R9-28-1206. Extraordinary Care Review

A. Each ALTCS Contractor, including DES/DDD, shall develop an ECR process to be submitted to the Administration for review prior to implementation. B. The ECR process shall adhere to the provisions of this Section and shall include: 1. The purpose, 2. The notification process to members of the availability of ECR, 3. How the ECR may be requested, including the information that must be provided, 4. The type of clinician performing the ECR pursuant to subsection (C), and 5. Description of how the ECR records shall be maintained. C. The ECR process shall be conducted by a clinician with relevant professional experience and licensure or certification. D. When a member or HCDM disagrees with the time assessed on the HNT, the ALTCS Contractor, including DES/DDD, shall notify members, in writing, of the ECR process. E. A request for ECR shall be made in writing. 1. The request shall be made by the member or HCDM. 2. The request shall include: a. Whether the member is seeking additional Direct Care Services, Habilitation Service, or both; b. How many additional hours are requested for each service type, and for attendant care services, task- specific rationale must be provided. c. The reason the member should be granted additional time for Extraordinary Care. Any additional supporting documentation can be included for review. F. Upon request for ECR, each ALTCS Contractor, including DES/DDD, shall: 1. Complete an ECR for Direct Care Services, Habilitation Service, or both consistent with the request. 2. Render a decision in writing. a. Inform the member, the HCDM, and the member’s Case Manager of the ECR determination which shall be incorporated into the member’s PCSP by the ALTCS Case Manager. b. When the total time assessed for Direct Care Services, Habilitation Service, or both, is increased from the previous authorized hours, the services shall be authorized for service delivery by the ALTCS Case Manager. c. When the total time assessed for Direct Care Services and Habilitation Service, or both, is less than the amount of time requested by the member in the ECR process, the ALTCS Contractor, including DES/DDD, shall issue a Notice of Adverse Benefit Determination pursuant to A.A.C. R9-34-205. 3. Adhere to federal timelines regarding decision making and notification of the outcome to members/families.