CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Request and authorization process for hiring a Legally Responsible Individual (LRI) as a paid Personal Care Services (PCS) provider

Defines requirements and process for members/parents/guardians/legal representatives to request that a Legally Responsible Individual (LRI) be authorized as a paid caregiver for PCS under EPSDT, Agency Based Community Benefit (ABCB), or Self-Directed Community Benefit (SDCB). Applies to submissions to the member's Managed Care Organization (MCO).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyRequest and authorization process for hiring a Legally Responsible Individual (LRI) as a paid Personal Care Services (PCS) provider

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain written prior authorization from the member's MCO before hiring an LRI and submit the completed LRI Request Form with supporting documentation for MCO review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

AnnualLRI requests must be resubmitted for review

WrittenApproval/denial must be provided in writing by MCO

Prior approval requiredMCO authorization required before LRI may be hired

Policy summary and scope

This policy defines the requirements and process for members, parents, guardians, or legal representatives to request that a Legally Responsible Individual (LRI) be authorized as a paid caregiver for Personal Care Services (PCS) under EPSDT, Agency Based Community Benefit (ABCB), or Self-Directed Community Benefit (SDCB). It applies to requests submitted to the member's Managed Care Organization (MCO) and requires that the MCO provide written approval or denial and that prior authorization be obtained before the LRI may be hired.

Form details summary

LRI Request FormLegally Responsible Individual Request Form

Required fieldsMember name, Member date of birth, Medicaid Card ID #, Phone, Address, Name of requested employee (LRI), Legal relationship to member, Service to be provided (EPSDT PCS, Agency Based PCS, Self-Directed PCS), Care plan dates and type (Initial, Annual, Revision), Member/Legal Representative signature (note: person requesting to be paid LRI cannot sign), Responses to: attempts to find other providers; extraordinary circumstances; LRI skills and abilities; specific job duties requested; reasons non-LRI is unable to provide service, Any additional information

MCO office useApproved/Denied checkbox, Approved start and end dates, Notes section, MCO authorized signature and date

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyRequest and authorization process for hiring a Legally Responsible Individual (LRI) as a paid Personal Care Services (PCS) provider

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain written prior authorization from the member's MCO before hiring an LRI and submit the completed LRI Request Form with supporting documentation for MCO review.

SourceLink

On This Page

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When an LRI may be authorized as a paid caregiver

Conditions under which an LRI may be hired as paid PCS

An LRI can be authorized as a paid caregiver only when the following conditions are met.

ALL of the following

The request is submitted to and authorized by the member's MCO in writing prior to services being provided.
The LRI meets employment qualifications and training standards required for caregivers.
Caregiving services provided by the LRI meet the definition of a covered service and are specified in the member's approved care plan.
There are extraordinary circumstances demonstrating inability to find and retain other qualified, suitable caregivers (necessitating the LRI to remain at home to ensure member's health and safety and avoid institutionalization).
Services requested are not duties the LRI would ordinarily perform in the household for individuals of the same age without disability or chronic illness.

What providers must do

Prior Authorization

MCO authorization required before hiring LRI

Prior approval by the member's MCO must be obtained in writing before the LRI may be hired to provide personal care services. The MCO must approve or deny the request in writing.

Documentation Required

Submission of LRI Request Form and supporting information

The member or caregiver must complete and submit the Legally Responsible Individual Request Form with detailed explanations of: attempts to find other qualified, suitable providers; any extraordinary circumstances; the LRI's special skills and abilities; the specific job duties requested; and reasons a non-LRI cannot provide the service. The Personal Care Agency and Care Coordinator or SDCB Support Broker and Employer of Record (when appropriate) assist with submission to the MCO.

Responses to: attempts to find other qualified, suitable providers
Description of extraordinary circumstances requiring the LRI
LRI skills and abilities that meet the member's needs
Specific job duties or tasks requested of the LRI
Reasons a non-LRI provider is unable to provide the approved covered service

Documentation Required

Annual review requirement

LRIs must be resubmitted to the MCO on an annual basis for review of ongoing LRI needs.

Billing Rule

Scope limitation on payable tasks

LRIs may not be paid for services that they would ordinarily perform in the household for individuals of the same age who do not have a disability or chronic illness; any paid tasks must be services specified in the member's approved care plan and meet the definition of covered personal care services.

Form and submission details

Send the completed Legally Responsible Individual Request Form to the member's MCO. Required form fields include: Member name; Member date of birth; Medicaid Card ID #; Phone; Address; Name of requested employee (LRI); Legal relationship to member; Service to be provided (EPSDT PCS, Agency Based PCS, Self-Directed PCS); Care plan dates and type (Initial, Annual, Revision); Member/Legal Representative signature (note: the person requesting to be paid LRI cannot sign); responses describing attempts to find other providers; extraordinary circumstances; LRI skills and abilities; specific job duties requested; reasons a non-LRI cannot provide the service; and any additional information. For MCO office use the form provides: an Approved/Denied checkbox; Approved start and end dates; Notes section; and MCO authorized signature and date.

Form fields and MCO use

MCO office useApproved/Denied checkbox, Approved start and end dates, Notes section, MCO authorized signature and date

Form required fieldsMember name, Date of birth, Medicaid Card ID #, Phone, Address, Name of requested employee (LRI), Legal relationship to member, Service to be provided (EPSDT PCS, Agency Based PCS, Self-Directed PCS), Care plan dates and type (Initial, Annual, Revision), Member/Legal Representative signature (individual requesting to be paid LRI cannot sign), Responses to attempts to find other providers; extraordinary circumstances; LRI skills and abilities; specific job duties requested; reasons non-LRI is unable to provide service, Any additional information

OpenPayer

Request and authorization process for hiring a Legally Responsible Individual (LRI) as a paid Personal Care Services (PCS) provider

Policy summary and scope

When an LRI may be authorized as a paid caregiver

What providers must do

Terms used in this policy

Form and submission details

Policy updates