Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation

Effective Date: 3/2012

Instructions

Updated: 4/2012

Purpose

To document justification of the individual's need for adaptive aids, medical supplies, home modifications, dental services or dental sedation.

Procedure
When to Prepare

The case manager issues Form 3660 to the individual/legally authorized representative (LAR) when an adaptive aid, medical supply, minor home modification, dental service or dental sedation is requested.

Transmittal

The Direct Service Agency (DSA) retains (signed/dated) Form 3660 in the individual's record. A copy is provided to the case manager and the individual/LAR.

Form Retention

The case manager and DSA retain Form 3660 according to the terms of the Community Living Assistance and Support Services (CLASS) Provider Manual.

Detailed Instructions

Identifying Information — To be completed by the case manager or individual/LAR.

1. Individual Name — Enter the name of the CLASS individual.

2. Medicaid No. — Enter the Medicaid number of the CLASS individual.

3. Age — Enter the age of the CLASS individual.

4. Individual's Address — Enter the individual's complete current address.

5-7. DSA Name, DSA Vendor No., DSA Telephone No. — Enter the DSA contact information.

8-10. CMA Name, CMA Vendor No., CMA Telephone No.—Enter the contact information for the Case Management Agency (CMA).

11. Type of Item/Service Requested — Check the appropriate box. Note: A separate Form 3660 should be completed for each item/service requested.

12. Description of Item/Service Requested — Enter the item/service requested. Avoid general terms such as bathroom modifications. Instead, request each specific item/service involved in the bathroom modification on a separate Form 3660. For example, request "conversion of bathtub to roll-in shower" on one form and on a separate form, "conversion of cabinet style sink to pedestal style sink."

Part A. To be Completed by the Individual/LAR

The individual/LAR, with the assistance of the case manager if necessary, completes and signs/dates this section that addresses the related condition and the expected benefits of the requested item/service.

13. Related Condition(s) — Identify the related condition(s) that pertain to the requested item/service.

14. Describe and Explain Functional Limitations — Provide a detailed outline of functional limitations relevant to the requested item.

15. Describe the Benefits of the Item/Service — Provide a detailed description of how functional limitations will be alleviated by the requested item/service.

Signature – Individual/LAR — The individual/LAR must sign and date this form.

Part B. To be Completed by the Case Manager

16. List non-CLASS Resources and the status of each non-CLASS resource — Upon receipt of Form 3660, signed by the individual/LAR,and appropriate professional, the case manager identifies non-CLASS resources. List and provide the status of non-CLASS resources identified.

17. CMA Action Taken
PROCEED — Based on information presented, the case manager agrees that the item/service requested is justified based on necessity and appropriateness of the requested item/service (see applicable appendix to CLASS Provider Manual).

  • Ensure parts A and B of Form 3660 are completed.
  • Mark the box to proceed with the request process.
  • Forward the request (Form 3660) to the DSA.

DENY — Based on information presented, the case manager disagrees with the necessity and/or appropriateness of the requested item/service.

  • Mark the box for denial by the case manager.
  • List the reason for denial (include applicable language from Texas Administrative Code (TAC), Waiver or CLASS Provider Manual).
  • Notify the individual/LAR via Form 3624, Termination, Reduction or Denial of CLASS.

Within 14 calendar days after receipt of this form, the CMA must complete Part B and forward Form 3660 to the DSA selected by the individual/LAR.

Signature — The case manager must sign and date the form. If the requested item or services was denied by the case manager (Field 17), the case manager must issue Form 3624 and forward this record to the individual/LAR. The case manager must check the box to signify that Form 3624 was sent to the individual/LAR.

Part C. To be Completed by Appropriate Professional

Within 30 calendar days of receipt, the DSA must facilitate completion of Part B. This section must be completed by the appropriate professional practicing within the scope of his license (see Appendix I, Adaptive Aids, and Appendix II, Minor Home Modification Services, of the CLASS Provider Manual). Detailed descriptions must accompany the licensed professional recommendation for adaptive aids that cost more than $500. A letter or other format may be attached for this section as long as all information required in this section is included. Request for minor home modifications should clearly describe accessibility/safety issues being addressed.

18. Professional's Name — Print the name of the appropriate professional.

19. Telephone No. — Enter the professional's telephone number.

20. License No.—Enter the professional's license number.

21. Type of Profession — Enter the type of profession.

22. Fax No. — Enter the professional's fax number.

23. Diagnosis and explain functional limitations — Enter the primary diagnosis of the individual and provide any functional limitations related to the diagnosis.

24. Describe item/service recommended — Enter a brief description of the item/service.

25. Explain how the item/service will benefit the individual — Enter a brief explanation of how the item/service will meet the specific needs of the individual and how the individual will benefit from the item/service.

26. Describe relevant behavior issues related to the item/service requested — Describe any behavior issues that the individual displays and how the behavior relates to the item/service being requested.

Signature and Professional Title, and Date — The appropriate professional must sign, date and enter his/her professional title.

Part D. To be Completed by the DSA Representative

27. DSA Action Taken — The DSA makes a determination about pursuing the purchase through CLASS.
PROCEED — Based on information presented, the DSA agrees that the item requested is justified based on necessity and appropriateness of the requested item/service (see applicable appendix to CLASS Provider Manual).

  • Mark the box to proceed with the request process.
  • Notify the case manager by sending a copy of Form 3660 with Form 2067, Case Information.

DENY — Based on information presented, the DSA disagrees with the necessity and/or appropriateness of the requested item/service.

  • Mark the box for denial by the DSA.
  • List the reason for denial (include applicable language from Texas Administrative Code (TAC), Waiver or CLASS Provider Manual).
  • Notify the case manager by returning Form 3660 with Form 2067.

Within 60 calendar days of obtaining the professional's recommendation(s), the DSA must obtain vendor bids, select a vendor, and complete Part D of this form.

Signature and Date — The DSA representative must sign and date the form.

Note: Once Section D is complete, the DSA must submit the completed form to the CMA within five business days.

Additional Comments — Provide any additional comments.