SHC Verification of Relative/Legal Guardian as Provider Process Decision Tree

1. SHC Verification of Relative/Legal Guardian as Provider Process Decision Tree Is relative/Legal Guardian as Provider applicable to this situation STOP! This process is not applicable. Does the Relative/Legal Guardian live in the same household as the waiver participant? No Yes STOP! This process is not applicable. Is the Waiver participant 18 years of age or older? No Yes Is the Relative/Legal Guardian the: Employer of Record or Managing Employer in an agency with Choice Model, Respite Service provider, or the spouse of the waiver participant? STOP! This process is not applicable. Yes No The service to be provided is: Community Networking, Day Supports, Personal Care, In-Home Skill Building, In-Home Intensive Supports, and Residential Supports Yes Relative/Legal Guardian has been previously approved to provide services to the waiver participant living in the same household under this process Prior to December 1st, 2012. Complete the Part A Application Complete the Part B Application No Yes

2. SHC Verification of Relative/Legal Guardian as Provider Process Part A New Employees Provider agency is unable to hire qualified staff to meet the member’s need for: Community Networking, Day Supports, Personal Care, In-Home Skill Building, In-Home Intensive Supports, and Residential Supports Provider Agency completes the Verification of Relative/Legal Guardian as Provider Part A Application Provider Agency submits the Part A Application to SHC’s Network Operations Department Application is automatically denied and returned to the Provider Agency (Provider Agency is asked to resubmit a complete application) Application is reviewed by Network Operations Department to insure it is complete Incomplete Complete Provider Agency completes the Verification of Relative/Legal Guardian as Provider Part A Application If the request meets the criteria the Network Management Manager will notify the SHC UM Department that the provider agency meets the criteria for the requested hours/daily units per week. The UM Department is responsible for authorization Network Operations send the Provider Agency a Letter of Disagreement Not Met/Denied Met/Approved Provider Agency has one opportunity to complete and resubmit the Verification of Relative/Legal Guardian as Provider Part A Application with additional information they feel meets the criteria Network Operations sends the Provider Agency a Letter of Agreement

3. SHC Verification of Relative/Legal Guardian as Provider Process Part B Existing Employees Provider agency hired relative as staff to meet the member’s need for: Community Networking, Day Supports, Personal Care, In-Home Skill Building, In-Home Intensive Supports, and Residential Supports Provider Agency completes the Verification of Relative/Legal Guardian as Provider Part B Application for an initial or annual renewal determination Provider Agency submits the Part B Application to SHC’s Network Operations Department Application is automatically denied and returned to the Provider Agency (Provider Agency is asked to resubmit a complete application) Application is reviewed by Network Operations Department to insure it is the correct application and is complete Incomplete Correct application submitted Complete Yes If the request meets the criteria the Network Management Manager will notify the SHC UM Department that the provider agency meets the criteria for the requested hours/daily units per week. The UM Department is responsible for authorization Provider Agency completes the Verification of Relative/Legal Guardian as Provider Part B Application Not Met/Denied Network Operations send the Provider Agency a Letter of Disagreement Met/Approved Provider Agency has one opportunity to complete and resubmit the Verification of Relative/Legal Guardian as Provider Part B Application with additional information they feel meets the criteria Network Operations sends the Provider Agency a Letter of Agreement

4. SHC Verification of Relative/Legal Guardian as Provider Process Part C Request to Exceed 40 Hours Provider agency is requesting for Relative/Legal Guardian to provide more than 40 hours per week or 7 daily units to meet the member’s need for: Community Networking, Day Supports, Personal Care, In-Home Skill Building, In-Home Intensive Supports, and Residential Supports Provider Agency completes the Verification of Relative/Legal Guardian as Provider Part C Application in addition to the Part A or Part B Application Provider Agency submits the Part C Application with Part A or Part B Application to SHC’s Network Operations Department Network Operations approves or denies the Part A or Part B Application Part C Application is automatically denied if the Part A or Part B Application is denied Denied Approved Network Operations reviews the Part C Application and determines if additional hours/units will be approved Provider Agency can resubmit a Part C Application with its resubmission of the Part A or Part B Application Denied If the request meets the criteria the Network Management Manager will notify the SHC UM Department that the provider agency meets the criteria for the requested hours/daily units per week. The UM Department is responsible for authorization The Part C Denial is included in the Network Operations Letter of Agreement it sends to the Provider Agency The Provider Agency has 7 days to resubmit a Part C Reconsideration Request to the Network Committee Approved The Part C Approval is included in the Network Operations Letter of Agreement it sends to the Provider Agency Network Committee reviews - decision is final