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ModifiedExecutive Office of Health and Human ServicesPolicy N/A

Personal Assistance Services and Supports (PASS) Practice Standards

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Standards governing certification, delivery, prior approval, clinical criteria, and service planning for PASS for Medicaid-eligible children and adolescents in Rhode Island; affects PASS provider agencies, clinical consultants, direct service workers, families and guardians.

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyPASS Practice Standards (Personal Assistance Services and Supports)

Policy CodePolicy N/A

Change TypeMaterial revisions to authorization, consultation frequency, and service limits

Effective DateJan 1, 2016

Last ReviewJan 1, 2016

Next Review Date

Key ActionObtain prior authorization and complete an Assessment and Service Plan (authorized for 12 months) before initiating Direct Services; families must sign off on Direct Service Worker readiness.

SourceLink

POLICY UPDATE CHANGES

PASS Service Plans are approved for 12 months with required 6 month progress reports.

Clinical Consultation (T1027) will increase from 2 hours every 2 months to 2 hours monthly, with additional hours determined case-by-case.

PASS can be provided up to a maximum of 6 hours per day unless otherwise clinically justified.

If a child is receiving HBTS and PASS, combined weekly treatment hours must be documented and substantiated up to 25 hours, and preferred to be from same provider agency.

PASS service plans will no longer be required to be aligned with or reviewed by CEDARR Family Care Plans/clinicians.

12 monthsService plan approval period

6 monthsProgress report interval

6 hrs/dayMax hours/day

2 hrs/moClinical consultation

≤20 hrs/wkWeekly treatment cap

15%Plans reviewed annually

Coverage and Medical Necessity Criteria

Initial Clinical Criteria

Covered when ALL of the following are met (initial determination):

Initial Eligibility Criteria: A formal diagnosis made within the last two years by a licensed health care professional competent in child psychology, child psychiatry, or child development; clinical information must demonstrate the child is disabled with evidence of functional impairment(s) using a standardized assessment tool (e.g., Vineland).within 2 years

From Clinical Criteria for initial determination

Diagnostic criteria: The child demonstrates symptoms and behavior consistent with a diagnosis from the current version of the DSM and/or ICD that requires therapeutic intervention.

Family willingness and participation: The child and the parent(s)/caregiver(s)/legal guardian(s) are willing to accept and cooperate with PASS, including the degree of parental participation outlined in the PASS Service Plan.

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyPASS Practice Standards (Personal Assistance Services and Supports)

Policy CodePolicy N/A

Change TypeMaterial revisions to authorization, consultation frequency, and service limits

Effective DateJan 1, 2016

Last ReviewJan 1, 2016

Next Review Date

SourceLink

On This Page

Initial Determination (Eligibility for PASS Service Plan)

Covered when ALL of the following are met:

ALL of the following

Diagnosis recency and assessor: A formal diagnosis made within the last two years by a licensed health care professional competent in child psychology, child psychiatry, or child development.within 2 years
Functional impairment: Clinical information must demonstrate the child is disabled with evidence of functional impairment(s), as reflected by use of a standardized assessment tool (e.g., Vineland).
Diagnostic criteria: The child demonstrates symptoms and behavior consistent with a DSM and/or ICD diagnosis that requires therapeutic intervention.
Family willingness: The child and the parent(s)/caregiver(s)/legal guardian(s) are willing to accept and cooperate with PASS, including the degree of parental participation outlined in the PASS Service Plan.

Operational note: Service Plan approval requires documentation of each of the above elements in the record and inclusion in the Assessment and Service Plan.

Treatment Intensity Determination

Coverage and hours authorized when ALL following are documented and considered:

Medical necessity documentation: Treatment hours per week must be substantiated through establishment and documentation of medical necessity and measurable goals with frequency and duration for each service to be delivered; authorization is up to 20 hours per week unless otherwise justified.<=20 hours/week

Clinical considerations: Recommendations for intensity must account for the child's age, ability to engage in sustained treatment, severity of behaviors, type/course of condition, other services received, co-existing conditions, family functioning, biological/neurological abnormalities, current functional capacities, and interaction with other agencies/providers; collaboration with family and relevant parties is required.

Staff Qualifications and Role Minimums

Staff qualification requirements for delivering PASS services

General credentialing and training: Staff must have applicable credentials with primary-source verification, background checks (e.g., BCI/CANTS), documented orientation and ongoing training, job descriptions outlining qualifications, caseload expectations, supervision and continuing education requirements; personnel files must document credential verification and training.

Role-specific minimum qualifications: PASS Agency Coordinator: minimum high school diploma or equivalent, two years college in human services or related field, demonstrated competency with families of children with special health care needs, and at least one year experience with a similar population. Clinical Consultant: must be a licensed Rhode Island health care professional (LICSW, LCSW, Registered Nurse with MS, Licensed Psychologist, Licensed Physical Therapist, Licensed Occupational Therapist, Licensed Speech-Language Pathologist, Licensed Mental Health Counselor, Licensed Marriage & Family Therapist, or BCBA) with minimum two years' relevant experience. Direct Service Worker: at least 18 years old, high-school diploma or equivalent, demonstrated competency to perform Service Plan tasks, not a household member and no legal obligation to support the child.

Direct Service Worker readiness: Agency and child-specific training (including CPR/First Aid, client rights, confidentiality, reporting and documentation, payroll/tax) must be completed prior to initiation of Direct Services and family must certify Direct Service Worker readiness by signing the Job Description and Contractual Agreement.

Organizational QA, Info Mgmt, and Safety

Organizational quality, information, and safety requirements

Quality Assurance/Performance Improvement: The organization must maintain a written QA/PI program with a written performance improvement plan, annual review of goals/objectives, data analysis, outcomes management, records of PI activities, timetables and measurable objectives, and evidence that data and client preferences are integrated into decision-making.

Information management and record keeping: The organization must maintain a written information management plan addressing client record policies, confidentiality, record security, timely and accurate data collection, reporting schedules, backups/encryption/password protection for electronic records, incident and grievance reporting, standardized data collection forms, and ensure client records support billing and document assessments, goals, services and outcomes.

Health and safety/risk management: Policies must designate managers to monitor health and safety implementation, have protocols for identification/monitoring of safety risks, family crises and medical emergencies, an effective incident review process, and comply with OSHA and applicable federal/state mandates.

Agency Certification, Operations, and Timeliness Criteria

Agencies must meet the following operational and service-delivery criteria to be certified and provide PASS:

Intake and eligibility protocols: Applicants must provide written intake protocols, referral management procedures, eligibility and admission criteria (including assessment of child stability, home safety, and family willingness for consumer-directed care), alternative recommendations for ineligible families, and HIPAA compliance.

Assessment and Service Plan development: Agencies must demonstrate standardized, analytic, strength-based assessment and Service Plan development processes that establish goals/objectives, roles/responsibilities, and the techniques/tools used; Service Plans form the foundation for PASS.

Service Plan implementation protocols: Applicants must describe procedures for implementing Service Plans, including staff orientation and training materials, documented approaches for delivering Service Plan tasks, and mechanisms for monitoring implementation.

Clinical consultation: Agencies must have protocols for clinical consultation including monthly visits with families and/or Direct Service Workers as clinically indicated, documentation of consultation sessions and resulting Service Plan modifications, and procedures for recommending solutions to Service Plan challenges.monthly as indicated

Family-centered and consumer-directed practice: Agencies must incorporate family-centered, consumer-directed philosophies, ensure active family involvement in Service Plan development/management, assess family capability to assume risks/responsibilities, and provide processes for family input and grievance resolution.

Staffing, roles and supervision: Agencies must provide organizational charts, job titles and detailed job descriptions (including for Clinical Consultants and PASS Coordinators), reporting relationships, supervision structures, and demonstrate staff competencies and training; families are identified as day-to-day supervisors of Direct Service Workers while agencies ensure compliance with employment and payment requirements.

Continuity, emergency and access standards: Agencies must demonstrate guidance for continuity/back-up plans, crisis/emergency coverage for sudden events posing serious risk, define hours of operation and year-round care availability, and meet timeliness standards: offer first meeting within 14 days of referral, complete assessment and Service Plan within 30 days of first meeting, initiate services within 30 days of signing the Service Plan, and complete reauthorization at least 15 days prior to expiration.first meeting <=14 days; assessment and Service Plan <=30 days after first meeting; initiate services <=30 days after signing; reauthorization >=15 days before expiration

Operational Provider Requirements

Covered when provider-agency complies with the following operational criteria:

Timeliness: PASS Agency must offer a first meeting within 14 calendar days of referral; complete an assessment and Service Plan within 30 calendar days of the first meeting; initiate direct services within 30 calendar days of signing the Service Plan; and complete reauthorization Service Plans at least 15 calendar days prior to expiration.

Documentation and recordkeeping: Systematic weekly recording of direct service hours verified by designated family supervisors is required; Direct Service Worker timesheets must be co-signed weekly by the family supervisor(s); billed services shall correspond to approved Service Plan hours and be supported by written documentation.

Parent satisfaction measurement: Parent satisfaction surveys must be conducted at the completion of each authorized Service Plan; results must be analyzed and reported to EOHHS annually; measurement tools must address family-centeredness, clinical consultant availability, progress, communication/collaboration, and staff availability/promptness.

Procedure Codes, Units, and Limits

Referenced Procedure/Billing CodesHCPCS

T1027	Clinical Consultation (as referenced in PASS standards)
T1013U1	Interpretation code allowable for PASS Clinical Consultations up to 2 hours monthly
H2016	Implementation (referenced as not billable until Direct Service Worker identified)

Assessment and Service Plan DevelopmentCPT | HCPCS | mixedCovered

T1023-U1

Assessment and Service Plan Development

Direct ServicesHCPCSCovered

T1019	Direct Services - standard rate
T1019 TF	Direct Services - alternate rate
T1019 TG	Direct Services - alternate rate

Service Plan Implementation / Coordination / ConsultationHCPCSCovered

H2016	Service Plan Implementation / Direct Implementation
T1016U1	Direct Coordination per diem
T1027	Clinical Consultation
T1013U1	Interpretation

inv-27: Maximum weekly combined treatment hours (PASS + HBTS)

Maximum combined weekly hours (PASS + HBTS)Up to 25 hours per week when receiving both HBTS and PASS; documentation of medical necessity, measurable goals, frequency/duration, and evidence of collaboration required

inv-28: PASS daily maximum

Daily maximum for PASSMaximum 6 hours per day unless otherwise clinically justified

inv-29: Unit length

Reimbursable unit lengthOne unit equals 15 minutes

inv-30: Weekly treatment intensity cap

Weekly treatment intensity capUp to 20 hours per week (must be substantiated by medical necessity and measurable goals)

Provider Responsibilities, Prior Authorization, and Documentation

Billing Rule

Prior approval and billing notes

PASS requires prior approval for Medicaid-eligible clients; provider agencies must submit prior authorizations in weekly batch form to EOHHS for fee-for-service families. Clinical Consultation is billed as T1027 (2 hours monthly standard) and interpretation for consultations may be billed using T1013U1 (up to 2 hours monthly). Agencies must maintain written documentation of coordination of care and session-level data supporting billed services.

Submit prior authorizations from each PASS Agency once a week (batch) to EOHHS for fee-for-service families.
Bill Clinical Consultation as T1027 (standard 2 hours per month); use T1013U1 for interpretation up to 2 hours monthly when necessary.
Maintain documentation supporting coordination of care and data for each PASS treatment session to substantiate billed services.

Prior Authorization

Service Plan Authorization (T1023-U1)

Assessment and Service Plan Development is billed under code T1023-U1 and Service Plans are authorized for 12 months; they are renewable annually. The PASS Agency Coordinator and Clinical Consultant must participate in plan development and the Clinical Consultant must sign the Service Plan.

Code: T1023-U1 — Assessment and Service Plan Development authorized for 12 months and renewable annually.
PASS Agency Coordinator and Clinical Consultant assist in development, review, and must sign the Service Plan.

Billing Rule

Direct Services Codes (T1019 variants)

Direct Services are billed using codes T1019, T1019 TF, and T1019 TG (three reimbursement rates) with one unit equal to 15 minutes. Units billed and the Direct Service Worker's qualifications must be documented in the Service Plan and supporting records.

Codes: T1019, T1019 TF, T1019 TG — three reimbursement levels based on worker experience/education.
Unit length: 1 unit = 15 minutes; document units and worker qualifications in the Service Plan.

Billing Rule

Other service component codes

Other service components and their codes include Service Plan Implementation (H2016), Direct Coordination per diem (T1016U1), Clinical Consultation (T1027), and Interpretation (T1013U1) with specified personnel qualifications and unit limits.

H2016 — Service Plan Implementation / Direct Implementation (may require individual approval for more intense needs).
T1016U1 — Direct Coordination (per diem).
T1027 — Clinical Consultation (standard allocation; referenced as monthly/weekly in different parts; documentation required).
T1013U1 — Interpretation (case basis; up to 2 hours per month).

Note

Medical necessity determination

Medical necessity requires a prescription or recommendation from a physician or other medical service provider, but final determination rests with the Medical Assistance Program. Services must be medically necessary and provided cost-effectively.

A provider's prescription/recommendation is required to consider medical necessity, but EOHHS (Medical Assistance Program) makes the final determination.
Services must prevent regression, be appropriate, and not provided solely for convenience.

Prior Authorization

Prior Authorization required for Service Plan Implementation

Direct Services may begin only after completion of the Assessment and Service Plan and approval of the Prior Authorization. Family sign-off that the Direct Service Worker is competent (per the job description/contract) is required prior to implementation and reimbursement for Service Plan Implementation.

Do not bill H2016 (Service Plan Implementation) until the Assessment and Service Plan are complete and Prior Authorization is approved.
Family must certify Direct Service Worker readiness by signing the Job Description and Contractual Agreement before Direct Services commence.

Denial Risk

Service Plan authorization and appeal

Service Plans require authorization; if a parent/caregiver objects to an EOHHS authorization decision they may request an Administrative Fair Hearing, and hearing outcomes may adjust prior authorizations necessary for claims payment.

Parents must sign Service Plans as prime contributors to development and approval.
An Administrative Fair Hearing can be requested; its written decision may change prior authorizations for claims payment.

Prior Authorization

Timeliness Requirements

Timeliness standards: offer a first meeting within 14 calendar days of referral; complete assessment and Service Plan within 30 calendar days of the first meeting; initiate direct services within 30 calendar days of signing the Service Plan; complete reauthorization Service Plans at least 15 calendar days before expiration.

First meeting with family: within 14 calendar days of referral.
Assessment and Service Plan: complete within 30 calendar days of first meeting.
Initiate direct services: within 30 calendar days of signing the Service Plan.
Reauthorization: complete at least 15 calendar days prior to plan expiration.

Step Therapy

Direct Service Worker identification requirement

If a PASS Agency cannot identify a Direct Service Worker after a 4-month period, the case may be closed and referred to another provider; H2016 may not be billed until a Direct Service Worker is identified and written notice to the family must be provided if the agency closes the case.

Case closure and referral to another provider is permitted after 4 months of unsuccessful Direct Service Worker identification.
Do not bill H2016 until a Direct Service Worker is identified; provide written notification to the family if the case is closed.

Step Therapy

Treatment intensity requirement

Treatment intensity (hours per week) must be substantiated by medical necessity and measurable goals with frequency and duration; PASS treatment hours are capped at 20 hours per week unless otherwise documented and justified. If receiving HBTS and PASS combined, document total weekly hours up to 25 hours with evidence of collaboration.

PASS weekly treatment hours: substantiated and documented medical necessity, measurable goals; standard cap = up to 20 hours/week.
When child receives HBTS and PASS, combined weekly treatment hours must be documented and may total up to 25 hours with documented collaboration between agencies.

Note

Relationship to other services

PASS is intended to complement other services and must not replace indicated therapeutic or medical services; when adding PASS to HBTS, providers must document why other services (e.g., Treatment Support) are not indicated.

PASS should be used to complement existing supports (e.g., psychotherapy, medical treatment, school services) and not substitute for them.
If adding PASS when HBTS is present, document rationale why Treatment Support is not clinically indicated.

Documentation Required

Training and Family Sign-off Prerequisite

Agency and child-specific training for Direct Service Workers must be completed prior to initiation of Direct Services; the family must sign off on the worker's competency by signing the job description and contractual agreement.

Complete agency and child-specific training (including CPR/First Aid) before Direct Services begin.
Family signs the Job Description and Contractual Agreement to certify Direct Service Worker readiness.

Note

Non-preferential enrollment

PASS Agencies shall not intentionally exhibit preferential enrollment of children and families based on referral source or third-party payer; violations may affect certification status.

Do not preferentially enroll based on referral source or payer.
Consistent refusal of referrals may prompt comprehensive review of the agency's approval status.

Prior Authorization

Licensure Requirement

All clinical staff providing Clinical Consultation must possess a valid Rhode Island Department of Health license and meet competency requirements specified in the Practice Standards (see Appendix 2); new applicants must demonstrate compliance upon application.

Clinical consultants (LICSW, LCSW, psychologist, OT, PT, SLP, etc.) must have a valid RI DOH license and meet competency standards.
Applicant agencies must demonstrate compliance with licensure requirements during application.

Documentation Required

Service plan and session documentation

Provider agencies must maintain written documentation supporting coordination of care during transfers and preserve data for each PASS treatment session that demonstrate the child's response to specific interventions; Service Plans must include a weekly schedule with clinical goals and objectives.

Keep session-level data demonstrating the child's response to interventions; agencies oversee correct data collection and review.
Include a weekly schedule with clinical goals/objectives in each Service Plan.
Maintain written documentation supporting coordination when transferring a child's care between agencies.

Documentation Required

Required documentation for Service Plan and assessment

Service Plans must document a formal diagnosis made within the last two years, evidence of functional impairment using a standardized assessment tool (e.g., Vineland), assessment findings, goals/objectives tied to PASS domains, family willingness to participate, and Clinical Consultant summaries at the 12-month conclusion.

Diagnosis: formal diagnosis within last two years by a qualified professional; include standardized assessment evidence of functional impairment.
Document assessment findings, goals/objectives linked to PASS domains, and family willingness/readiness.
Clinical Consultant must summarize child and family response at the 12-month conclusion of the Service Plan.

Documentation Required

Clinical documentation and consultation requirements

Direct Service Workers must submit child progress notes to the Clinical Consultant monthly and participate in Clinical Consultation and family-provided trainings; utilize Clinical Consultant technical assistance as needed.

Submit monthly progress notes to the Clinical Consultant.
Participate in family-provided trainings and in Clinical Consultation with the family.
Use technical assistance from the Clinical Consultant to support Service Plan implementation.

Documentation Required

Required Documentation (personnel files, credential verification)

Maintain personnel files containing job descriptions, primary-source credential verification, annual credentialing records, documentation of agency orientation and trainings, and client records that substantiate all billings and document services and outcomes.

Personnel records must include job titles/descriptions, primary source verification of credentials, and annual credentialing documentation.
Document agency orientation, trainings, and continuing education in staff files.
Client records must support billed services with assessments, goals, service documentation, and outcomes.

Documentation Required

Required application documentation

Applications for PASS Agency approval must include written policies and procedures addressing intake protocols, eligibility/admission criteria, assessment and Service Plan development techniques and tools, and documentation of consumer-directed orientation for staff.

Provide written intake protocols for managing referrals and providing PASS information to families.
Include documentation of eligibility/admission criteria, assessment tools, and Service Plan development processes.

Billing Rule

Record Keeping and Billing Documentation

Systematic recording of PASS direct service hours must be provided weekly; Direct Service Worker timesheets must be co-signed weekly by the designated family supervisor(s). Services billed must correspond to approved Service Plan hours and be supported by written documentation.

Provide weekly verified records of direct service hours; timesheets co-signed weekly by family supervisor(s).
Ensure billed services match approved Service Plan hours and have supporting documentation.

Documentation Required

Monitoring and Reporting

EOHHS may request additional reports, documentation, and site visits as described in Appendix 3 to monitor compliance; agencies must be prepared to provide requested materials.

Appendix 3 details monitoring/reporting; EOHHS can request further reports and conduct site visits.
Maintain records and reporting systems to respond to EOHHS monitoring requests.

Denial Risk

Medicaid coverage verification and reimbursement risk

Providers must verify continuous Medicaid coverage for clients; loss of Medicaid coverage can result in nonpayment of claims. Providers may request retroactive reimbursement once coverage resumes only if there has been no lapse in coverage and the child has an approved PASS Service Plan.

Verify continuous Medicaid eligibility via the provider portal; loss of coverage risks nonpayment.
Retroactive reimbursement may be requested only if there was no lapse in coverage and the child has an approved PASS Service Plan.

Denial Risk

Non-participation may suspend services

Failure of a family to participate in the renewal process may result in suspension of services; agencies must document attempts to obtain family participation.

Document family participation efforts; non-participation in renewals can suspend services.
Maintain records of reasons if agency declines to write a Service Plan due to family unwillingness or safety concerns.

Billing Rule

Timely claims submission

All claims must be submitted within 12 months of the date of service for reimbursement; ensure timely claims submission and retention of supporting documentation.

Submit claims within 12 months of date of service to be eligible for reimbursement.
Retain supporting documentation that substantiates billed services.

Denial Risk

Triggers for service suspension/termination

Services may be suspended or terminated for loss of Medicaid eligibility, safety risks in the home, admission to a residential program or hospital, risk of harm to self or others, or failure of the child/family to follow PASS Agency rules despite documented attempts to remediate.

Triggers include loss of Medicaid eligibility; admission to hospital/residential program; safety risks in the home; risk of harm to self/others; noncompliance with agency rules.
Document and report instances leading to suspension/termination to EOHHS as required.

Denial Risk

Refusal/Decline Risks

PASS Agencies may decline to write a Service Plan when PASS is unsuitable due to health/safety concerns, family unwillingness/unability to accept risks/responsibilities, or clinician determination that PASS level of care is not required; agencies must document specific reasons and consistent refusal may prompt review of approval status.

Document the specific reasons when declining to develop a Service Plan.
Be aware that consistent refusal of referrals may lead to comprehensive review of agency approval.

Denial Risk

Appeals may change prior authorization

If a parent/caregiver objects to an EOHHS decision about authorization, they may request an Administrative Fair Hearing; the hearing officer issues a written decision and prior authorizations necessary for claims payment may be adjusted based on the outcome.

Parents/caregivers can request a hearing through EOHHS to dispute authorization decisions.
Hearing outcomes can alter prior authorizations affecting claims payment.

Denial Risk

Sanctions for Non-Compliance

EOHHS may enforce corrective actions and sanctions for non-compliance, including inspections, corrective action plans, suspension of new referrals for up to 6 months, recoupment of funds, rate reductions, provisional approval with enhanced oversight, and revocation of provider approval for unresolved deficiencies or fraud.

Possible actions: site/record inspections, corrective action plans with timelines, suspension of new referrals up to 6 months, recoupment of funds, rate reductions.
Provisional Approval may be instituted after 121 days of continued non-compliance; agencies may appeal within 30 days.

Documentation Required

Service plan and session documentation

Service Plans and session records must include a weekly schedule with clinical goals/objectives; direct service hours must be recorded systematically and timesheets co-signed weekly by the family supervisor(s) to substantiate billed services.

Include a weekly schedule with clinical goals/objectives in each Service Plan.
Record direct service hours weekly and have timesheets co-signed by designated family supervisor(s).

Key Terms and Definitions

inv-60: PASS definition / purpose

PASS definitionPersonal Assistance Services and Supports (PASS): assistant services funded under EPSDT to enable children/youth with special health care needs to live, develop, and function as independently as possible in home/community settings

inv-61: Eligibility criteria summary (Medicaid-eligible children birth-21)

Age and eligibilityMedicaid-eligible children from birth through their 21st birthday (primary target 6–21)

Coverage pathwaysEligible through SSI, Katie Beckett (through age 18), Adoption Subsidy, Rite Care, or Rite Share

Disability standardMust meet the Federal Disability definition (marked and severe functional limitations) and have conditions expected to last ≥12 months or be life-threatening

Residence and consentChild must be living at home with consenting legal guardian or, if ≥18, consent to services themselves

inv-62: Service Plan definition

Service Plan definitionA written agreement developed from assessment that identifies assessment findings, goals and objectives tied to PASS domains, roles and responsibilities of family, Direct Service Worker(s), and PASS Agency, and includes schedule, monitoring and back-up plans

inv-63: Direct Service Worker definition

Direct Service Worker roleAn individual employed by the PASS Agency who provides one-to-one personal assistance under the direction of the parent/caregiver in accordance with an individualized approved Service Plan

Minimum qualificationsAt least 18 years old, high school diploma or equivalent, BCI and CANTS checks; not a household member or legally obligated to support the child

LimitationsDirect Service Workers may NOT administer medication; families must arrange another adult if medication is required during service delivery

inv-64: PASS purpose (maximize independence)

Primary purposeTo maximize a child's independence, self-determination, social integration, and participation in the least restrictive, most natural environment

Family-centered objectiveStrengthen family functioning and support consumer-directed decision-making

Complementary roleComplement existing therapeutic services or serve as step-down/alternative when clinically indicated

inv-65: Medical Necessity definition

Medical necessity definitionServices required for prevention, diagnosis, cure, or treatment of a health-related condition, including preventing regression; requires provider recommendation but final determination rests with the Medical Assistance Program

inv-66: PASS service components

Service componentsFour required PASS components: (1) Assessment and Service Plan Development, (2) Direct Services, (3) Service Plan Implementation, and (4) Clinical Consultation

Assessment roleAssessment and Service Plan Development produce the foundational Service Plan with goals, roles, and monitoring

Implementation and consultationService Plan Implementation and Clinical Consultation support training, oversight, and periodic case review

inv-67: Direct Service Worker readiness

Family confirmation of readinessDirect Service Worker training must be completed prior to services and family must certify worker competency by signing job description and contractual agreement

Required trainingsIncludes CPR/First Aid for children, client rights, ethics/confidentiality, reporting and documentation, payroll/tax procedures

Condition for billingDirect Services and Service Plan Implementation reimbursement begin only after family sign-off and Prior Authorization approval

inv-68: Service Plan / Assessment and Service Plan Development

Service Plan development processAssessment and Service Plan Development is conducted by PASS Agency coordinator under supervision of a qualified RI-licensed health care professional and includes standardized, strength-based tools to identify needs, goals, roles, and implementation details

Documentation requirementsService Plans must include a weekly schedule with clinical goals/objectives and back-up plans for Direct Service Worker absence

Authorization periodService Plans are authorized for 12 months and are renewable annually; six-month progress reports required

inv-69: Direct Service Worker (alternate index)

Direct Service Worker (definition repeat)Individual providing PASS Direct Services as specified in the Service Plan under family day-to-day supervision and PASS Agency employment oversight; duties support ADLs/IADLs and social participation

Employment contextAgency supports employment (e.g., payroll administration) while family manages daily supervision and training

inv-70: Clinical Consultation definition

Clinical Consultation definitionServices rendered by licensed clinical staff (e.g., LICSW, LCSW, psychologist, OT, PT, SLP, marriage and family therapist) who possess a valid Rhode Island Department of Health license and provide periodic consultation to families and Direct Service Workers

Standard allotmentClinical Consultation (T1027) standard provision increased to 2 hours monthly; additional hours may be authorized case-by-case

Interpretation allowanceInterpretation (T1013U1) may be billed for Clinical Consultation when necessary, up to 2 hours monthly

Personal Assistance Services and Supports (PASS) Practice Standards

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Coverage and Medical Necessity Criteria

Procedure Codes, Units, and Limits

Provider Responsibilities, Prior Authorization, and Documentation

Key Terms and Definitions

Background and Scope

Policy Changes and Dates