CurrentExecutive Office of Health and Human ServicesPolicy N/A

Appendix J — Window Replacement and Spot Repair/Removal Prior Authorization Form and Worksheet

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Appendix J provides the prior authorization form and worksheet for window replacement and spot repair/removal related to lead remediation activities; includes title, ownership, and table of contents headings for certification standards and the Lead Center program, affecting providers and administrators in Rhode Island's lead remediation program.

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyAppendix J — Window Replacement and Spot Repair/Removal Prior Authorization Form and Worksheet

Policy Code (N/A)N/A

Change TypeNo material changes noted

Effective DateNovember 2006

Next Review Date

Key ActionUse Appendix J prior authorization form and worksheet to request DHS preauthorization for window replacement and spot repair/removal.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Nov 2006Doc date

JAppendix

MultipleTOC fragments

≥15 µg/dLFamily eligibility BLL

>20 µg/dLDOH inspect trigger

Coverage Criteria and Policy Locations

TOC pointers for intensive environmental control and housing supports

Table of contents entries indicating where coverage/criteria for intensive environmental control and related services appear in the document.

TOC entries list Intensive Environmental Control and related Housing Advocacy and Support subsections including Visual Environmental Lead Assessment, Provision of Lead Education, DOH Comprehensive Environmental Lead Inspection and CLC Work Specification Review and Clearance Inspection, Housing Relocation Assistance, and Intensive Environmental Control: Intensive Cleaning, Window Replacement/Refurbishment and Spot Removal (page references repeated; Intensive Environmental Control appears on page 14).

Referenced sections (TOC)

Sections referenced (details not included here):

5.3 Housing Advocacy and Support: Visual Environmental Lead Assessment; Provision of Lead Education; DOH Comprehensive Environmental Lead Inspection and CLC Work Specification Review and Clearance Inspection; Housing Relocation Assistance (TOC references).

5.4 Intensive Environmental Control: Intensive Cleaning; Window Replacement/Refurbishment and Spot Removal (TOC indicates multiple subsections; specifics not present in excerpt).

5.5 Family Involvement and Responsibility (listed following Intensive Environmental Control).

6.0 Lead Center Certification Requirements (includes Services, Staffing, Financial Resources and other organizational requirements referenced elsewhere in the TOC).

TOC: Intensive Environmental Control and Lead Center Certification

Table of contents entries for sections relevant to lead remediation services — no coverage criteria present in this excerpt.

TOC repeats '5.4 Intensive Environmental Control: Intensive Cleaning, Window Replacement/Refurbishment and Spot Removal' and references related sections for certification requirements (6.0) and family responsibilities (5.5).

Reimbursement and reporting locations (TOC)

Sections where reimbursement and coverage-related content is located in the full policy:

Reimbursement section: 7.0 with specific subsections 7.1 Window Replacement/Refurbishment and 7.2 Intensive Cleaning; record keeping and reporting subsections referenced as 6.9.1–6.9.3 (Financial Reporting, Reporting Responsibilities, Closed Case Summary Report).

Reimbursement TOC entries

Locations in the full document where reimbursement and service-specific criteria would be found:

7.1 Window Replacement/Refurbishment — reimbursement details and prior authorization workflow referenced in TOC (see Appendix J).

7.2 Intensive Cleaning — reimbursement and service description referenced in TOC.

Organization & Certification TOC entries

Organizational and certification requirements located in full document:

8.1 Initial Certification and 8.2 Recertification — processes for initial certification and recertification are listed in the TOC and detailed in sections 8.x.

9.0 Requirements for Organization of Service Delivery — includes Agreement to Accept all Medicaid Referrals, Clinical Roles and Scope of Practice, Staff Training and Orientation, Service Monitoring, and Record Keeping Requirements (TOC references 9.1–9.5).

N/A (no coverage statements in this text)

No coverage statements in this text.

This excerpt contains TOC material for the Qualified Entity and organizational topics (10.0 series) and does not include explicit coverage determinations in these lines.

Lead Center coverage criteria

Eligibility and coverage rules:

All Medicaid-eligible children (including RIte Care and RIte Share) and their families are eligible for Lead Center services; only RIte Care/RIte Share-enrolled children are eligible to receive Medicaid funding for window replacement and spot repair/removal; eligible families are those with a child with BLL ≥ 15 µg/dL.

Providers must be certified by DHS as Lead Centers and enroll with EDS to receive reimbursement; DHS may limit number of centers and conduct on-site reviews.

Coverage criteria and service workflow for CLC-managed remediation and support

Eligibility and service coverage summary for window replacement and spot repair/removal services under Medicaid for RIte Care/RIte Share-enrolled children:

All Medicaid-eligible children and families may receive Lead Center services; Medicaid-funded window replacement and spot removal are limited to RIte Care/RIte Share-enrolled children; eligible families have a child with BLL ≥ 15 µg/dL.

DHS will prior authorize all window replacement and spot removal services and directly reimburse certified partners when authorized services are provided.

DOH performs Comprehensive Environmental Inspection for children with BLL >20 µg/dL or persistent >15 µg/dL; families with a single venous BLL 15–19 µg/dL are not eligible for DOH comprehensive inspection—CLC arranges Work Specification Review and ensures Clearance Inspection when CLC-provided remediation occurs.

Window replacement and spot repair/removal may be provided by CLC staff, a qualified subcontractor, or a pre-approved partner; DHS may separately certify partner agencies limited to these services.

Service eligibility and provision criteria

When and how CLCs should provide intensive cleaning, window replacement/refurbishment, and spot removal services:

Intensive environmental cleaning: CLC provides instruction for families to perform cleaning; CLC provides/arranges cleaning directly only when family unable due to cognitive/physical limitations or hardship; reimbursement for intensive cleaning is built into fee schedule (not separately reimbursable).

Window replacement/refurbishment and spot removal: prior approval by DHS is required for reimbursement (see Appendix J). CLC determines need based on Visual Environmental Lead Assessment, DOH inspection or Work Specification Review and assessment of family's situation; window replacement is inappropriate if family intends to move or dwelling is unfit/condemned or out of code.

When extensive abatement required, CLC collaborates with DOH and funding sources to maximize available resources; relocation is last resort and CLC assists in locating temporary or permanent lead-safe housing when needed.

Window services reimbursement and authorization

Window replacement/refurbishment and spot removal — reimbursement and authorization

DHS will preauthorize window replacement/refurbishment and spot removal services; reimbursement will be at an established rate based on authorized work performed and number of windows involved (see Appendix J Prior Authorization Form and Reimbursement Worksheet).

Financial and case reporting

Financial reporting and case reporting obligations

State will establish financial viability benchmarks (balance sheet activity, cash flow/liquidity, aging of receivables, profitability, operating budget YTD, off-budget contribution intent, annual audit with management report); CLC must provide necessary financial information and comply with corrective actions; upon request provide financial reports and audited statements within 10 business days.

CLC is responsible for providing reports as specified in the document; Closed Case Summary Reports must be submitted electronically to DOH on a case-by-case basis and a copy sent to PCP within 10 business days following the month in which the case was closed.

Certification and organizational criteria

Certification, recertification, organizational, governance, and management requirements

Initial certification must occur prior to performing services; applicants submit letter of application with qualifications (staffing, capacity, ability to provide services, management, financial resources, outreach, QA/PI, record keeping) and DHS evaluates with DOH input.

Recertification review performed by DHS at a frequency to be determined including standards compliance, financial performance, operational/organizational review, and QA/PI evaluation.

Applicants must be legally incorporated; certified entity serves as accountable entity; partnership option allowed (applicant must specify whether core services provided directly or via partner); window replacement/lead hazard reduction may be provided through a partner.

Governance/mission and management structure must be delineated: governing body composition, bylaws, recruitment/replacement, executive oversight; applicant must identify accountability for administration, clinical quality, service delivery and financial management.

Certification requirements and application criteria

Standards and application requirements that applicants must meet or describe in their submission:

Governance and Mission: agency must have clearly stated mission and governing body with bylaws, recruitment/replacement processes, and final accountability for programs; governing body hires and supervises executive.

Management and Operating Structure: applicant must identify who is accountable for Lead Center service performance including administration, clinical program quality, service delivery management, and financial management.

Administration: executive responsible for financial management, program outcomes and client needs; maintain organizational chart; staff qualification documentation; corporate compliance plan adopted and annually reviewed.

Financial Systems: require experienced financial manager; up-to-date accounting methods; annual budgeting, revenue projections, billing audits, independent financial audits; written financial policies and internal fiscal controls; track utilization by individual and aggregate; billing office and coordination of benefits compliance.

Human Resources and Staffing: hire and train staff to ensure proper staffing; provide clear job requirements and continuing education; include policies for Family Independence Program participants where applicable.

Quality Assurance/Performance Improvement: maintain written QA/PI plan with annual review, data analysis, outcomes management, records of QA/PI activities, timetables, measurable goals and client input.

Information Management and Record Keeping: maintain written information management plan covering client record-keeping, confidentiality, security, HIPAA compliance, standard forms for intake/assessment/referral/service/discharge, incident and grievance reporting; client record is basis for billing.

Health and Safety and Risk Management: policies/procedures to assure services provided safely in home-based Lead Center services and reduce risk to clients, family members, and staff.

Application Submission and Review: submit original + five copies; applications reviewed for completeness and compliance; incomplete applications returned; applications scored with Section 6 heavily weighted; possible site visit; readiness to begin within 30 days.

Scoring and Certification Thresholds: applications scored by review team; average scores used; certification not recommended if any individual standard score is below 3; Section 6 carries major weight in scoring (example shows 75%).

Billing, Codes, and Key Numeric Thresholds

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Reimbursement sections (no codes)mixed

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Prior authorization reference (Appendix J)mixed

Prior authorization form / worksheet referenced in Appendix J for window replacement and spot repair/removal

Prior authorization referencesmixed

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Reimbursement referencesmixed

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inv-24: Section page reference for intensive environmental control

SectionIntensive Environmental Control appears on page/section 14

ComponentsIntensive Cleaning; Window Replacement/Refurbishment; Spot Removal

TOC contextListed under Housing Advocacy and Support (Section 5.4) in the Table of Contents

inv-25: N/A (placeholder key/value)

PlaceholderN/A — no content in this section of the excerpt

NoteThis entry is a placeholder in the brief; no thresholds or codes provided here

TOC locationAppears as continued TOC fragments in document

inv-26: Document part (TOC fragment)

Document partTable of Contents — lists sections for Housing Advocacy and Support, Intensive Environmental Control, Family Involvement, Lead Center Certification Requirements, Reimbursement and Certification/Recertification

Relevant TOC sectionsSections 5.3–5.5 (housing/support and intensive control), 6.0 (certification), 7.0 (reimbursement), 8.0 (certification/recertification)

PurposeTOC fragments indicate where operational details and forms (e.g., Appendix J) are located in the full policy

inv-27: Lead level thresholds (surveillance/elevated/significant definitions)

Surveillance thresholdAny child under six with BLL ≥ 10 µg/dL (for RI DOH surveillance)

Elevated lead levelOne venous BLL 15–19 µg/dL

Significant childhood lead poisoningOne venous BLL >20 µg/dL OR two BLLs (capillary or venous) >15 µg/dL done 90–365 days apart

inv-28: Blood lead level thresholds for family eligibility and DOH inspection trigger

Family eligibility thresholdFamilies eligible for Lead Center services when child BLL ≥ 15 µg/dL

DOH comprehensive inspection triggerDOH conducts Comprehensive Environmental Inspection for children with BLL > 20 µg/dL or persistent > 15 µg/dL

Medicaid-funded remediation eligibilityOnly RIte Care/RIte Share–enrolled children eligible for Medicaid funding for window replacement and spot repair/removal

inv-29: Spot removal threshold per RIGL citation

Spot removal definitionRemoval of interior lead-based paint not considered lead hazard reduction when amount removed is less than amount specified in subsection 11.1(b)(1) of RIGL Title 23, Chapter 24.6

Regulatory citationDefined by Lead Poisoning Prevention Regulations (Title 23, Chapter 24.6 of RIGL)

Operational noteCLC must comply with DOH regulations when performing spot removal versus licensed abatement

inv-30: Reimbursement rate effective date

Effective dateReimbursement rates effective May 1, 2006

Reference for ratesRefer to Appendix R for rates of reimbursement effective May 1, 2006

ContextRates noted in the Reimbursement section of the document

Provider Requirements, Prior Authorization, and Certification Actions

Prior Authorization

Use Appendix J prior authorization form & worksheet

Appendix J is the official prior authorization form and reimbursement worksheet for window replacement and spot repair/removal; providers must use Appendix J when requesting DHS prior authorization and reimbursement for these services.

Appendix J: Window Replacement and Spot Repair/Removal Prior Authorization Form and Worksheet (see Appendix J)

Documentation Required

Follow TOC-listed housing & lead service components

The table of contents identifies service components under Housing Advocacy and Support that providers must follow, including Visual Environmental Lead Assessment, Provision of Lead Education, DOH Comprehensive Environmental Lead Inspection and CLC Work Specification Review and Clearance Inspection.

Visual Environmental Lead Assessment for Family Lead Education (5.3.1)
Provision of Lead Education (5.3.2)
DOH Comprehensive Environmental Lead Inspection and CLC Work Specification Review and Clearance Inspection (5.3.3)

Note

Intensive Environmental Control TOC entry (Section 5.4)

The Table of Contents lists Intensive Environmental Control (Section 5.4) and shows that Intensive Cleaning, Window Replacement/Refurbishment and Spot Removal are grouped under that heading; providers should refer to Section 5.4 for those service details.

Intensive Environmental Control: Intensive Cleaning; Window Replacement/Refurbishment; Spot Removal (Section 5.4, page 14)

Note

Intensive Environmental Control services listed

The document lists Intensive Environmental Control services (Intensive Cleaning, Window Replacement/Refurbishment and Spot Removal) as program components; this excerpt does not include operational prior-authorization rules but confirms these services are part of CLC scope.

Intensive Cleaning
Window Replacement/Refurbishment
Spot Removal

Note

Intensive Environmental Control services referenced in TOC

Intensive Environmental Control services (Intensive Cleaning; Window Replacement/Refurbishment; Spot Removal) are referenced throughout the TOC as covered components of CLC services and are tied to reimbursement and certification sections elsewhere in the document.

Referenced in Reimbursement (7.0) and Certification sections

Billing Rule

Reimbursement overview — see sections 7.1 and 7.2

Reimbursement sections in the Table of Contents identify Window Replacement/Refurbishment (7.1) and Intensive Cleaning (7.2) as reimbursable items; providers must refer to the reimbursement section for rate and authorization details.

7.1 Window Replacement/Refurbishment
7.2 Intensive Cleaning

Prior Authorization

Prior authorization noted in TOC (Window Replacement/Refurbishment)

The Table of Contents references prior authorization in connection with window replacement/refurbishment reimbursement (see Section 7.1); providers must obtain DHS authorization prior to billing for these services.

Prior authorization is required for window replacement/refurbishment reimbursement

Documentation Required

Agreement to accept Medicaid referrals and provide authorized services

Certified Lead Centers must agree to accept all appropriate Medicaid referrals and provide the authorized services listed in the TOC in a timely manner.

Agreement to accept Medicaid referrals and provide authorized services

Documentation Required

Qualified Entity TOC entries — organizational requirements

The Table of Contents lists Qualified Entity topics (10.0) such as incorporation/accountable entity, partnership option, governance, management and operating structure, administration, financial systems, HR/staffing, and quality performance improvement—applicants must address these areas in their application.

10.1 Incorporation and Accountable Entity
10.1.1 Partnership Option
10.2 Governance and Mission
10.3 Management and Operating Structure
10.3.2 Financial Systems
10.4 Human Resources, Staffing
10.5 Quality Performance Improvement

Documentation Required

TOC excerpt — governance, admin, finance, HR, QA, records

The Table of Contents excerpts list governance, administration, financial systems, human resources/staffing, quality performance improvement, information management/record-keeping and health and safety/risk management—applicants must demonstrate compliance with these TOC areas.

Governance and Mission
Administration
Financial Systems
Information Management/Record-Keeping
Health & Safety / Risk Management

Prior Authorization

Certification and prior authorization required for reimbursement

Providers must be certified by DHS as Lead Centers and enroll with EDS to receive reimbursement; Appendix J contains the prior authorization form and worksheet for window replacement and spot repair/removal.

Certification by DHS required to be reimbursed
Enrollment with EDS after certification
Appendix J contains prior authorization form and worksheet

Documentation Required

Submit application per Appendix A; original + 5 copies; incomplete apps returned

Applicants must submit certification applications per Appendix A and follow submission instructions; incomplete applications will be returned without further review and DHS may conduct on-site reviews and limit the number of certified centers.

Follow Appendix A Application Guide
Submit original + five copies (original and five copies required)
Incomplete applications returned without further review
DHS may conduct on-site review and limit certified centers per area

Denial Risk

Ongoing compliance required; risk of modification or termination

Certified Lead Centers must notify DHS of any material changes; DHS will monitor performance and may modify certification status (provisional, probationary) or terminate for noncompliance—noncompliance risks loss of certification and reimbursement.

Notify DHS of material organizational or program changes
DHS monitoring and possible modification/probation/termination for noncompliance

Prior Authorization

DHS will prior-authorize and directly reimburse authorized window/spot services

DHS will prior authorize all window replacement and spot removal services and will directly reimburse certified partners for authorized services; providers must obtain DHS prior authorization before performing work to be reimbursed.

DHS prior authorization required for window replacement and spot removal
DHS will directly reimburse certified partner agencies for authorized work

Prior Authorization

Prior approval required for window replacement/refurbishment (see Appendix J)

Prior approval by DHS is explicitly required for reimbursement of window replacement/refurbishment and spot removal; see Appendix J Prior Authorization Form and Reimbursement Worksheet for the authorization and billing process.

Prior approval required (See Appendix J Prior Authorization Form and Reimbursement Worksheet)

Billing Rule

CLC must assist with property liens and pay lien-filing fees when DHS funds are used

When DHS funds are used for window replacement the CLC must assist DHS in placing liens on properties per DHS protocols and is responsible for any lien-filing fees; see Appendix K for template letter and lien agreement.

Assist DHS in placing lien on property when DHS funds used
CLC responsible for payment of lien-filing fees
See Appendix K: Template Letter and Lien Agreement

Documentation Required

Comply with DOH lead hazard reduction regulations and licensure requirements

All certified CLCs and DHS-approved partners must comply with applicable DOH regulations for lead hazard reduction activities and with licensure requirements for individuals performing inspections and hazard control.

Comply with DOH Rules and Regulations for Lead Poisoning Prevention
Ensure licensure requirements are met for inspectors and hazard control personnel

Prior Authorization

Preauthorization required for window replacement/refurbishment and spot removal (Appendix J)

DHS will preauthorize window replacement/refurbishment and spot removal services; providers must use the Appendix J prior authorization form and reimbursement worksheet when seeking authorization and reimbursement.

DHS preauthorization required
Use Appendix J for prior authorization and reimbursement worksheet

Documentation Required

Submit original + 5 copies and signed letter of transmittal

Applications must be submitted to the named DHS contact with an original and five copies; include a letter of transmittal signed by an owner, officer, or authorized agent acknowledging agreement to comply with program requirements and certification standards.

Submit original + five copies to Sharon M. Kernan at CCFH (address and phone in document)
Include letter of transmittal signed by authorized agent confirming agreement to comply with certification standards

Prior Authorization

Applications undergo a completeness check; incomplete ones returned

Submitted applications will be reviewed for completeness and compliance prior to technical review; incomplete applications will be returned without further review and may be resubmitted after correction.

Applications reviewed for completeness before technical review
Incomplete applications returned without further review

Prior Authorization

Be prepared for site visit/readiness review; must be ready to begin within 30 days

The review team may conduct a site visit and readiness review as part of certification; applicants must be ready to begin service delivery within 30 days of formal notification of certification.

Site visit and readiness review may be required
Applicants must be ready to begin services within 30 days of certification notification

Key Terms and Definitions

inv-52: Appendix J — form and worksheet name

Form nameAppendix J: Window Replacement And Spot Repair/Removal Prior Authorization Form And Worksheet

Document ownerState of Rhode Island Department of Human Services (Executive Office of Health and Human Services)

PurposePrior authorization and reimbursement worksheet for window replacement and spot repair/removal

inv-53: Visual Environmental Lead Assessment (housing support component)

Service componentVisual Environmental Lead Assessment for Family Lead Education

TOC locationListed under Housing Advocacy and Support (Section 5.3.1)

RolePart of initial home assessment to guide temporary hazard control and remediation decisions

inv-54: DOH Comprehensive Environmental Lead Inspection and CLC Work Specification Review and Clearance (5.3.3)

DefinitionDOH Comprehensive Environmental Lead Inspection and CLC Work Specification Review and Clearance Inspection (Section 5.3.3)

DOH roleDOH conducts comprehensive inspection for BLL >20 µg/dL or persistent >15 µg/dL using licensed inspectors per state regulations

CLC roleCLC conducts Work Specification Review for cases not eligible for DOH inspection and ensures Clearance Inspection after remediation

inv-55: Intensive Environmental Control (definition / heading)

HeadingIntensive Environmental Control

IncludesIntensive Cleaning; Window Replacement/Refurbishment; Spot Removal

TOC referenceAppears as Section 5.4 in the Table of Contents

inv-56: Housing Relocation Assistance definition

DefinitionHousing Relocation Assistance — referrals for housing and legal services to support families needing relocation

TOC locationListed under Housing Advocacy and Support (Section 5.3.4)

CLC roleProvide individualized assistance and coordinate with DHS housing services and legal resources

inv-57: Lead assessment, education, and inspection services (list of service components)

Service listVisual Environmental Lead Assessment; Provision of Lead Education; DOH Comprehensive Environmental Lead Inspection/Work Specification Review and Clearance; Housing Relocation Assistance; Window Replacement and Spot Removal

Core servicesCase Management & Education; Housing Advocacy & Support; Window Replacement and Spot Removal

PurposeServices designed to assess, educate, inspect, and remediate lead hazards in the home and support family needs

inv-58: Intensive Environmental Control (short label)

Short labelIntensive Environmental Control

SectionSection 5.4 in TOC — groups cleaning, window, and spot removal services

UsageUsed as a heading for remediation activities in the CLC program

inv-59: Lead Center Certification Requirements (short label)

Short labelLead Center Certification Requirements (CLC Certification)

IncludesServices, Staffing, Financial Resources, Management and Organization, Availability and Operations, Record Keeping

TOC locationSection 6.0 and subsections in Table of Contents

inv-60: Intensive Environmental Control repeated heading

Heading repeatedIntensive Environmental Control — repeated as TOC heading grouping remediation services

Components repeatedIntensive Cleaning; Window Replacement/Refurbishment; Spot Removal

Page referenceAppears around page/section 14 in TOC fragments

inv-61: Lead Center Certification Requirements (services/staffing/finance)

Services/Staffing/FinanceLead Center Certification Requirements include specified standards for Services, Staffing, Financial Systems and Management/Organization

Operational requirementsApplicants must demonstrate administrative, financial, and staffing capacity as part of certification

Reporting/recordsRecord keeping and reporting (including financial reporting) are part of certification standards

inv-62: Intensive Environmental Control (detailed listing)

Repeated headingIntensive Environmental Control — appears multiple times in TOC and section headers

FunctionGroups the remediation activities that may require prior authorization and reimbursement rules

Relation to certificationCLC must be certified to provide these services and comply with DOH regulations

inv-63: Lead Center Certification Requirements (availability and operations)

Availability & operationsCertification requirements cover availability (e.g., acceptance of Medicaid referrals), record keeping, and readiness to deliver services

Operational commitmentsApplicants must accept Medicaid referrals and provide authorized services in a timely manner

Site readinessCertification may require site visit and readiness to begin services within 30 days of notification

inv-64: 7.1 — Window Replacement/Refurbishment (TOC reference)

TOC reference7.1 — Window Replacement/Refurbishment (listed under Reimbursement section)

ContextFound in Reimbursement/7.0 area of the Table of Contents

ActionSee Appendix J for prior authorization and reimbursement worksheet

inv-65: 7.2 — Intensive Cleaning (TOC reference)

TOC reference7.2 — Intensive Cleaning (listed under Reimbursement)

Reimbursement noteIntensive cleaning is the responsibility of the CLC with no additional reimbursement in some instances (see certification criteria)

TOC contextAppears alongside 7.1 in Reimbursement section

inv-66: 8.1/8.2 — Certification & Recertification (TOC reference)

TOC reference8.1 & 8.2 — Initial Certification & Recertification

PurposeDescribe certification lifecycle and requirements for Lead Centers

TOC placementFound after Reimbursement (7.0) in TOC continuation

inv-67: Qualified Entity (TOC reference)

TOC referenceQualified Entity — main heading (10.0) covering incorporation, governance, management and partners

Subsections10.1 Incorporation and Accountable Entity; 10.1.1 Partnership Option; 10.2 Governance and Mission; 10.3 Management/Operating Structure

Page rangeTOC indicates coverage across pages in the mid-20s of the document

inv-68: Requirements for Organization of Service Delivery (TOC reference)

TOC referenceRequirements for Organization of Service Delivery — Section 9.0 with subsections 9.1–9.5

IncludesAgreement to accept Medicaid referrals; Clinical roles and scope; Staff training; Service monitoring; Record keeping

PlacementListed after Certification sections in the TOC

inv-69: Qualified Entity (additional TOC reference)

Additional TOC referenceQualified Entity — expanded in TOC across sections 10.1–10.5 covering human resources, QA/PI and information management

Application implicationApplicants must demonstrate organizational capacity as described in these TOC entries

Relation to certificationCore part of certification standards and scoring

inv-70: Qualified Entity (main heading reference)

Main heading10.0 Qualified Entity — primary TOC heading for certified entity requirements

ScopeCovers governance, administration, financial systems, HR, QA/PI, information management and health & safety

Certification relevanceDefines organizational standards applicants must meet

inv-71: Information Management / Record-Keeping (TOC reference)

TOC referenceInformation Management / Record-Keeping — Section 10.6 and Record Keeping Requirements under Section 9.5

Requirements hintRecord keeping policies must ensure confidentiality and long-term storage per Medicaid rules (10 years)

Operational tie-inClient records form the basis for billing and reporting obligations

inv-72: Significant childhood lead poisoning definition (one venous >20 µg/dL or two >15 µg/dL 90-365 days apart)

Significant childhood lead poisoningOne venous BLL >20 µg/dL in a child under six OR two BLLs (capillary or venous) >15 µg/dL done 90–365 days apart

Alternate termTwo BLLs >15 µg/dL may be referred to as 'persistent' lead poisoning

ReferenceDefinitions provided by RI Department of Health and cited in DOH regulations

inv-73: Elevated lead level definition (one venous 15-19 µg/dL)

Elevated lead levelOne venous BLL between 15–19 µg/dL

Confirmatory testingCapillary screening results prompt a DOH recommendation for confirming venous test

ImplicationDetermines eligibility pathways and inspection eligibility per DOH guidance

inv-74: Surveillance threshold (any child under six with BLL ≥10 µg/dL)

Surveillance thresholdAny child under six with BLL ≥ 10 µg/dL for RI Department of Health surveillance purposes

UseSurveillance-level definition; triggers public health monitoring

SourceRI Department of Health childhood lead poisoning definitions cited in the document

inv-75: Certified Lead Center (CLC) definition

DefinitionCertified Lead Center (CLC) — a provider certified by DHS to deliver lead center services and eligible for Medicaid reimbursement when enrolled with EDS

Core servicesCLC must provide case management & education; housing advocacy & support; window replacement & spot removal

Certification obligationsCLC must comply with certification standards, monitoring, and reporting requirements

inv-76: Work Specification Review definition (licensed inspector guidance)

Work Specification ReviewA licensed inspector's written determination of how many windows need replacement and the level of spot repair required to develop a work order

Use casePerformed when Visual Environmental Lead Assessment indicates need and DOH comprehensive inspection is not applicable

OutputProvides detail for work order and guides CLC and contractors

inv-77: Clearance Inspection definition

Clearance InspectionInspection the Lead Center must ensure is completed after window replacement/spot repair services have been provided for children not eligible for DOH Comprehensive Environmental Inspection

CLC responsibilityCLC ensures Clearance Inspection and conducts it for cases where DOH inspection is not applicable

PurposeConfirms that remediation work achieved required clearance standards

inv-78: Work Specification Review operational note (CLC educates family/landlord)

Operational noteCLC educates family and landlord on findings and recommendations in the Work Specification Review

RoleWork Specification Review guides window replacement and spot removal work orders

LimitationCLC may not perform Work Specification Review for units eligible for DOH comprehensive inspection

inv-79: Spot Removal definition (amount less than RIGL subsection 11.1(b)(1))

Spot Removal definitionRemoval of interior lead-based paint not considered lead hazard reduction when amount removed is less than subsection 11.1(b)(1) of RIGL Title 23, Chapter 24.6

Regulatory sourceLead Poisoning Prevention Regulations, Title 23, Chapter 24.6 of RIGL

ImplicationDistinguishes small spot repairs from regulated hazard reduction requiring licensed abatement

inv-80: Clearance Inspection (CLC-conducted post-service inspection when DOH inspection not applicable)

CLC-conducted clearanceCLC conducts or ensures a Clearance Inspection after window replacement/spot repair when DOH comprehensive inspection does not apply

PurposeTo confirm work achieved required clearance for children not eligible for DOH inspection

ReferenceDescribed in CLC responsibilities in Housing Advocacy and Support section

inv-81: CLC — Certified Lead Center (short label)

Short labelCLC — Certified Lead Center

MeaningA DHS-certified entity authorized to deliver Lead Center services and subject to certification standards

Related obligationsMust comply with reporting, financial and operational requirements set by DHS

inv-82: Governing body (definition / TOC reference)

DefinitionGoverning body — legally or officially established body with authority and responsibility for operation of the organization, with bylaws and recruitment/replacement processes

RoleHas final accountability for programs and hires/supervises the executive

Certification relevanceComposition and authority of governing body must be described in certification application

inv-83: Executive (CEO or director) definition

Executive definitionExecutive — chief executive officer or director supervised by the governing body and responsible for administration and program implementation

ResponsibilitiesFinancial management, achieving program outcomes, meeting client needs, and implementing governing body strategic goals

Certification implicationExecutive's role and qualifications are part of application standards

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyAppendix J — Window Replacement and Spot Repair/Removal Prior Authorization Form and Worksheet

Policy Code (N/A)N/A

Change TypeNo material changes noted

Effective DateNovember 2006

Next Review Date

Key ActionUse Appendix J prior authorization form and worksheet to request DHS preauthorization for window replacement and spot repair/removal.

SourceLink

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Appendix J — Window Replacement and Spot Repair/Removal Prior Authorization Form and Worksheet

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Coverage Criteria and Policy Locations

TOC pointers for intensive environmental control and housing supports

Table of contents entries indicating where coverage/criteria for intensive environmental control and related services appear in the document.

Referenced sections (TOC)

Sections referenced (details not included here):

5.4 Intensive Environmental Control: Intensive Cleaning; Window Replacement/Refurbishment and Spot Removal (TOC indicates multiple subsections; specifics not present in excerpt).

5.5 Family Involvement and Responsibility (listed following Intensive Environmental Control).

6.0 Lead Center Certification Requirements (includes Services, Staffing, Financial Resources and other organizational requirements referenced elsewhere in the TOC).

TOC: Intensive Environmental Control and Lead Center Certification

Table of contents entries for sections relevant to lead remediation services — no coverage criteria present in this excerpt.

Reimbursement and reporting locations (TOC)

Sections where reimbursement and coverage-related content is located in the full policy:

Reimbursement TOC entries

Locations in the full document where reimbursement and service-specific criteria would be found:

7.1 Window Replacement/Refurbishment — reimbursement details and prior authorization workflow referenced in TOC (see Appendix J).

7.2 Intensive Cleaning — reimbursement and service description referenced in TOC.

Organization & Certification TOC entries

Organizational and certification requirements located in full document:

8.1 Initial Certification and 8.2 Recertification — processes for initial certification and recertification are listed in the TOC and detailed in sections 8.x.

N/A (no coverage statements in this text)

No coverage statements in this text.

This excerpt contains TOC material for the Qualified Entity and organizational topics (10.0 series) and does not include explicit coverage determinations in these lines.

Lead Center coverage criteria

Eligibility and coverage rules:

Providers must be certified by DHS as Lead Centers and enroll with EDS to receive reimbursement; DHS may limit number of centers and conduct on-site reviews.

Coverage criteria and service workflow for CLC-managed remediation and support

Eligibility and service coverage summary for window replacement and spot repair/removal services under Medicaid for RIte Care/RIte Share-enrolled children:

DHS will prior authorize all window replacement and spot removal services and directly reimburse certified partners when authorized services are provided.

Window replacement and spot repair/removal may be provided by CLC staff, a qualified subcontractor, or a pre-approved partner; DHS may separately certify partner agencies limited to these services.

Service eligibility and provision criteria

When and how CLCs should provide intensive cleaning, window replacement/refurbishment, and spot removal services:

Window services reimbursement and authorization

Window replacement/refurbishment and spot removal — reimbursement and authorization

Financial and case reporting

Financial reporting and case reporting obligations

Certification and organizational criteria

Certification, recertification, organizational, governance, and management requirements

Recertification review performed by DHS at a frequency to be determined including standards compliance, financial performance, operational/organizational review, and QA/PI evaluation.

Certification requirements and application criteria

Standards and application requirements that applicants must meet or describe in their submission:

Health and Safety and Risk Management: policies/procedures to assure services provided safely in home-based Lead Center services and reduce risk to clients, family members, and staff.

Billing, Codes, and Key Numeric Thresholds

Not specified in this sectionmixed

No codes listed

No procedure codes in this windowmixed

No codes listed

No billing/coding listed in this windowmixed

No codes listed

Reimbursement sections (no codes)mixed

No codes listed

No billing or procedure codes in excerptmixed

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No billing or clinical codes present in this segmentmixed

No codes listed

Prior authorization reference (Appendix J)mixed

Prior authorization form / worksheet referenced in Appendix J for window replacement and spot repair/removal

Prior authorization referencesmixed

No codes listed

Reimbursement referencesmixed

No codes listed

inv-24: Section page reference for intensive environmental control

SectionIntensive Environmental Control appears on page/section 14

ComponentsIntensive Cleaning; Window Replacement/Refurbishment; Spot Removal

TOC contextListed under Housing Advocacy and Support (Section 5.4) in the Table of Contents

inv-25: N/A (placeholder key/value)

PlaceholderN/A — no content in this section of the excerpt

NoteThis entry is a placeholder in the brief; no thresholds or codes provided here

TOC locationAppears as continued TOC fragments in document

inv-26: Document part (TOC fragment)

Relevant TOC sectionsSections 5.3–5.5 (housing/support and intensive control), 6.0 (certification), 7.0 (reimbursement), 8.0 (certification/recertification)

PurposeTOC fragments indicate where operational details and forms (e.g., Appendix J) are located in the full policy

inv-27: Lead level thresholds (surveillance/elevated/significant definitions)

Surveillance thresholdAny child under six with BLL ≥ 10 µg/dL (for RI DOH surveillance)

Elevated lead levelOne venous BLL 15–19 µg/dL

Significant childhood lead poisoningOne venous BLL >20 µg/dL OR two BLLs (capillary or venous) >15 µg/dL done 90–365 days apart

inv-28: Blood lead level thresholds for family eligibility and DOH inspection trigger

Family eligibility thresholdFamilies eligible for Lead Center services when child BLL ≥ 15 µg/dL

DOH comprehensive inspection triggerDOH conducts Comprehensive Environmental Inspection for children with BLL > 20 µg/dL or persistent > 15 µg/dL

Medicaid-funded remediation eligibilityOnly RIte Care/RIte Share–enrolled children eligible for Medicaid funding for window replacement and spot repair/removal

inv-29: Spot removal threshold per RIGL citation

Regulatory citationDefined by Lead Poisoning Prevention Regulations (Title 23, Chapter 24.6 of RIGL)

Operational noteCLC must comply with DOH regulations when performing spot removal versus licensed abatement

inv-30: Reimbursement rate effective date

Effective dateReimbursement rates effective May 1, 2006

Reference for ratesRefer to Appendix R for rates of reimbursement effective May 1, 2006

ContextRates noted in the Reimbursement section of the document

Provider Requirements, Prior Authorization, and Certification Actions

Prior Authorization

Use Appendix J prior authorization form & worksheet

Appendix J: Window Replacement and Spot Repair/Removal Prior Authorization Form and Worksheet (see Appendix J)

Documentation Required

Follow TOC-listed housing & lead service components

Visual Environmental Lead Assessment for Family Lead Education (5.3.1)
Provision of Lead Education (5.3.2)
DOH Comprehensive Environmental Lead Inspection and CLC Work Specification Review and Clearance Inspection (5.3.3)

Note

Intensive Environmental Control TOC entry (Section 5.4)

Intensive Environmental Control: Intensive Cleaning; Window Replacement/Refurbishment; Spot Removal (Section 5.4, page 14)

Note

Intensive Environmental Control services listed

Intensive Cleaning
Window Replacement/Refurbishment
Spot Removal

Note

Intensive Environmental Control services referenced in TOC

Referenced in Reimbursement (7.0) and Certification sections

Billing Rule

Reimbursement overview — see sections 7.1 and 7.2

7.1 Window Replacement/Refurbishment
7.2 Intensive Cleaning

Prior Authorization

Prior authorization noted in TOC (Window Replacement/Refurbishment)

Prior authorization is required for window replacement/refurbishment reimbursement

Documentation Required

Agreement to accept Medicaid referrals and provide authorized services

Certified Lead Centers must agree to accept all appropriate Medicaid referrals and provide the authorized services listed in the TOC in a timely manner.

Agreement to accept Medicaid referrals and provide authorized services

Documentation Required

Qualified Entity TOC entries — organizational requirements

10.1 Incorporation and Accountable Entity
10.1.1 Partnership Option
10.2 Governance and Mission
10.3 Management and Operating Structure
10.3.2 Financial Systems
10.4 Human Resources, Staffing
10.5 Quality Performance Improvement

Documentation Required

TOC excerpt — governance, admin, finance, HR, QA, records

Governance and Mission
Administration
Financial Systems
Information Management/Record-Keeping
Health & Safety / Risk Management

Prior Authorization

Certification and prior authorization required for reimbursement

Certification by DHS required to be reimbursed
Enrollment with EDS after certification
Appendix J contains prior authorization form and worksheet

Documentation Required

Submit application per Appendix A; original + 5 copies; incomplete apps returned

Follow Appendix A Application Guide
Submit original + five copies (original and five copies required)
Incomplete applications returned without further review
DHS may conduct on-site review and limit certified centers per area

Denial Risk

Ongoing compliance required; risk of modification or termination

Notify DHS of material organizational or program changes
DHS monitoring and possible modification/probation/termination for noncompliance

Prior Authorization

DHS will prior-authorize and directly reimburse authorized window/spot services

DHS prior authorization required for window replacement and spot removal
DHS will directly reimburse certified partner agencies for authorized work

Prior Authorization

Prior approval required for window replacement/refurbishment (see Appendix J)

Prior approval required (See Appendix J Prior Authorization Form and Reimbursement Worksheet)

Billing Rule

CLC must assist with property liens and pay lien-filing fees when DHS funds are used

Assist DHS in placing lien on property when DHS funds used
CLC responsible for payment of lien-filing fees
See Appendix K: Template Letter and Lien Agreement

Documentation Required

Comply with DOH lead hazard reduction regulations and licensure requirements

Comply with DOH Rules and Regulations for Lead Poisoning Prevention
Ensure licensure requirements are met for inspectors and hazard control personnel

Prior Authorization

Preauthorization required for window replacement/refurbishment and spot removal (Appendix J)

DHS preauthorization required
Use Appendix J for prior authorization and reimbursement worksheet

Documentation Required

Submit original + 5 copies and signed letter of transmittal

Submit original + five copies to Sharon M. Kernan at CCFH (address and phone in document)
Include letter of transmittal signed by authorized agent confirming agreement to comply with certification standards

Prior Authorization

Applications undergo a completeness check; incomplete ones returned

Applications reviewed for completeness before technical review
Incomplete applications returned without further review

Prior Authorization

Be prepared for site visit/readiness review; must be ready to begin within 30 days

The review team may conduct a site visit and readiness review as part of certification; applicants must be ready to begin service delivery within 30 days of formal notification of certification.

Site visit and readiness review may be required
Applicants must be ready to begin services within 30 days of certification notification