3. PARTIAL APPROVAL OF A SERVICE DENIED BY DIDD: (This section is to be completed only by DIDD for partial approval of a HCBS Medicaid Waiver Service.) A C D E F G H (DIDD Use Only) Service Name Service Code Provider Name Site Name Start Date Unit Rate Units of Svc Partial Approval of & & & & & & & Denied Service Type of Request Fund Source Provider Code Site Code End Date Unit Type Cost of Svc 1. [ ] 2. [ ] 3. [ ] 4. [ ] $ Revised Total Cost of Services Approved: DIDD Review and Authorization of Partially-Approved Services: Note: The total units for any combination of day services listed here in Section C.3 will be shown just for the type of Day Service with the highest unit rate. Day Services are limited to 243 days across any and all combinations of day services and settings. (Title) (Date) (Authorizing Signature)
3. PARTIAL APPROVAL OF A SERVICE DENIED BY DIDD: (This section is to be completed only by DIDD for partial approval of a HCBS Medicaid Waiver Service.) A C D E F G H (DIDD Use Only) Service Name & Type of Request Service Code & Fund Source Provider Name & Provider Code Site Name & Site Code Start Date & End Date Unit Rate & Unit Type Units of Svc & Cost of Svc Partial Approval of Denied Service 1. [ ] 2. [ ] 3. [ ] 4. [ ] Revised Total Cost of Services Approved: $ DIDD Review and Authorization of Partially-Approved Services: Note: The total units for any combination of day services listed here in Section C.3 will be shown just for the type of Day Service with the highest unit rate. Day Services are limited to 243 days across any and all combinations of day services and settings. (Authorizing Signature) (Title) (Date)
80.3.4.a%20-%20ISP%20Support%20Plan%20with%20Person%20Centered%20Prompts.docx