Checklist for Preauthorization of MR Waiver Services 

This checklist may be used by the case manager for guidance in composing or reviewing narratives prior to submitting requests for increases in services or adding a service. All applicable items must be explained for preauthorization of additional services. 


Date of request            03-12-02 
Note if urgent              yes 
Consumer name           Jane Doe
Medicaid number          111-222222-33-4
Case Manager name     John Johnson
CM Phone number        540-555-2415
CM Fax number            540-555-3261


Identifies specific issues/circumstances that have changed or have emerged that are NOT addressed in a current plan of care or alternate resource.

EXAMPLE: Ms. Doe has fallen and continues to exhibit unsteadiness at night, now requiring physical assistance to and from the toilet to prevent other falls or further injury. One fall resulted in bone fracture to the foot and subsequent surgery on 3/10/02, so she also needs assistance and training in caring for wound to enable proper healing. 

Indicates relevant dates of events, as applicable.

EXAMPLE: Fall during the night while walking to toilet first observed on 1/25/02. Data was begun to track frequency of bathroom trips and need for assistance. Physician consulted on 1/26/02. 


  Describes current living situation (e.g., group home, family home, facility resident, ALF/AFC resident, own home, emergency/respite residence, etc.). Only as it relates to services being requested, documentation includes information on other individuals in the living situation and their relationship(s) to the individual for whom services are being requested (including guardianship, when applicable).

EXAMPLE: Ms. Doe resides in a 4-bed DMHMRSAS-licensed group home with congregate services provided by XYZ Residential Corp.

Presents other potential resources/non-Waiver services available to the individual to address the current issues or documents if none are available.

EXAMPLE: Receives SSI and earns $15 monthly. No other financial support.


Lists current Waiver services (weekly amounts noted, as applicable)

EXAMPLE: 50 hrs/wk Congregate Residential, 10 units/wk Regular Day Support

If applicable, explains reason asking for additional services when current services (within past year) are not being utilized and billed at the maximum authorized amounts.

EXAMPLE: Billing less for services in February due to a home visit for a week.

Includes other non-Waiver services (e.g., Family Support, CSA-funded, KOVAR, other grants)

EXAMPLE: VATS grant purchased “call system.”

Notes current formal or informal supports (e.g., formal =Center for Independent Living, senior citizens group, etc. or informal = those received through friends, neighbors, churches, etc.)

EXAMPLE: Attends Diabetic support group Tuesday evening once monthly for 2 hours. No Waiver staff time being utilized.
Also, church friends transport Ms. Doe to and from services Wednesday nights and Sunday mornings (3 hours weekly). No Waiver staff time being utilized.

5) SUPPORTS/SERVICES THAT HAVE PREVIOUSLY BEEN EXPLORED AND THE RESULTS OF THAT EXPLORATION ARE DESCRIBED (e.g., revisions to the ISP objectives or services, EPSDT, other Waivers such as E&D or Tech Waiver, Mental Health services, Substance Abuse Services, DRS, Family Support, CSA funding, etc.)

Indicates efforts at exploration of alternative supports.

EXAMPLE: Physicians (regular and urologist) have been consulted regarding consumer’s need to toilet frequently at night. No abnormal physical cause was determined. Fluid restriction several hours before bedtime has been incorporated. Also, a toileting program has been implemented. Physical therapy exercises are being conducted as recommended to address strength and balance. Regular monitoring of blood sugar levels currently normal, so likely not a contributing factor to consumer’s unsteadiness at night. Will continue medical monitoring by a physician as prescribed and/or indicated per need.


Lists the type and amount (units/hours per week as applicable) of MR Waiver services being requested.

EXAMPLE: Increase of 14 hrs/wk to total 64 hrs/wk of Congregate Residential

Includes a schedule or describes how it was determined that the individual needed “x” number of hours or units of service. Estimates or identifies specific allowable activities/services that will be provided, the duration and what issues/needs they will address.

EXAMPLE: Add 7 hrs/week = 30 minutes 2 times daily (8 am & 8 pm) for training and assistance to clean, apply topical meds, bandage foot wound, and elevate foot per doctor’s orders. Also see additional 7 hrs/week of specialized supervision below.

Includes the amount of specialized supervision being requested and indicates reasons for it.

EXAMPLE: Add 7 hrs/week = 15 minutes 4 times per night to assist Ms. Doe in getting to and from bathroom.

Includes staff to individual ratios for congregate settings.

EXAMPLE: 2:4 staffing ratio for the 10 pm – 6 am shift

Indicates the number of other housemates receiving Waiver specialized supervision at the same time frames being  requested for the individual.

EXAMPLE: One other individual receives specialized supervision overlapping 2 times for 15 minutes per night  (different staff person).

Submits summarized data to support the time requested. (Relevant data may include sleep, behavior incidents, seizure, toileting).

EXAMPLE: For the quarter 1/02 – 3/02, data revealed Ms. Doe fell or requested staff help to prevent falling a minimum of 2 times to a maximum of 5 times during each night shift.

States the anticipated duration for which the individual will need these services.

EXAMPLE: Medical treatments and healing of the foot is expected to take 8 weeks, but assistance is recommended by the physician for an additional 4 weeks to ensure steadiness. We will reassess Ms. Doe’s ambulation skills at the end of this quarter period and submit a request for a decrease should walking/toileting skills no longer require assistance.

Documents anticipated outcomes for the individual should these services be denied.

EXAMPLE: Ms. Doe is unable to provide the necessary care for healing of her foot independently such that medical complications may be predicted and/or risk total foot disablement. Also, further falling and additional injury is likely to occur with the extent of balance such as it is.

    DMH 885E 1214 03/21/03