HCBS-AMH Provider Selection Update Form

• Provider Selection Update Form is one of the forms used by the current provider to change the current service provider upon an individual’s request in a Home and Community Based Services Adult Mental Health (HCBS-AMH) entity.
• Clinical Management for Behavioral Health Services (CMBHS) provides Health and Human Services Commission (HHSC) service-contracted providers a place where they can document the “End Date” of service for current providers and can make selection of new providers for an individual with authorization from HHSC.
• “Provider Selection Form” must be in closed complete status to change a provider in the “Provider Selection Update Form.”
• The Provider Selection Update Form can be used to change the provider irrespective of the Individual Recovery Plan (IRP).

Before You Start

1. You must be assigned a CMBHS role that allows you to utilize the Provider Selection Update Form functionality in the CMBHS application .
2. The Client must have a Client Profile in CMBHS.
3. You must be in the client’s CMBHS record, at the Client Workspace, to create a Provider Selection Update Form in the CMBHS application.
4. If the user wants to change the provider in the CMBHS application, then the system must satisfy the following scenarios:

a. If there is no Individual Recovery Plan (IRP) record on file in the system, then “Clinical Eligibility” and “Provider Selection Form” must be in Closed Complete status.

b. If there is an existing record of an IRP in the system (Initial/Update/Annual), then the most recently approved version of the Individual Recovery Plan (IRP) and Clinical Eligibility (CE) must be in Closed Complete status.

Pre-Conditions Not Met Errors

1. If “Provider Selection Form” or “Clinical Eligibility” is not in closed complete status, and user tries to access the Provider Selection Update Form, then the system must display an error message on selection of “Provider Selection Update Form.”   Error message: “In order to access the Provider Selection Update Form, Provider Selection and Clinical Eligibility must be completed and placed in Closed Complete Status.”
2. If the existing version of the IRP is in draft status, and the user tries to access Provider Selection Update Form, then the system must display an error message: “ Provider Selection Update form cannot be accessed because IRP is in draft status.”
3. If the existing version of the IRP is in “Ready for Review” status, and the user tries to access the Provider Selection Update Form, then the system must display an error message: “ Provider Selection cannot be accessed because IRP is in ready for review status. Please contact HHSC.”
4. If the existing version of the “Provider Selection Update Form” is in Ready for Review status, and a user tries to access the Provider Selection Update Form, then the system must display an error message: “ Provider Selection Update Form in Ready for Review status already exists for this individual.”

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Provider Selection Update Page Details

Provider Selection Update Form page has the following sections:

Section 1: Individual Information

• Individual Name: Pre-populating from Client Profile
• Individual Number: Pre-Populating from Client Profile
• Individual Date of Birth: Pre-populating from Client Profile
• Care ID: Pre-populating from Client Profile
• Legally Authorized Representative: Pre-populating from Client Profile. If the Individual has multiple LARs, then the system will display all the LARs with a comma separator.

Section 2: Provider Information Section

Functioning of “No Change” Check Boxes:

• If the user is not changing the current provider, the ‘No Change’ check box should be checked for the Current Service County/LMHA/HCBS-AMH RME/HCBS-AMH PA.
• “No Change” check box works in alignment with future provider selection fields (Future Service County, Future LMHA, Future HCBS-AMH RME, HCBS-AMH PA), Effective Date and End Date data fields.
• If the user selects “No Change” check box for specific provider (could be Current Service County/LMHA/HCBS-AMH/HCBS-AMH PA), then the system will grey out the Future selection of that provider along with Effective and End Date fields.
• If the user is not selecting “No Change” check box for any of the four providers (Current Service County/LMHA/HCBS-AMH RME/HCBS-AMH PA), then the user is required to make a new selection in the future dropdown list of changing providers.
• If ‘No Change’ check boxes are selected/checked for all the current Providers (Current Service County, Current LMHA, Current HCBS-AMH RME and Current HCBS-AMH PA) and the user tries to Save the document in Draft or Ready for Review, the following error message is displayed.
• Error message: In order to save the document, there must be a change to at least one option .

Current Service County, Current LMHA, Current HCBS-AMH RME and Current HCBS-AMH PA:

The information must be pre-populated from the “Provider Selection Form.” These fields are not editable (Read Only form).

End Date

• This is a date when “Current” providers will stop providing the HCBS-AMH services to the individual. The End Date has impact on the claims processing of the changing provider. The Current providers would not be able to bill the claims after the effectiveness of the “End Date.”
• If the “No Change” check box is not selected by the user, then the “End Date” field is a required field and the date needs to be manually entered.
• The “End Date” cannot be future dated.
• The “End Date” can be backdated to “Transfer Request Date.”
• If the user has not selected/checked ‘No Change’ check box for any of the providers (Current Service County/LMHA/HCBS-AMH/HCBS-AMH PA) and the ‘End Date’ field is missing the date, then the system displays the following error message:

Error message: End Date is required for ….  (Possibilities: Current Service County/LMHA/HCBS-AMH/HCBS-AMH PA.)

Original Referring Entity: The system defaults the value from the 'Original Referring Entity' field captured on the 'Provider Selection Form' to the 'Original Referring Entity' field regardless of the different versions of the Provider Selection Update form. The pre-populated value will not be editable by the user.  

Future Service County, Future LMHA, Future HCBS-AMH PA and Future HCBS-AMH RME Functioning

• Future Service County, Future LMHA, Future HCBS-AMH PA and Future HCBS-AMH RME are the dropdown fields. “Select Future Service County, Future LMHA, Future HCBS-AMH PA and HCBS-AMH RME values from their respective drop-downs.
• If the user selected the same value in the in the “Future HCBS-AMH PA” and “Future HCBS-AMH RME” dropdown lists, a conditional message check box displays with the below message:
• “You have selected the same organization for both Provider Agency and Recovery Management Entity. By checking this box, you affirm this organization is the provider of last resort.”
• If the user omits to check the conditional message check box and tries to save the document in Ready for Review status, the following message is displayed: “To save this document the check box should be checked or PA and RME values should be different.”
• If the user selects different values in the “Future HCBS-AMH PA” and “HCBS-AMH RME” dropdown lists, the conditional message will be hidden.

Effective Date

The Effective Date indicates the date when the future providers will start providing HCBS-AMH services to individuals. The changing providers can bill after the Effective Date.

• The “Effective Date” is auto-calculated based on the value entered in the “End Date” field.
• The Effective Date will be in ‘Read Only Form.’
• The system calculates the “Effective Date” value one day after the “End Date” value. For example, if the user is making the current date as an End Date for the current provider, then the system calculates the value in the “Effective Date” as tomorrow’s date for the Future/New Providers.HHSC staff has all the authority to change the “Effective Date” for the new providers.

Consent verbiage check box:

This is a required check box. The user should check the consent verbiage to save the document in ready for review:

By signing this form, I am giving permission for the above – listed entities to use and disclose all HCBS-AMH-related health information, including Client Demographic Information, HCBS-AMH ANSA, Diagnosis, Clinical Eligibility, Progress Notes, Day Rate Attendance, Critical Incident Report, Provider Selection Form, Provider Selection Update Form, Individual Recovery Plan, and Notification of Individual’s Rights. I authorize the use and disclosure of this information for HCBS-AMH continuity of care and service provision.
This authorization is valid as long as I am receiving services from above- selected HCBS-AMH Provider Agency and Recovery Management Entity.

 

Section 3

Contact Information

• Name (Required): It is free text field.
• Email (Required): It is free text field.
• Phone (Required): It is a numeric field with xxx-xxx-xxxx format. Any invalid entry will prompt system to generate the following error message: Phone Number is invalid.

Section 4

Signature (Required)

• Individual (Required)
• Legally Authorized Representative (LAR) (Required)
• Staff (Required)

Individual: This signature field will have three (3) radio buttons from which the users can select:

• Signed: When the user selects this option the system will display the date field with the current system date. The date field cannot be prior to the Provider Selection Date.
• Refused: This option will be selected when the individual client refuses to sign the form. When the user selects this option, the system will not display the date field and displays the free text box to enter the reason for refusal. It is required to enter the reason, if ‘Refused’ radio button is selected.
• Unable to Sign: This option will be selected when the individual is unable to sign. When the user selects this option, the system will not display the date field.

LAR: This signature field will have two (2) radio buttons for users to select:

• Signed: When the user selects this option, the system will display the dropdown field with all the LAR name’s listed. The user should select the name from the dropdown or Other. Once the user selects the LAR from the dropdown, the system will display the Date field with the current system date. The date field cannot be prior to the Provider Selection date.
• Other: The system will display Other free-text field for the user to enter the name. The name entered in the Other field will only be saved on the form and not on the Client Profile Page.

No LAR: This option will be selected when there is no LAR present with the individual or the individual agrees not to have a LAR signature. When the user selects this option, the system will not display the date field.

Staff Date is required.

Section 5

Document Status (Required): The drop-down values are Draft, Ready for Review, and Closed Complete.

• If the user selects “Draft” drop-down value, then the user can make the changes in the document later or in the future, only if the Provider Selection Update Form is in Edit View.
• If the Document status is selected as “Ready for Review,” the user can save the document and can make the changes in the document in the future, only if the Provider Selection Update is in Edit View.
• The drop-down value “Closed Complete” is only effective at the Approver location.

Document Status Date (Required): It is a system generated date/pre-populated date in the Document Status Date field. It is in read-only form.

 

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Pre-Transfer Form

1. Scenarios in which the pre-conditions must be displayed on the screen:

1. When the user selects a dropdown value from the Future LMHA and there is no change in the Future HCBS-AMH RME/Future HCBS-AMH PA, the system DOES NOT display ‘Pre-Transfer Form’ in another tab.
2. When the user selects a dropdown value from the Future LMHA, Future HCBS-AMH RME and Future HCBS-AMH PA, the system DOES NOT display ‘Pre-Transfer Form’ in another tab.
3. When the user selects a dropdown value from the Future HCBS-AMH RME, the system displays ‘Pre-Transfer Form’ in another tab. In that case, the user is required to complete the Pre-Transfer information to save the “Provider Selection Update Form” in Ready for Review status.
4. When the user selects a dropdown value from the Future HCBS-AMH PA, the system displays ‘Pre-Transfer Form’ in another tab. In that case, the user is required to complete thePre-Transfer information to save the “Provider Selection Update Form” in Ready for Review status.
5. When the user selects a dropdown value from the Future HCBS-AMH RME and Future HCBS-AMH PA, the system displays ‘Pre-Transfer Form’ in another tab. In that case the user is required to complete the Pre-Transfer information to save the “Provider Selection Update Form” in Ready for Review status.

2. Pre-Transfer Form has the following sections:

Reasons for Request Transfer

Select one or more options from the following nine check boxes:

3. List strategies that have been used to resolve the issue (e.g., copying strategies, mediation, IDT meeting).

The user can enter the comments in the text box. This is a required field.

4. What action steps did the RM take to assist in resolving the issues? Please list time frames and strategies.

The user can enter the comments in the text box. This is a required field.

 

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Audit Information

This section provides following details to the user, when the document is saved in the system:

• Created By: System-generated value. It displays the name of the user who has the initiated to complete the document.
• Created Date: System-generated value. It displays document saved date and time.
• Last Saved By: System-generated value. The system displays the name of the user who saved the document in the system.
• Last Saved Date: System-generated value. The system displays the document last saved date.
• Approved By: This information is displayed only when the document is in closed complete status.
• Approved Date: System-generated value. The system displays the last approved date of document and time of the document.

Blank English and Spanish PDF Forms

Blank PDF forms in English and Spanish versions are available to be used to avoid any inconvenience caused by system down time or technical issues.

The navigation path to locate the forms in CMBHS Data > Print Blank Form.

Document Sharing with effective providers listed on close completing the Provider Selection Update Form

• The system will disclose the HCBS-AMH documents available in both ‘Records created at business entity’ and ‘Consented Records’ section of Client Workspace to the changing provider on the Provider Selection Update form from the effectiveness of 'Effective date of new provider'. 
• From the effectiveness of ‘End Date of old provider’, old provider would have no longer access to the HCBS-AMH documents (all the new documents to be created for the continuation of care).