Certification Standards: Personal Assistance Services and Supports (PASS)
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Certification standards and operational requirements for agencies providing consumer-directed Personal Assistance Services and Supports (PASS) to Medicaid-eligible Children with Special Health Care Needs in Rhode Island; describes certification, service components, prior authorization, and agency responsibilities.
No material clinical or coverage changes in this revision.
Coverage, Eligibility, and Clinical Criteria
PASS coverage and authorization stance
Coverage is certification-based and requires prior authorization coordinated through CEDARR Family Centers; certified PASS Agencies may be reimbursed when criteria are met.
Based on Certification Standards and introduction.
EDS adjudicates claims and notifies agencies when authorization is entered.
Consumer-directed, family-centered model emphasized.
PASS coverage criteria and operational rules
PASS is covered when medical necessity is documented and an approved Service Plan is authorized by DHS following CEDARR Family Center review; reimbursement applies to four defined service components.
See definition of PASS and medical necessity requirement.
Services without PA are non-reimbursable.
Initial plans may be shorter to align with CEDARR reviews.
Four service components specified for reimbursement.
Renewal timetable and criteria.
PASS eligibility and clinical appropriateness
Eligibility and clinical appropriateness criteria determine whether PASS is appropriate for initiation or continuation of services.
Eligibility elements and population.
Family readiness and exclusion criteria.
Seven initiation criteria listed in Section 4.2.1.
Continuation criteria from Section 4.2.2.
Initiation criteria
Initial clinical appropriateness criteria for initiating PASS services (all must be met and documented):
Criterion 1 in Section 4.2.1.
Criterion 2 in Section 4.2.1.
Criterion 3 in Section 4.2.1.
Criterion 4 in Section 4.2.1.
Criterion 5 in Section 4.2.1.
Criterion 6 in Section 4.2.1.
Criterion 7 in Section 4.2.1.
Continuation criteria
Criteria for continuing or reauthorizing PASS services:
Continuation criterion 1.
Continuation criterion 2.
Continuation criterion 3.
Continuation criterion 4.
PASS service billing and documentation criteria
Requirements for Assessment, Service Plan content, Direct Services, and Service Plan Implementation to be billable/reimbursable:
Sections 5.4.1, 5.4.5.
Sections 5.4.1 - 5.4.5.
Service component table and direct services requirements.
Sections 5.4.3, 5.4.5 and reimbursement trigger.
Sections 5.4.4 and 5.4.5.
Sections 5.4.1, 5.4.3, 6.8.
PASS coverage criteria
Coverage is defined by required personnel, qualifications, approved units, frequencies, and rates for PASS service components.
Service component table (T1023) and related text.
Service component table (T1019 series) and approved units.
Service component table (H2016, T1016).
Service component table (T1027) and qualifications.
PASS service and agency criteria
Program requirements and operational criteria for PASS services and agencies.
Sections 5.5.3 and 5.4.3.
Section 5.5.4.
Section 5.6.
Sections 5.10 and 5.11.
Section 5.10(7).
Section on transportation requirements (referenced).
Sections 5.11 and 6.7.
Section 5.12.
Section 6.2.
PASS certification and service criteria
Applicant PASS agencies must include written policies and protocols addressing intake, eligibility, assessment, service plan development, direct services, training, and implementation to be certified.
Section 6.5.1.2 and 6.5.1.3.
Section 6.5.1.3 referring to Section 5.4.1.
Sections 6.5.1.4 and 6.5.1.5.
Sections on termination and transition (4.2.3/6.5).
Staffing, training, availability, and timeliness criteria
Staffing, qualifications, training, and preparation requirements for PASS Agencies and personnel:
Section 6.5.2 and 6.5.2.3.
Sections 6.5.2.3.1 and 6.5.2.3.2.
Section 6.5.2.3.3 and staffing requirements.
Sections 6.5.2.3.4 and 6.5.2.3.5.
Section 6.5.2.3.5.
Section 6.6.4.
PASS operational and certification criteria
Key operational criteria and reporting requirements PASS Agencies must meet for certification and ongoing compliance.
Sections 5.10 and 5.11.1/5.11.2 references.
Sections 6.6.4 and 6.6.4.1.
Section 6.6.4.1.
Sections 6.6.5 and 6.7.2.
Sections 6.7.1, 6.7.2 and reporting instructions.
Section 6.8 and Documentation Guidelines.
Section 6.9.
Sections 7.1, 7.2, 7.3.
PASS authorization and service plan criteria
Authorization and service plan requirements for PASS services:
Appendix 2 items a and 5.10(1).
Appendix 2 items a and 2.
Appendix 2 items 2 and 3-5.
Appendix 2 items f, g, h.
Sections 5.7.1 and 5.10(3-4).
PASS coverage criteria and operational requirements
PASS may be appropriate for children with a range of diagnostic and functional needs; appropriateness is individually determined and support level set by assessment.
Appendix 3 diagnostic descriptions.
Levels of Support and expected hours referenced in document.
Sections on provider requirements and Medicaid eligibility verification.
Hearing rights and procedures
Hearing rights and appeals process for families and applicants:
Hearing rights described in Section 6.
Section 8 timelines and decision basis.
Section on representation and Entry of Appearance.
PASS monitoring and quarterly reporting criteria
PASS Quarterly Reporting performance standards and calculation steps (metrics and worksheets):
Report 1 steps in chunk 224.
Report 2 steps in chunk 225.
Report 3 steps in chunk 226.
Report 4 steps in chunk 227.
PASS Reporting Criteria (draft fields)
Draft PASS Quarterly Report templates include fields used to assess timeliness and implementation of PASS activities (date fields and calculated days).
Draft report format with intake and plan submission fields.
Draft report format for direct service implementation fields.
Draft renewal fields in report format.
Confidentiality and Legal Compliance
Confidentiality and legal compliance requirements for personnel accessing PASS records:
Acknowledgement and statutory text.
Statutory restrictions in RIGL 40-6-12.
Service Codes, Rates, and Key Time/Limit Values
| Certified PASS Agencies will use specific procedure codes and may submit claims for reimbursement for sessions of direct service provided to an eligible child by an appropriately trained Direct Service Worker. |
| Rates for PASS services and units are listed in Table 2 (effective Oct 1, 2004) including a completed Service Plan = $280 (Schedule A) and per-15-minute unit rates for Direct Services dependent on worker level. |
| Assessment and Service Plan Development flat rate: $280 per completed plan (Schedule A). | |
| Direct Services: unit = 15 minutes; reimbursement per unit dependent on worker level: $5.00, $5.38, or $5.75 (Schedule A). | |
| Service Plan Implementation: Direct Implementation = $5.50 per day; Direct Coordination = $8.25 per 15-minute unit (typical 1-2 hours/month) with maximum $33.00 per week. | |
| Clinical Consultation: $17.50 per 15-minute unit (Schedule A). |
| T1027 | Clinical Consultation reimbursed at $17.50 per 15-minute unit; minimum: 1 hour every two months (typically), equivalently $70 per hour; face-to-face required once every two-month period (routine limit 3 visits/2 months). |
| T1023 | Development/Assessment and Service Plan (flat rate for completed Assessment and Service Plan; anticipated 5-8 hours; rate $280; Min = 1 unit). |
| T1019 | Direct Services (one of tiered codes T1019 / T1019 TF / T1019 TG) - 1 unit = 15 minutes; three reimbursement levels determined by Direct Service Worker education/experience; approved units up to 80 units/week (20 hours). |
| T1019 TF | See T1019 (tiered direct service code variant). |
| T1019 TG | See T1019 (tiered direct service code variant). |
| H2016 | Service Plan Implementation – Direct Implementation (per diem rate: $5.50 per day). |
| T1016 | Service Plan Implementation – Direct Coordination (rate: $33 per hour; typical 1-2 hours/week or as specified). |
| T1027 | Clinical Consultation (code T1027; approved units: minimum 1 hour every two months; rate shown as $70 per hour in unit terms or $17.50 per 15-minute unit). |
| Draft PASS Quarterly Report format includes repeated date and days-calculation fields such as Date of Intake Appointment, Date of Service Plan Submission, and 'Days from Intake to Plan Submission' placeholders for multiple records. |
Provider Responsibilities, Timelines, and Operational Rules
Prior authorization required for PASS Direct Service hours
Personal Assistance Services and Supports (PASS) Direct Service hours require prior authorization from DHS; CEDARR Family Centers make recommendations to DHS and manage recommendations and renewals. Services provided without prior authorization will not be reimbursed; EDS will notify agencies in writing when an authorization has been entered into the claims system.
- Families choose a certified PASS Agency; CEDARR Family Centers manage recommendation and renewal processes (20).
- Claims for services provided without PA are non-reimbursable; EDS adjudicates claims and issues written PA notifications (30).
Obtain DHS prior authorization; reimbursement contingent on PA
PASS Agencies must obtain DHS prior authorization before reimbursement; CEDARR Family Centers submit recommendations to DHS, and EDS adjudicates claims and notifies agencies when prior authorization has been entered. The PA stipulates authorized period and number of direct service hours; the maximum authorization period is six months.
- All claims are adjudicated by EDS; agencies are notified in writing when an authorization is entered (30).
- Maximum authorization period for a PASS Service Plan is six months (31).
Reimbursement tied to certification status and schedules
Reimbursement rates and schedules depend on an agency's certification status; Table 1 links certification outcomes to Rate Schedule A or B and Table 2 lists service-specific rates (effective Oct 1, 2004).
- Certification outcomes: Certified (no conditions), Certified (with conditions), Provisional Certification (max six months) determine Schedule A or B (41).
- Examples: Completed Service Plan = $280 (Schedule A) vs $238 (Schedule B); Clinical Consultation = $17.50 per 15-minute unit under Schedule A (41).
DHS may limit or exclude services on medical necessity grounds
DHS may limit amount, duration, and scope of services and may exclude items or services determined not medically necessary, unsafe, experimental, or not generally recognized; such oversight can affect authorization and reimbursement.
- DHS oversight includes establishing service limits consistent with Medicaid regulations (45).
Clinical Consultant must approve Service Plans before submission
A certified PASS Agency Clinical Consultant must review and approve all Service Plans prior to submission to the CEDARR Family Center. After CEDARR review and DHS authorization, the family, PASS worker, and PASS Agency are responsible for Service Plan implementation.
- Clinical Consultant must review and sign the Service Plan before submission (78).
- A minimum of one home visit must occur before plan submission (78).
Minimum once-per-two-month face-to-face clinical consultation
Face-to-face clinical consultation is required at least once every two months during a Service Plan and routine visits shall not exceed three visits per two-month period; DHS may approve exceptions.
- Minimum: one face-to-face visit every two months; routine cap: ≤3 visits per two-month period (72).
Clinical Consultation billing rate and unit limits
Clinical Consultation is reimbursed at $17.50 per 15-minute unit; face-to-face consultation must occur at least once every two months and not exceed three visits per two-month period except when DHS authorizes exceptions.
- Rate: $17.50 per 15-minute unit (Schedule A) (72).
- Clinical Consultant qualifications and minimum 1 hour every two months noted in service component table (104).
Assessment and Service Plan must be supervised and signed by qualified clinician
Assessment and Service Plan Development must be completed under supervision of a qualified licensed health care professional (Psychologist, LICSW, PT, OT, SLP, or RN with a Master’s); the Clinical Consultant must review and sign the Service Plan prior to submission.
- Approved licensed professions listed: Psychologist, LICSW, PT, OT, SLP, RN (Master's) (77).
- Service Plan must be reviewed and signed by the PASS Agency Clinical Consultant before submission to CEDARR (78).
Bill using designated PASS service codes and unit definitions
Use specified service component codes and units when billing: T1023 for Assessment/Service Plan (flat rate), T1019 variants for Direct Services (15-minute units), H2016 and T1016 for Service Plan Implementation (per diem and coordination), and T1027 for Clinical Consultation; approved units and worker qualifications determine allowable billing.
- T1023 — Assessment and Service Plan Development; flat rate; anticipated 5–8 hours; rate $280 (min 1 unit) (103).
- T1019 / T1019 TF / T1019 TG — Direct Services; 1 unit = 15 minutes; max 80 units/week; tiered rates by worker education/experience (103).
- H2016 — Direct Implementation (per diem $5.50); T1016 — Direct Coordination (typical 1–2 hrs/week; $33/hr); T1027 — Clinical Consultation (min 1 hour every two months; $70/hr) (104).
Submit Service Plans and reauthorization requests ≥30 days before start date
Reauthorization requests must be submitted to the CEDARR Family Center at least 30 days prior to the proposed start date for the new Service Plan to ensure reimbursement; the DHS re-authorization start date will not be less than 30 days from submission, and both initial and renewal plans must be submitted at least 30 days prior to anticipated service start.
- Reauthorization requests must include progress over the past six months and be submitted a minimum of 30 days prior to proposed start date (112).
- Responses to CEDARR requests for additional information must be provided within 9 calendar days to avoid disruptions in reimbursement (115).
- PASS Service Plans must be submitted no later than four weeks after written referral and no later than 30 calendar days prior to anticipated service start (196).
Families may appeal to DHS via administrative fair hearing
Families may request an administrative fair hearing through DHS to appeal CEDARR or DHS decisions about PASS Service Plans; hearing outcomes may adjust prior authorizations and affect claims payment.
- Hearing decisions are rendered in writing and may result in adjustment of prior authorization necessary for claims payment (138).
Coordinate referrals and authorization recommendations with CEDARR
CEDARR Family Centers evaluate referrals and make authorization recommendations to DHS; PASS Agencies must accept appropriate referrals, submit service plan proposals/renewals within certification timelines, and maintain required communication with CEDARR.
- PASS Agencies must outline processes to ensure coordination/communication with CEDARR Family Centers and accept referrals (133).
- CFC forwards recommendations to DHS and collaborates with agencies to facilitate implementation (131).
Service Plan Implementation reimbursement begins after assessment, PA, and family sign-off
Reimbursement for Service Plan Implementation begins only after completion of Assessment and Service Plan, approval of Prior Authorization, and family sign-off on training and the Job Description/Contractual Agreement.
- Agency must ensure agency/child-specific training completed and family certifies worker competence by signing Job Description and Contractual Agreement prior to Direct Services (155).
- Direct Services begin and reimbursement for Service Plan Implementation follows approval of the Prior Authorization (155).
Timely written responses to CEDARR review: 5-day and 9-day limits
PASS Agency and Clinical Consultant must respond in writing to CEDARR reviewer clarification requests within five (5) calendar days; additional information requested during reauthorization must be provided within nine (9) calendar days for 100% of plans or provisional certification and reimbursement changes may result.
- Respond to reviewer clarification in writing within 5 calendar days (162).
- Provide requested additional information during reauthorization within 9 calendar days for all plans with questions to avoid provisional certification or reimbursement changes (162,115).
Submit PASS Service Plan to CEDARR within 4 weeks of referral and ≥30 days before service start
PASS Agencies must develop and submit a written PASS Service Plan to the CEDARR Family Center no later than four weeks after receiving the written referral and no later than thirty (30) calendar days prior to anticipated start of Direct Services; PASS services are not reimbursable without prior authorization.
- CEDARR Clinician reviews PASS Service Plans within 30 calendar days of receipt (196).
- Reauthorization requests must be submitted 30 calendar days prior to expiration (197).
Respond within 9 calendar days to avoid denial or plan modification
If a PASS Service Plan is unsatisfactory, the PASS Agency has nine (9) calendar days to respond in writing to CEDARR reviewer questions; untimely or unsatisfactory responses may lead to plan reductions or denial. Families retain appeal rights to the PASS Agency, CEDARR Family Center, or DHS.
- Untimely responses may disrupt reimbursement and lead to plan changes or denial (197).
- Families may appeal denials or modifications to PASS Agency, CEDARR, or DHS (197,138).
CEDARR review precedes DHS prior authorization; submit reauthorization ≥30 days before expiry
CEDARR Family Center reviews PASS Service Plans and forwards them to DHS for prior authorization; PASS Agencies must submit reauthorization requests thirty (30) calendar days before plan expiry and actively cooperate with CEDARR throughout the review and authorization process.
- CFC forwards plans to DHS for authorization within 30 days of receipt and EDS sends written notification to PASS Agencies (196,197).
- Agencies must cooperate with CEDARR to resolve questions prior to denial; revised plans require family consent before authorization (197,198).
Verify Medicaid eligibility before billing; nonpayment if coverage lost
Providers must verify recipients' Medicaid eligibility (e.g., via REVS or DHS website); loss of Medicaid coverage results in nonpayment of claims.
- Eligibility verification can be done via the Recipient Eligibility Verification System (REVS) or DHS website after completing a Trading Partner Agreement (206).
Legal representatives must file a written Entry of Appearance for hearings
If a legal representative is used, the representative must file a written Entry of Appearance with the Hearing Office at or before the hearing; the Entry of Appearance acts as a release of confidential information and confirms representation for follow-up or continuances.
- Entry of Appearance permits the legal representative access to the agency case record and is required for hearing follow-up (216).
Include Intake-to-Plan timeliness fields in quarterly report
Quarterly reporting must include timeliness measures from intake to plan submission (Date of Intake, Date of Service Plan Submission, and Days from Intake to Plan Submission) using the draft PASS Quarterly Report Format fields.
- Report template captures Date of Intake and Date of Service Plan Submission and calculates Days from Intake to Plan Submission (252).
- Timeliness metrics reference a 7-day standard in the draft format (234).
Report Direct Service implementation metrics each quarter
Quarterly reports must capture Direct Service Activities Implementation fields (e.g., intake date, date worker signed agreement, date worker completed training, worker wages, date direct services implemented, and days from intake to direct service) to monitor implementation timeliness against standards.
- Fields include Date Worker Signed Agreement, Date Worker Completed Training, Date of Direct Service Implementation, Days from Intake to Direct Service, and flags for Meets Implementation Standard (260).
Report timeliness of Service Plan renewals in quarterly submissions
Quarterly reporting must include Timeliness of PASS Service Plan Renewals (e.g., Service Plan authorization expiration date, date submitted for renewal, days from submission to expiration, timeliness standard, and whether the renewal meets the standard) using the draft template fields.
- Template fields: Date Service Plan Authorization expires; Date Service Plan submitted for renewal; Days from submission to expiration; Meets Timeliness Standard flag (263).
Execute Acknowledgement and Pledge of Confidentiality (RIGL 40-6-12)
All personnel accessing PASS records must acknowledge and pledge to comply with RIGL 40-6-12; violation of the confidentiality statute is a misdemeanor punishable by a fine up to $200, imprisonment up to six months, or both.
- Acknowledgement form references RIGL 40-6-12 and requires signature (269).
- RIGL 40-6-12 declares PASS records confidential and prescribes misdemeanor penalties for violations (271).
Key Terms and Program Definitions
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