* Goods and services projected to exceed $2,000 (annual aggregate) require prior approval by the DDP Regional Manager. The service, equipment or supply is designed to meet the participant’s functional and medical needs by advancing the outcomes in the plan of care. Functional remedially necessary: appropriate to assist the person in increased independence and integration in their environment/community. Medical medically necessary: appropriate and effective for the medical needs and health and safety of the person. (If marked No to all questions then proceed) Yes No Please mark yes or no to the following questions. purchases are prohibited by the Federal or State statues or regulations Do these purchases include experimental goods and services The service equipment or supply is available through another source. (If no, denial from sources such as personal/family, insurance, school, Medicaid) (If one or more of the following additional criteria are met with a Yes answer then proceed) Yes No Please mark yes or no to the following questions. 1.The services, equipment or supply promotes inclusion in the community and increases the participants functioning related to the disability 2.The service equipment or supply increases the person’s safety in the home environment 3.The service equipment or supply decreases the individual’s dependence on other Medicaid Services. If you answered yes to questions 1, 2 and 3, explain. Also, explain what each service, equipment or supply is and how it is related to the person’s disability and how it would enhance opportunities for the person to achieve their desired outcome. Provide documentation of the cost of the and provide a prescription or letter from the professional recommending these purchase/purchases. Also provide documentation of any financial denials. (These items need to be attached to the PSP document and need to be present before purchase of the service requested) (All receipts and/or packing slips need to accompany the purchase. Case Manager: yes no Name of Case Date: Manage: yes no Regional Manager Name of Regional Date: Approval over $2,000: Manager:
* Goods and services projected to exceed $2,000 (annual aggregate) require prior approval by the DDP Regional Manager. The service, equipment or supply is designed to meet the participant’s functional and medical needs by advancing the outcomes in the plan of care. Functional remedially necessary: appropriate to assist the person in increased independence and integration in their environment/community. Medical medically necessary: appropriate and effective for the medical needs and health and safety of the person. (If marked No to all questions then proceed) Yes No Please mark yes or no to the following questions. purchases are prohibited by the Federal or State statues or regulations Do these purchases include experimental goods and services The service equipment or supply is available through another source. (If no, denial from sources such as personal/family, insurance, school, Medicaid) (If one or more of the following additional criteria are met with a Yes answer then proceed) Yes No Please mark yes or no to the following questions. 1.The services, equipment or supply promotes inclusion in the community and increases the participants functioning related to the disability 2.The service equipment or supply increases the person’s safety in the home environment 3.The service equipment or supply decreases the individual’s dependence on other Medicaid Services. If you answered yes to questions 1, 2 and 3, explain. Also, explain what each service, equipment or supply is and how it is related to the person’s disability and how it would enhance opportunities for the person to achieve their desired outcome. Provide documentation of the cost of the and provide a prescription or letter from the professional recommending these purchase/purchases. Also provide documentation of any financial denials. (These items need to be attached to the PSP document and need to be present before purchase of the service requested) (All receipts and/or packing slips need to accompany the purchase. Case Manager: yes no Name of Case Manage: Date: Regional Manager Approval over $2,000: yes no Name of Regional Manager: Date:
IGSFormfor0208Waiver.docx