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REQUIRED: Provider Statement of Need for PAS, PCS and HAB Services

Date: 02/22/17

Consistent with Superior HealthPlan’s mission to improve health outcomes for our members, we have modified our policies for Personal Assistance Services (PAS), Personal Care Services (PCS) and Community First Choice (CFC) Habilitation (HAB) for the STAR+PLUS, STAR Kids and STAR Health and STAR+PLUS MMP programs.  

Superior will now obtain a Provider Statement of Need (PSON) before an assessment for PAS, PCS, and/or HAB is conducted. Following the assessment, the provider will receive information regarding the number of provider hours (if any) to be authorized for his/her patient, and the opportunity to discuss any concerns related to that determination. These steps are designed to facilitate more holistic collaboration between the provider and Superior’s Service Coordination team, which includes increased communication regarding the member’s functional needs and the way those needs are being met, as well as the opportunity to ensure that any underlying medical conditions or complications are addressed by appropriate medical professionals. This process is also designed to preserve consistency among Medicaid programs and facilitate transitions between them, in compliance with updated contractual requirements implemented by the Texas Health and Human Services Commission (HHSC), which require that a PSON process be implemented for both STAR Kids and STAR Health. 

These guidelines are effective April 1, 2017 (with the exception of STAR+PLUS MMP, which has a start date of June 1, 2017) and are as follows:

A.  ASSESSMENT

  1. Initial PAS, PCS or CFC HAB Request
    •  A Provider Statement of Need (PSON) is required by a provider who has examined the member and reviewed the medical record within the last 12 months in order to initiate the assessment process.
    • The PSON will only be accepted from a physician, advanced practice registered nurse or physician assistant, and must be signed by the provider no more than 90 calendar days prior to the date of the request.
    • Superior’s Service Coordinator will be responsible for coordinating with the physician to obtain the required PSON, or in the alternative, may accept a PSON obtained by the service provider.
    • Superior’s Service Coordinator will complete the functional needs assessment following receipt of the PSON.
  2. PAS, PCS or CFC HAB Change in Condition
    • A new functional needs assessment is required when there is any change in the member’s condition or environment.
    • Superior’s Service Coordinator will be responsible for coordinating with the physician to obtain the required PSON, or in the alternative, may accept a PSON obtained by the service provider.    
  3. PAS, PCS or CFC HAB Reassessment
    • A new functional needs assessment will be completed by Superior’s Service Coordinator, a minimum of once a year.
    • A new PSON will be obtained prior to the member’s annual reassessment for PAS/HAB services each year.   Superior’s Service Coordinator will be responsible for coordinating with the physician to obtain the required PSON, or in the alternative, may accept a PSON obtained by the service provider.

B.    DETERMINATION/AUTHORIZATION

  1. Superior’s Service Coordinator will notify the provider of the recommended hours (if any) derived from the completed assessment.
  2. The provider will have the opportunity to discuss any concerns or questions related to the recommended hours, to include indicating formal disagreement with those hours, and obtain a complete copy of the assessment document if needed.
  3. The functional needs assessment will be sent to a Superior Medical Director for review and determination if the provider does not agree with the assessment and recommendation.

For any questions, please feel free to contact your dedicated Account Manager, or Provider Services at 1-877-391-5921.