Certification of Need for ICF/ID or O The reviewer determines if the DP 250 is signed and dated by the QDDP and the Consolidated and PFDS waivers ICF/ORC LOC DP 250 completed County MH/MR Program/AE. AE OA (signed and dated). Persons entering the waiver directly from a state center or private ICF/ID can Bulletin 00-08-04 Eligibility for Waiver substitute the required documents with a Utilization Review (UR) form. Services Mark Yes if both signatures and both dates are completed on the DP 250. Mark No if the QDDP or County MH/MR Program /AE signature is missing, the QDDP or County MH/MR Program /AE date is missing or if the DP 250 is not available. Mark NA if the individual was not enrolled in the waiver within the last fiscal year. Certification of Need for ICF/ID or R Consolidated and PFDS waivers ICF/ORC LOC DP 250 completed AE OA (signed and dated). Bulletin 00-08-04 Eligibility for Waiver Services Missing documentation is located R The AE has located the completed LOC determination. Consolidated and PFDS waivers Mark YES if Missing documentation was located. AE OA Mark NA if no remediation action is required or another remediation action was Bulletin 00-08-04 Eligibility for Waiver selected. Services The LOC evaluation form was R The LOC form is considered to meet criteria only if both signatures and both dates Consolidated and PFDS waivers corrected to include both legible are obtained and legible. AE OA signatures and dates. Mark Yes, if the form is properly completed. Bulletin 00-08-04 Eligibility for Waiver Mark NA if no remediation action is required or another remediation action was Services selected. LOC form was completed indicating R The AE must complete a LOC determination. Consolidated and PFDS waivers person meets eligibility requirements. If the determination is that the person meets eligibility criteria, the LOC form is AE OA considered COMPLETE only if both signatures and both dates are completed and Bulletin 00-08-04 Eligibility for Waiver legible. Services Mark Yes, if the form is properly completed. Mark NA if no remediation action is required or another remediation action was selected.
Certification of Need for ICF/ID or ICF/ORC LOC DP 250 completed (signed and dated). O The reviewer determines if the DP 250 is signed and dated by the QDDP and the County MH/MR Program/AE. Persons entering the waiver directly from a state center or private ICF/ID can substitute the required documents with a Utilization Review (UR) form. Mark Yes if both signatures and both dates are completed on the DP 250. Mark No if the QDDP or County MH/MR Program /AE signature is missing, the QDDP or County MH/MR Program /AE date is missing or if the DP 250 is not available. Mark NA if the individual was not enrolled in the waiver within the last fiscal year. Consolidated and PFDS waivers AE OA Bulletin 00-08-04 Eligibility for Waiver Services Certification of Need for ICF/ID or ICF/ORC LOC DP 250 completed (signed and dated). R Consolidated and PFDS waivers AE OA Bulletin 00-08-04 Eligibility for Waiver Services Missing documentation is located R The AE has located the completed LOC determination. Mark YES if Missing documentation was located. Mark NA if no remediation action is required or another remediation action was selected. Consolidated and PFDS waivers AE OA Bulletin 00-08-04 Eligibility for Waiver Services The LOC evaluation form was corrected to include both legible signatures and dates. R The LOC form is considered to meet criteria only if both signatures and both dates are obtained and legible. Mark Yes, if the form is properly completed. Mark NA if no remediation action is required or another remediation action was selected. Consolidated and PFDS waivers AE OA Bulletin 00-08-04 Eligibility for Waiver Services LOC form was completed indicating person meets eligibility requirements. R The AE must complete a LOC determination. If the determination is that the person meets eligibility criteria, the LOC form is considered COMPLETE only if both signatures and both dates are completed and legible. Mark Yes, if the form is properly completed. Mark NA if no remediation action is required or another remediation action was selected. Consolidated and PFDS waivers AE OA Bulletin 00-08-04 Eligibility for Waiver Services