additional lettered, drop down fields at the bottom of the Services column for additional trips or Revisions. Note that separate lines must be used for travel to and from Adult Day.
 | 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 |  | Requesting Provider #: Enter the requesting provider's Medical Assistance Program provider number.
 | 6 |  | Client's County:  Enter the client's county of residence.
 | 7 |  | Case Number (for Agency use) - Optional:  Enter the agency's case number for this PAR.
 | 8 |  | [NAME] (From and Through):  Enter the PAR start date and PAR end date.
 | 9 |  | Description:  List of approved procedure codes.
 | 10 |  | Provider - Optional: For SEP use only.  The field has a 13 character limit.
 | 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 you are requesting reimbursement.
 | 13 |  | Cost Per Unit:  Enter the cost per unit of service.
 | 14 |  | Total $ Authorized:  The total dollar amount authorized for the service 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 procedure code and date span here.
 | 16 |  | Total Authorized HCBS Expenditures:  Total 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 HCBS 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: The monthly state cost containment amount automatically populates.
 | 20B. |  | Divided by 30.42 days = Daily Cost Containment Ceiling: The daily cost containment ceiling automatically populates.
 | 21 |  | Immediately prior to HCBS enrollment, this client lived in a:  Check the appropriate facility type.
 | 22 |  | Case Manager Name:  Enter the name of the Case Manager.
 | 22A. |  | Case Manager Signature:  Case Manager's signature.
 | 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's [NAME]: Enter the name of the Case Manager's Supervisor.
 | 27A. |  | Case Manager's Supervisor Signature: Case Manager's [NAME] signature.
 | 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:
 | Mail:
 | Xerox State Healthcare
 | PARs
 | [NAME] 30
 | Denver, CO 80201-0030
 | Note: If submitted to the Department’s Fiscal Agent, the following correspondence will not be returned to case managers, outreach will not be performed to fulfill the requests, and all such requests will be recycled: 1) Paper PAR forms that do not clearly identify the case management agency in the event the form(s) need to be returned and/or 2) PAR revision requests not submitted on Department approved PAR forms, including typed letters with revision instructions. Should questions arise about what Fiscal Agent staff can process, please contact the appropriate Department Waiver manager.