Participant Name:
SAR #:
SAR Submit Date:
NC Innovations Waiver and B3 DI (with U4 modifier)
Specialized Consultation Services: T2025; BCBA T2025HO
Met
Not
Met
N/A
Criteria to Approve Service
The request includes services to provide expertise, training, and technical assistance in a specialty
area (psychology, behavior intervention, speech therapy, therapeutic recreation, augmentative
communication, assistive technology equipment, occupational therapy, physical therapy, or
nutrition) to assist family members, support staff and other natural supports in assisting participants
with developmental disabilities who have long-term intervention needs.
The request includes training for family members and other paid/unpaid caregivers by a certified,
licensed, and/or registered professional, or qualified assistive technology professional to carry out
therapeutic interventions, consistent with the Individual Support Plan, therefore increasing the
effectiveness of the specialized therapy OR
The request includes services utilized to allow specialists defined to be an integral part of the
Individual Support Team to participate in team meetings and provide additional intensive
consultation and support for participants whose medical and/or behavioral/psychiatric needs are
considered to be extreme or complex.
The request includes at least one of the following activities:
o Observing the beneficiary to determine needs
o Assessing any current interventions for effectiveness
o Developing a written intervention plan which may include recommendations for assistive
technology/ equipment, home modifications, and vehicle adaptations. Intervention plan
clearly delineates the interventions, activities and expected outcomes to be carried out by
family members, support staff, and natural supports
o Training of relevant persons to implement the specific interventions/support techniques
delineated in the intervention plan and to observe, record data and monitor implementation
of therapeutic interventions/support strategies
o Reviewing documentation and evaluating the activities conducted by relevant persons as
delineated in the intervention plan with revision of that plan as needed to assure progress
toward achievement of outcomes
o Training and technical assistance to relevant persons to instruct them on the implementation
of the beneficiary’s intervention plan
o Participating in team meetings and/or
o Tele-consultation through the use of two-way, real time interactive audio and video between
places of lesser and greater clinical expertise to provide behavioral and psychological care
when distance separates the care from the beneficiary.
The request does not duplicate services provided to family members or caregivers through Natural
Supports Education and Crisis Services or duplicate services provided to family members or
caregivers through Natural Supports Education.
The service is provided by staff who have one of the appropriate NC license for physical therapy,
occupational therapy, speech therapy, psychology and nutrition; board certified behavior analysis –
MA; master’s degree and expertise in augmentative communication; state certification in assistive
technology or state certification in recreation therapy.
Initial Review:
All Criteria Met:
YES – APPROVE
NO (Send to Clinical Reviewer)
Note: All Specialized Consultative Service requests must be reviewed by Clinical Reviewer (Smoky).
1/1/2015
Specialized Consultative Services
Page 1
Reviewer Name, Credentials:
Date:
Comments:
Clinical Review:
Approved
Send to Peer Review
Reviewer Name, Credentials:
Date:
Comments:
1/1/2015
Specialized Consultative Services
Page 2