GF Enhanced Benefit Plan
Tier II Determination
Consumer:
Primary Case Holder:
Date of Review:
Staff Completing Review:
___ Initial Determination
Case Number:
Program:
Title:
___ Continuing Determination
In order to determine consumer eligibility and authorization for services from the GF Enhanced Benefit
Plan, the following criteria should be used:
I.
Medicaid (check or attach Medifax)
Does Consumer have Medicaid?
Yes
No
If Yes, the necessary supports/services are authorized through Medicaid plan.
If no, Was Medicaid applied for? [ ]Yes [ ] No
If Yes, When was it applied for and what is status?
If applied for and denied what is the reason for denial?
If No, an application will be submitted by:
II.
Other Insurance/Third Party Payors
1. Does Consumer have other insurance/third party payors? (BCBS/Medicare/private
insurance)
Yes
No
If yes, the necessary supports/services are authorized through that benefit plan
III.
Alternative Supports/Services
1. What alternative supports/services have been accessed? List sources accessed and rationale for
denial:
IV.
Hospitalization/More Restrictive Placement
1. Is there imminent risk of hospitalization if services are denied?
Explain:
Yes
No
2. Is there imminent risk for more restrictive placement if services are denied?
Yes No
Explain:
V.
Medical Necessity/Amount/Scope/Duration
1. What are the types of services being requested?
GF Enhanced Benefit Plan Tier II Determination
Page 2 of 3
2. What is the amount of services? (number of units) What is the scope of services?
(who/how/where)? What is the duration of services? (length of time to be provided)
3. Are these services consistent with the Diagnosis, symptoms, functional impairment and
necessary to meet the needs of the consumer?
Yes
No
Explain:
4 Are these services the most cost effective?
Explain:
Yes
No
5. Are these services provided in the least restrictive environment?
Explain:
6. Are these services consistent with clinical standards of care?
Explain:
Yes
Yes
No
No
7. What is the criteria for discharge or to transition to less intensive supports and services?
VI.
Frequency of Evaluation
1. At what frequency will this plan be evaluated for continuation of GF Enhanced services? If
over or under utilization of authorized services occurs, how will this be reviewed? Include
rationale for time frame.:
Primary Caseholder Signature
VII.
Date:
Determination/Authorization
1. Eligible for GF Enhanced Benefit Plan?
Yes
No
2 Approve of Services Requested (including Amount, Scope, and Duration)
[If plan includes Trained Respite Sitter or Family Friend Respite, must complete Section VIII]
Yes
No
Form #021
Reference: General Fund Specialty Services Plan
Rev: 12/05
D:\106735607.doc
GF Enhanced Benefit Plan Tier II Determination
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If No, explain specific services (including amount, scope, and duration), that will be
approved:
3. If approving children’s group home or any child or adult partial hospitalization other than
LADT, has the required approval from the Medical Director (or designee) been obtained?
Yes
No
Next Review Date:
(Must review within 90 days)
Supervisor signature:
VIII.
Date
Respite:
Does this plan include:
1. Family Friend Respite at a level that would project to 100 hours or more annually?
Yes
No
2. Trained Respite Sitter services that would project to 180 hours or more annually?
Yes
No
If yes to either or both, approval signature is required below:
Family Friend Respite Plan:
Approved
Denied
N/A
Trained Respite Sitter Plan:
Approved
Denied
N/A
Division Director/Assistant Division Director/ Contract Manager
Date
Note: This form must be filed in the case record with the appropriate IPOS/Periodic
Review/Amendment Service Authorization Summary.
Form #021
Reference: General Fund Specialty Services Plan
Rev: 12/05
D:\106735607.doc