Service Approval

For certain services, approval is required for the service from a Division staff. A plan that contains one or more of such services requires all services to be approved before proceeding with plan approval.

The conditions for a service that requires approval are:

●       The Self-Directed Employee (SDE) rate is either above or below the “Reasonable & Customary” values

●       The Support Coordinator (SC) enters a customized rate for the service (in a Supports Program or CCW plan)

●       Services related to an evaluation performed by an Assistive Technology provider

●       The Support Coordinator has added an Individual Support service with daily unit type and a separate Individual Support service with 15 minute unit type; the Individual Support service with 15 min unit type, irrespective of the provider (previously the condition was both services are from the same provider), requires service approval

●       The Support Coordinator has added an Individual Support service with daily unit type and a separate Community Inclusion Services with 15 minute unit type and obligated from the Emp/Day budget, then the Community Inclusion Services require service approval

With this change, there is a document that must be included for Goods & Services and Transportation services. This feature is available on the Service section during addition of such a service.

There is a new plan status, known as Service Review, introduced for services that require approval by Division staff. The Support Coordination Supervisor (SCS) changes the plan status from Review to Service Review for a plan that includes the aforementioned service(s). The assigned Division staff reviews and then approves or denies appropriate service(s). A denied service includes service denial notes so that the SC can make the changes required for service approval.

The abbreviation for Service Review in iRecord is SR. On tiles that abbreviate the plan status, SR refers to a Service Review plan status.

In iRecord, designated Division staff is assigned a duty to approve or deny services. The user may approve the plan (after services are approved) provided the Support Coordination agency of the participant has self approval status or send the plan for standard State Review otherwise.  

The following figure displays an outcome that requires approval. The services shown in the figure are at various stages of the approval process.

Features

●       For services that require an approval, a litmus indicator on tile header displays the current status of service. The following table provides a reference for litmus indicator status.

●       The Outcomes (left navigation) tile displays a litmus indicator that represents the status of the services, as shown in the figure below. Refer to the following table for indicator conditions.

●       On Notes, Service Approval Notes - Approved category displays for any system notes entry during approval of a service.

●       On Notes, Service Approval Notes - Not Approved category has been introduced for notes entered during denial of a service.

To approve a service

1.        On Plans, select the Outcome and then click  of the appropriate service to view the service menu.

2.        Click Service Approved.

3.        For an approved service, the status indicator displays green (changes from yellow for a pending service or red from a not approved service).

4.        The service menu options available for an approved service are:

•        View Service

•        View Exceptions

•        Email Service Detail

•        Service Not Approved

Note: The user (with the assigned duty) has the option to approve or not approve a service until the plan changes from Service Review to the next appropriate status.

To view Service Approval Notes - Approved

1.        On Notes, search for appropriate note using Note Category and Note Date. There is a new category for such notes and they are classified by Service Approval Notes - Approved.

2.        Click the appropriate line item and view the Notes pop-up.

To not approve a service

1.        On Plans, select the outcome and then click   of the appropriate service to view the service menu.

2.        Click Service Not Approved.

3.        View the Service Not Approved pop-up, as shown below.
Select Reason has the following options: Requires Additional Information, Final Denial and Other. It is required for the user to select a reason and then enter notes, limited to 1000 characters, pertinent to service denial. For certain services, there is the additional option of the Fair Hearing Letter, which is documented in a separate section below.

4.        Click  to save and close Service Not Approved pop-up.

5.        View a red litmus indicator for a denied service.

6.        The service menu options available for a denied service are:

•        View Service

•        View Exceptions

•        Email Service Detail

•        Service Approved

•        View/Edit Service Approval Notes - Not Approved

Note: The user (with the assigned duty) has the option to approve or not approve a service until the plan changes from Service Review to the next appropriate status.

To view/edit Service Approval Notes - Not Approved

1.        On Plans, select the appropriate Outcome and then click  on the appropriate service.

2.        Click View/Edit Service Approval Notes - Not Approved.

3.        The View/Edit Service Approval Notes - Not Approved pop-up appears, as shown below.
The field, highlighted below, is view-only and displays the most recently entered denial notes for the service.

Note: The user may also view the notes on the Notes screen. The Service Approval Notes - Not Approved category has been introduced to filter such notes.

4.        Edit notes in the highlighted section, as shown below. The notes are limited to a maximum of 1000 characters.

5.        Click  to save and close the View/Edit Service Approval Notes - Not Approved pop-up.

Plan Approval

The instructions below indicate the complete sequence of steps for plan approval when adding service(s) to a plan that requires service approval.

To approve a plan

1.        On Plans, the Support Coordinator (SC) adds the required service(s).

2.        A yellow litmus indicator appears on each service that requires service approval.
The Outcome(s) also displays a yellow litmus indicator when there are one or more services that require service approval.

3.        The SC changes the plan status to Review on the Change Plan Status tile.

4.        The Support Coordination Supervisor reviews the plan details and then changes the status of the plan to Service Review.

●       For the user assigned with Service Approval duty, the Due-List is as shown in the figure below. The following table provides a reference to the information on the Due-List tile.

5.        Click the appropriate line item in the Due-List and the user approves or denies the service(s), adding Service Approval Notes - Not Approved  for each service that was not approved.
After a decision has been completed on all appropriate services and the plan includes a service that was not approved, the plan status is changed to Revision by the assigned user.
The Support Coordinator reviews the notes of services that are not approved and then applies the changes required for approval.
Repeat the steps 3 to 6 until approval of service(s) is complete.

Note: The user (assigned with service approval duty) has the option to Service Approved or Service Not Approved in all plan statuses except Approved, Approved-To-Inactive, Review-To-Inactive and Review-To-Reinstate. It is also not allowed in High Level Review with a previous status of Review-To-Reinstate.

6.        The assigned user changes the plan status to:

•        Approved (the SC agency has self-approval status and the duty is assigned to State Only user or the SC agency does not have a self-approval status and the duty assigned to a WAC, which is also responsible for the same agency)

•        State Review (the SC agency does not have self-approval status or the duty is assigned to a WAC who is not responsible for the agency)

7.        The standard guidelines are followed after services are approved and plan is in State Review or High Level Review.

Any Service Approval or Service Review related questions, please contact the Service Approval Help Desk (DDD.ServiceApprovalHelpDesk@dhs.state.nj.us).

Fair Hearing Letter

Approval is required for certain services from a Division staff.

There is additional functionality that supports Final Denial and Fair Hearing Letter for the Service Not Approved option. This functionality is applicable for the following services:

●       Goods & Services

●       Assistive Technology

●       Vehicle Modification

●       Environmental Modification

●       Individual Supports

●       Transportation

●       Self-Directed Employee Services

Final Denial

Final Denial is intended for new services or previously approved future services. There is a Fair Hearing Letter generated and sent to the Participant, Legal Guardian(s), Support Coordinator and the Support Coordination Supervisor on the Final Denial of the service, when the email address has been provided in iRecord. The user also has the option to not send the Fair Hearing Letter to the individuals. A copy of the Fair Hearing Letter is also uploaded to the Documents grid, when generated.

To select Final Denial with Service Not Approved

1.        On Plans, select the appropriate service and then click to view the service menu.

2.        The menu options appear, as shown. Click Service Not Approved.

3.        View Service Not Approved pop-up. Click the Select Reason field and view the drop-down options, which are:

•        Requires Additional Information

•        Final Denial

•        Other

4.        Click Final Denial.

Note: The user selects Requires Additional Information or Other, as appropriate, and then enter the notes to follow the standard process of the Service Not Approved option.

5.        There are additional fields that appear on the Service Not Approved pop-up, as shown below. The following table provides a brief description of the additional fields.

6.        Click  to save the details of Final Denial for Service Not Approved.

7.        The Service Not Approved pop-up displays the individuals (with email addresses on iRecord) that the Fair Hearing Letter will be sent, with the selection of the Save Fair Hearing Letter check box. Click to confirm.

8.        View the Service on the Plans tab with a red litmus status indicator for the service. Hover over the indicator to view the tooltip Final Denial.

9.        The Documents tab displays a copy of the Fair Hearing Letter within the grid, on confirmation of the previous step. The details of this entry are provided in the following table.

10.     The Notes tab displays an entry for the entered notes with the Note Category of Service Approval Notes – Not Approved.

Plan Approval after Final Denial

The Change Plan Status tile litmus indicator displays red, as shown, when the plan includes one or more services with Service Not Approved.

With the Division staff (user assigned with the Service Approval duty) performing a Final Denial on the service, the Support Coordinator must delete the service to follow the standard procedure of plan approval.

Email Notification on Fair Hearing

An email notification with an attached Fair Hearing Letter is sent to the Participant, Legal Guardian(s), Support Coordinator and Support Coordination Supervisor on Final Denial of the service. The email is sent to the participant and Legal Guardian(s) and cc(ed) for the Support Coordinator and Support Coordination Supervisor. In case the participant is assigned to an SC Agency and the case has not been transferred to an SC or SCS, the address provided in cc is the agency’s default email address.

The user assigned with the duty for Service Approval also has the option to not send the email notification on Final Denial.

Upload Additional Documentation for Final Denial

The Division staff (user assigned with Service Approval duty) and the VO-TS user has the option to upload additional documentation for Final Denial through the Documents page.

To upload additional documentation

1.        On the Documents page, click the Upload Document button.  

2.        The Upload Document pop-up controls appear, as shown in the following figure. Enter the details for each field, refer to the next table. All fields are mandatory unless indicated otherwise.

3.        Click  to save and close Upload Documents. View the document on the Documents page.