Participant Name:
SAR #:
SAR Submit Date:
NC Innovations Waiver and B3 DI (with U4 modifier)
Community Networking: Service-Individual-H2015; Group-H2015HQ;
Class and Conference-H2015U1; Transportation-H2015U2
Met
Not
Met
N/A
Criteria to Approve Service
The service interventions include individualized day activities that support the beneficiary’s
definition of a meaningful day and meaningful community relationships with non-disabled
individuals.
The service interventions include a combination of training, personal assistance and supports as
needed by the beneficiary during activities.
The service interventions are directed at increasing or maintaining the participant’s capacity for
independence and developing social roles valued by non-disabled members of the community.
The service interventions are designed to promote maximum participation in community life while
developing natural supports with integrated settings.
The request for service is individualized, specific and consistent with the participant’s assessed
disability and specific needs.
The service can be safely furnished, and no equally effective and more conservative or less costly
treatment is available statewide.
Service is not requested to be furnished in a manner primarily intended for the convenience of the
participant, primary caregiver, the provider, employer of record, or the managing employer.
The service is provided separate and apart from the participant’s private residence, other residential
living arrangement, and/or the home of a service provider.
Request does not include activities that would normally be a component of a participant’s
home/residential life or services.
The service is not being provided in a licensed facility
The service requested includes one or more of the following:
o Participation in adult education or Adult Basic Skills education classes through integrated
Community College settings,
o Development of community based time management skills,
o Community based classes for the development of hobbies or leisure/cultural interests,
o Volunteer Work,
o Participation in formal/informal associations and/or community groups,
o Training and education in self-determination and self-advocacy,
o Using Public Transportation
o Inclusion in a broad range of community settings that allow the beneficiary to make
community connections; and/or
o Transportation when the activity does not include staffing support and the destination of
the transportation is an integrated community setting or a self-advocacy activity. Payments
for transportation are an established per trip charge or mileage.
Children Only: Request may include staffing supports to assist children to participate in day care/
after school summer programs that serve typically developing children and are not funded by Day
Supports.
The service request does not include the participant volunteering for the Community Networking
service provider.
Request does not include pay for day care fees or fees for other childcare related activities.
If the recipient is eligible for educational services under the Individuals with Disability Educational
1/1/2015
Community Networking
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Act, this service does not include transportation to/from school settings, the recipient’s home or any
community location where the person may receive services before/after school.
Class/Conference Only: Request may include payment for attendance at classes and conferences.
Class/Conference Only: Request does not include the cost of any of the following:
Hotels, meals, materials or transportation while attending conferences.
The request does not include payment for overnight programs of any kind.
The request does not include payment for membership of any type.
The request does not include classes that offer one-to-one instruction and are in a non-integrated
community setting.
The request for payment for attendance at classes and conferences does not exceed $1000 per
participant plan year.
There is documentation of outcomes for these objectives.
The request does not duplicate services provided under Community Guide; Day Supports, In-Home
Intensive Supports, In-Home Skill Building, Personal Care, Residential Supports and/or Supported
Employment services.
Additional Criteria for QP Approval (If not met, promote to Clinical Reviewer)
No more than 40 hours/week combined habilitative services requested
Service has not been denied or partially denied this plan year
Guidance: If group service is available and appropriate, documentation present that it has been considered.
Initial Review:
All Criteria Met:
YES – APPROVE
Reviewer Name, Credentials:
NO (Send to Clinical Reviewer)
Date:
Comments:
Clinical Review:
Approved
Send to Peer Review
Reviewer Name, Credentials:
Date:
Comments:
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Community Networking
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