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340:100-3-33. Service authorization
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Revised 7-1-94
Services are prescribed as a result of determination by an IDT and informed consumer selection and authorized and implemented per provisions of DHS and DDSD policy and procedures. Authorization of services is contingent upon the availability of adequate resources.
- (1) All authorized, state funded services are implemented in accordance with DHS purchasing and contract policy and procedures.
- (A) No more than 12% of the individuals reflected on any provider agency claim for state funded services (e.g., group home, sheltered workshop, Community Integrated Employment) shall have a measured intelligence (full scale IQ) in excess of 70 (see OAC 340:100-3-1), except;
- (B) This cap shall be waived:
- (i) in cases where it is exceeded as a result of inclusion of individuals approved for services prior to 1-1-90. However, additional individuals with a measured intelligence of above 70 are not authorized for admission to state funded services through the provider agency until the percentage of individuals served with a measured intelligence (full scale IQ) exceeding 70 is reduced to 12% or less; or
- (ii) upon authorization by the Administrator of DHS/DDSD or his/her designee.
- (2) All Medicaid services are implemented in accordance with Title XIX (ICF-MR; HCBS Waiver) regulations or provisions, including freedom of choice requirements, of the HCBS Waiver and aggregate expenditure/recipient limitations established by HCFA, except; children eligible to receive services through public schools shall not be authorized for the same services through DHS/DDSD during the regular school session.
- (3) Case Managers are authorized to implement services prescribed for a client and documented within the IHP/Plan of Care, as follows:
- (A) Generic non-specialized services are to be accessed where possible;
- (B) Services are authorized for DDSD payment;
- (C) Authorization of HCBS Waiver services within an individual's plan of care does not exceed service specific utilization limitations established within Oklahoma's Title XIX Waiver;
- (D) The total expense of HCBW services does not exceed the statewide congregate average annual cost of HCBW services per client; and
- (E) Other services not addressed in the IHP and necessary to resolve an emergency, i.e., utilities, ambulance, not to exceed DDSD expenditures of $750.00 per event.
- (4) Area Managers or his/her designee are authorized to approve services exceeding the scope of authority of Case Mangers as follows:
- (A) Expenditures for HCBW services prescribed for a client on the Plan of Care, exceeding the statewide, congregate average annual HCBS Waiver expenditure by 35% or less per year.
- (B) Review and approval of expenditures requiring competitive bid (i.e., for Transportation and Adaptive Equipment and Architectural Modification services) of $750.00 or less.
- (5) The Administrator of DDSD or his/her designee reviews and authorizes the following:
- (A) Expenditures for HCBW services exceeding the statewide, congregate, average, annual cost of HCBW services by more than 35%.
- (B) The implementation of support or habilitative services not otherwise authorized by policy, subject to approval by the Director of DHS and/or the Commission for Human Services.
- (6) The DHS Medical Services Division reviews and authorizes Title XIX compensability of all HCBW and ICF-MR services.
- (7) The Board of Affairs authorizes state funded expenditures, for services requiring competitive bid (i.e., Transportation, Architectural Modification, and Adaptive Equipment), in excess of $750.00, following competitive bidding procedures established by state law and DHS policy.
- (8) Superintendents of Public ICF's-MR are authorized to approve the following:
- (A) Habilitation and support services required by each client as defined by Individual Habilitation Plans and regulatory standards, including the purchase of adaptive and mobility equipment;
- (B) The transition or discharge of clients from institutional services.
- (9) Consumers maintain the right to appeal service eligibility determinations as stipulated by Oklahoma's State Medicaid Plan and DHS rules. Consumers are provided literature and an understandable explanation describing procedures for exercising this right.
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