Participant Name: SAR #: SAR Submit Date:

NC Innovations Waiver and B3 DI (with U4 modifier)

Personal Care Services S5125

Met / Not Met / N/A / Criteria to Approve Service
Participant does not live in a licensed residential facility, licensed AFL home, licensed foster home, or unlicensed alternative family living home serving one adult.
Request may include support, supervision and engaging participation with eating, bathing, dressing, personal hygiene and other activities of daily living essential to the health and welfare of the participant.
Request includes flexible activities that encourage the beneficiary to maintain skills gained during habilitation while also providing supervision for independent activities.
The service goals/interventions include at least one of the following activities:
  • Support, supervision and engaging participation in ADLs (bathing, eating, dressing, etc.)
  • Housekeeping incidental to care provided when activities are essential to the health and welfare of the participant rather than the family and does not include home maintenance or housekeeping in areas used by other members of the household. Housekeeping chores must be specified in the ISP.
  • Meal preparation for the participant but not the cost of the meal itself (and only when someone in the family has not prepared the same meal for other members).
  • Assistance with monitoring health status and physical condition, assistance with transferring, ambulation and use of special mobility devices.

The request for service is individualized, specific and consistent with the participant’s assessed disability, specific needs.
The service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide.
Service is not requested to be furnished in a manner primarily intended for the convenience of the participant, primary caregiver, the provider, employer of record, or the managing employer.
Personal Care is not provided in the provider staff home unless there is documentation in the ISP that the beneficiary’s needs cannot be met in their own home or another community location.
Health and Safety Checklist present (not required for service approval).
If request indicates services will be provided outside of the home, the outcomes are consistent with the supports described in the ISP.
Personal Care is not provided as a substitute for childcare for children ages 11 and under unless specialized services are required because of the child’s disability.
The service goals/interventions do not include medical transportation (to/from appointments or staying during appointments).
Request does not include service provision in a licensed day program.
Requested service is provided on different days than State Plan Medicaid PCS, Home Health Aide visits, Residential Supports or other substantially equivalent service.
The ISP reflects that this service is a proper match/ effective for the beneficiary’s needs.
Additional Criteria for QP Approval
Service has not been denied or partially denied this plan year.
Initial Review:
All Criteria Met: YES – APPROVE NO (Send to Clinical Reviewer)
Reviewer Name, Credentials: Date:
Comments:
Clinical Review:
Approved Send to Peer Review
Reviewer Name, Credentials: Date:
Comments:

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Personal Care