55 Pa. Code § 52.26 - Service coordination services
(a) To be paid for rendering service
coordination services, an SCE shall:
(1)
Complete a person-centered assessment.
(2) Complete a level of care re-evaluation at
least annually.
(3) Develop a
service plan for each participant for whom the SCE renders service coordination
services. The provider shall complete the following:
(i) Develop and modify the participant's
service plan at least annually.
(ii) Modify the participant's service plan,
if necessary, when the participant has a significant medical or social
change.
(4) Review the
participant need, the participant goal and participant outcome with the
participant and other persons that the participant requests to be part of the
review as required by conducting the following:
(i) At least one telephone call or
face-to-face visit per calendar quarter. At least two face-to-face visits are
required per calendar year.
(ii)
More frequent calls or visits if the service coordinator or the Department
determines more frequent calls or visits are necessary to ensure the
participant's health and safety.
(5) Coordinate a service, TPR and informal
community supports with the participant to ensure the participant need, the
participant goal and the participant outcome are met.
(6) Provide the participant with a list of
providers in the participant's service location area that are enrolled to
render the service that meet the participant needs.
(7) Inform the participant of the
participant's right to choose any willing and qualified provider to provide a
service on the participant's service plan.
(8) Confirm with the participant's selected
provider that the provider is able to provide the service in the type, scope,
amount, duration and frequency as listed on the participant's service
plan.
(9) Provide information
regarding the authorized type, scope, amount, duration and frequency of
services as listed in the participant's service plan to the provider rendering
the service.
(10) Ensure and
document at least on a quarterly basis that the participant's services are
being delivered in the type, scope, amount, duration and frequency as required
by the participant's service plan.
(11) Evaluate if the participant need,
participant goal and participant outcome are being met by the
service.
(12) Ensure a participant
exercising participant-directed budget authority does not exceed the number of
service hours approved in the participant's service plan.
(b) If additional information is necessary to
ensure that services are provided to a participant in the type, scope, amount,
duration or frequency as required by the participant's service plan, the SCE
shall convey the additional information to a provider.
(c) The SCE shall ensure a waiver or Act 150
service assigned to a participant is a service offered under the waiver or Act
150 service in which the participant is enrolled.
(d) If a participant is available to receive
only a portion of the service coordination services in subsection (a), the
Department will pay for those portions of the services rendered to the
participant.
(e) If the SCE is an
OHCDS, then the SCE shall be a direct service provider of at least one vendor
good or service.
(f) If services are
not being delivered by a provider to a participant in the type, scope, amount,
duration or frequency as required by the participant's service plan, then the
SCE shall work with the provider to do either of the following:
(1) Ensure that services are being delivered
to the participant in the type, scope, amount, duration and frequency required
by the participant's service plan.
(2) Transition the participant to a provider
who is willing and qualified to provide services to the participant in
accordance with the participant's service plan.
(g) The Department may limit the number of
service coordination units available to participants as provided in the
approved applicable waiver, including approved waiver amendments.
(h) A provider may not bill for more units of
service coordination services for a participant than provided for in the
participant's service plan.
(i) If a
participant requires more units of service coordination services than provided
for in the participant's service plan, then the SCE shall submit:
(1) A request to increase the number of
service coordination units for the participant to the Department.
(2) Justification for why the participant
requires more units of service.
(3)
The number of service coordination units the participant is assessed to
need.
(j) If the service
is also offered as a Medicaid State Plan service, then the Medicaid State Plan
service shall be accessed prior to another Departmental program to provide the
service.
(k) The SCE or the
Department's designee shall assist a participant to collect and send
information to the Department to determine the participant's continued
eligibility for the waiver or Act 150 program, including financial
eligibility.
Notes
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No prior version found.