Day Activity and Health Services (DAHS) Guideline

Prior Authorization Required

Prior authorization is required for Day Activity and Health Services (DAHS). Texas Children's Health Plan (TCHP) evaluates whether submitted documentation supports DAHS as an eligible service for STAR Kids members ages 18 and older with chronic medical conditions who may benefit therapeutically.

• Requests are received by the Utilization Management Department via fax, mail, or electronic submission during normal business hours.
• The Utilization Management professional evaluates the submitted information and documentation supporting eligibility and medical necessity.
• A physician must establish the potential for therapeutic benefit and provide a physician's order.

No Primary-Insurance Denial Required

DAHS providers are not required to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement from a STAR Kids managed care organization.

Standard Daily Authorization

Requests for 1 unit per day for 3 hours but less than 6 hours per day for S5101 adult day care may be approved one year at a time.

• Approved transportation time provided by the DAHS facility counts toward the unit of service.

Extended Daily Authorization

Requests for 2 units per day—more than 6 hours per day—may be approved case by case when documentation establishes that the extended time is medically necessary.

• The documentation may need to show, for example, that the member lacks access to social and recreational activities in the living environment and requires more than 6 hours to meet medical needs.

Initial Authorization Submission

Submit the initial prior authorization request to the Utilization Management Department by fax, mail, or electronic transmission during normal business hours. The receiving Utilization Management professional reviews the request to determine whether the documentation supports an eligible DAHS service.

• Include the physician's assessment and order establishing potential therapeutic benefit.
• Include the DAHS facility nurse's health assessment and other documentation required to support medical necessity and eligibility.

Facility Health Assessment

A DAHS facility nurse must complete a health assessment for each STAR Kids member. The assessment may be performed by an RN or LVN, at the facility or the member's home, based on the member's condition at the initial assessment.

• The member or legally authorized representative must sign the assessment each time the nurse completes or revises it.
• The assessment must identify specific conditions that may affect the member's functioning.

Required Reassessment Events

The facility nurse must complete or update the member's health assessment at required reassessment events.

• Initial assessment for prior authorization by the STAR Kids managed care organization.
• Transfer to a new DAHS facility, completed by the new facility.
• Reauthorization.
• Whenever the DAHS nurse determines that reassessment is needed, including a change in condition.

Continued-Authorization Reassessment

For continued authorization, a physician must reassess the member at least every 12 months. The physician assessment submitted with an authorization request must be no older than 90 days from the request date.

• The facility nurse also reassesses the member at regular intervals and at reauthorization, transfer from another DAHS facility, or a change in condition.
• When a condition change requires it, the nurse coordinates with the member's service coordinator or physician for a physician assessment.

Required DAHS Forms

Use Form 3055, Physician's Orders (DAHS), and Form 3050, DAHS Health Assessment/Individual Service Plan for new enrollments, transfers to a different DAHS facility, and changes in the individual's condition.

• Submit the applicable forms with the authorization request or when the applicable enrollment, transfer, or condition-change event occurs.

Failure to Meet Criteria

Requests that do not meet the procedure's eligibility or medical-necessity criteria will be referred to a TCHP Medical Director or Physician Reviewer, and the Denial Policy will be followed.

• The physician assessment and order must establish potential therapeutic benefit.
• Required facility assessments, reassessments, forms, and medical-necessity documentation must support the request.
• The facility and provider must meet applicable licensure and regulatory requirements.

Avoid Duplication of Services

DAHS may be provided with services such as personal care services (PCS), Community First Choice (CFC), or consumer managed personal attendant services (CMPAS) only when the services do not duplicate one another.

• Review concurrent services and document that there is no duplication of services before requesting or billing DAHS.

Facility Licensure and Compliance

DAHS facilities must be licensed by the Texas Health and Human Services Commission (THHSC) and comply with Texas Administrative Code, Title 40, Part 1, Chapter 98, Adult Day Activity and Health Services Requirements.

• Failure to comply with state or federal regulatory requirements may result in retrospective audit and potential financial recoupment.

Insufficient Justification for Extended Hours

Two units per day are not automatically authorized. The provider must submit case-specific documentation demonstrating that extended hours are medically necessary to meet the member's needs.

• Insufficient justification for more than 6 hours per day may result in nonapproval or referral for Medical Director/Physician Reviewer review.

Authorization Is Not a Guarantee of Payment

Preauthorization is based on medical necessity and is not a guarantee of benefits or eligibility. An authorization applies only to the medical necessity of the authorized treatment or service.

• All services remain subject to benefit limitations and exclusions.
• Providers remain responsible for state and federal regulatory compliance.
• Noncompliance may result in retrospective audit and potential financial recoupment.