Fillable PASRR Comprehensive Service Plan (PCSP) Form PCSP (Texas Medicaid & Healthcare Partnership)

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PASRR Comprehensive Service Plan (PCSP) Form PCSP (Texas Medicaid & Healthcare Partnership)

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PASRR Comprehensive Service Plan (PCSP) Form, November, 2019, v2.1
Page 1 of 8
DLN Individual
PASRR Comprehensive Service Plan (PCSP) Form
PCSP
Submitter Information
A0300. NPI/API No.
A0200. Address
A0100. Name
A0400. Provider No.
A0600. County
A0500. Vendor No.
Meeting Information
Type of Meeting
1. Initial IDT/SPT
2. Annual IDT/SPT
3. Quarterly
4. LA Update
Reason Code
1. Change in Medical Condition
2. Change in Service
3. Deceased
4. Discharged
5. Refusal of Habilitation Coordination
6. Transfer
7. Transition
8. Refusal of MI Specialized Services
Transition To
1. CLASS (SG 2)
2. PACE (SG 11)
3. DBMD (SG 16)
4. MDCP (SG 18)
5. STAR+Plus (SG 19)
6. HCS (SG 21)
7. TxHmL (SG 22)
8. YES (DSHS Waiver)
9. Other
A0900. Reason Code
A0800. Date of Meeting
A0700. Type of Meeting
A1000. Transition To
A1200. Date of Event
A1100. Other
Nursing Facility Information
A1500. NPI No.
A1400. Vendor No.
A1300. Provider No.
A1600. Facility Name
A0810. Medicaid Eligibility
0. ME Not Found 1. ME Confirmed 2. ME Undetermined
PASRR Comprehensive Service Plan (PCSP) Form, November, 2019, v2.1
Page 2 of 8
DLN Individual
PASRR Comprehensive Service Plan (PCSP) Form
Local Authority Information
C. LA-MI NPI/API No.
B. LA-MI Vendor No.A. LA-MI Provider No.
A1700. LA-MI Information
C. LA-IDD NPI/API No.
B. LA-IDD Vendor No.A. LA-IDD Provider No.
A1800. LA-IDD Information
Individual Information
C. Last Name
B. Middle InitialA. First Name
A1900. Individual Name
D. Suffix
A2200. Medicaid No.
A2300. Birth Date
A2100. Medicare No.
A2000. Social Security No.
A2400. Individual is PASRR positive for:
1. IDD only 2. MI only 3. IDD and MI
PASRR Comprehensive Service Plan (PCSP) Form, November, 2019, v2.1
Page 3 of 8
DLN Individual
Participants Information
A. Participant Type
1. Individual
2. LA - IDD
3. LA - MI
4. Legally Authorized Representative
5. Nursing Facility - RN
6. Nursing Facility
7. Specialized Services Provider
8. Other
9. LIDDA - Habilitation Coordinator
B. Attendance Type
1. Yes - Attended in person
2. Yes - Attended via phone
3. No - Did not attend
4. No - Declined
C. Title
1. Diversion Coordinator
2. Habilitation Coordinator
3. Licensed Clinical Social Worker (LCSW)
4. Licensed Professional Counselor (LPC)
5. Licensed Psychologist
6. Occupational Therapist
7. Physical Therapist
8. Physician (MD or DO)
9. Qualified Mental Health Professional (QMHP)
10. Registered Nurse (RN)
A2500. Meeting Participation Identify all meeting participants:
A.
B. D. Other E. Full Name F. Type of Meeting G. Date of MeetingC.
1.
2.
3.
PASRR Comprehensive Service Plan (PCSP) Form
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
11. Service Coordinator
12. Speech Therapist
13. Other
14. N/A
15. Qualified Intellectual
Disability Professional
(QIDP)
PASRR Comprehensive Service Plan (PCSP) Form, November, 2019, v2.1
Page 4 of 8
DLN Individual
PASRR Comprehensive Service Plan (PCSP) Form
Alternate Placement Consideration
A2600. Alternate Placement Consideration
B. Does the Individual wish to transition into the community?
A. Individual Is Best Served In
1. PASRR Evaluation
2. Meeting Type
Date of Meeting =
Specialized Services Information
A2700. Nursing Facility Specialized Services
Indication
1. PASRR Evaluation
A. I certify that the need for all habilitative therapies (not
rehabilitative therapies) were discussed.
2. Meeting Type
Date of Meeting =
0. Nursing Facility
1. Community Setting
0. No
1. Yes
A2800. Nursing Facility Specialized Services
1. PASRR Evaluation
A. Individual/LAR Refused all Services
For each service, select the appropriate option from the drop-down list.
B. Customized Manual Wheelchair (CMWC)
C. Durable Medical Equipment (DME)
D. Specialized Assessment Occupational Therapy (OT)
E. Specialized Assessment Physical Therapy (PT)
F. Specialized Assessment Speech Therapy (ST)
G. Specialized Occupational Therapy (OT)
H. Specialized Physical Therapy (PT)
I. Specialized Speech Therapy (ST)
Please See Below
2. Meeting Type
Date of Meeting =
Options for the drop-downs for the Specialized Services
1. Individual/LAR Refused 3. Ongoing 5. Item Received 7. Not Needed
2. New 4. Discontinued 6. Pending 8. Completed
Complete only if A2400 = '1. IDD only' or '3. IDD and MI'.
PASRR Comprehensive Service Plan (PCSP) Form, November, 2019, v2.1
Page 5 of 8
DLN Individual
PASRR Comprehensive Service Plan (PCSP) Form
A2900. Durable Medical Equipment (DME)
1. PASRR Evaluation
A. Gait Trainer
For each service, select the appropriate option from the drop-down list.
B. Orthotic Device
C. Positioning Wedge
D. Prosthetic Device
E. Special Needs Car Seat or Travel Restraint
F. Specialized or Treated Pressure-Reducing Support Surface
Mattress
G. Standing Board/Frame
2. Meeting Type
Date of Meeting =
A3000. IDD Specialized Services
1. PASRR Evaluation
A. Individual/LAR Refused all Services
For each service, select the appropriate option from the drop-down list.
B. Alternate Placement Services
C. Behavioral Support
D. Day Habilitation
E. Employment Assistance
F. Habilitation Coordination
G. Independent Living Skills Training
H. Service Coordination
I. Supported Employment
2. Meeting Type
Date of Meeting =
PASRR Comprehensive Service Plan (PCSP) Form, November, 2019, v2.1
Page 6 of 8
DLN Individual
PASRR Comprehensive Service Plan (PCSP) Form
A3100. MI Specialized Services
1. PASRR Evaluation
A. Individual/LAR Refused all Services
For each service, select the appropriate option from the drop-down list.
B. Group Skills Training
C. Individual Skills Training
D. Intensive Case Management
E. Medication Training (Group)
F. Medication Training (Individual)
G. Medication Training & Support Services (Group)
H. Medication Training & Support Services (Individual)
I. Psychiatric Diagnostic Interview Examination
J. Psychosocial Rehabilitative Services (Group)
2. Meeting Type
Date of Meeting =
K. Psychosocial Rehabilitative Services (Individual)
L. Routine Case Management
M. Skills Training & Development (Group)
N. Skills Training & Development (Individual)
A3110. Additional MI Specialized Services
1. PASRR Evaluation
A. Cognitive Processing Therapy
For each service, select the appropriate option from the drop-down list.
B. Counseling Services (CBT - Individual or Group)
C. Crisis Intervention Services
D. Peer Support
2. Meeting Type
Date of Meeting =
E. Pharmacological Management
A3110 continued on next page
PASRR Comprehensive Service Plan (PCSP) Form, November, 2019, v2.1
Page 7 of 8
DLN Individual
PASRR Comprehensive Service Plan (PCSP) Form
Other Information
A3200. Nursing
Facility Comments
Comments
A3300. Local
Authority Comments
F. Screening Brief Intervention and Referral to Treatment
(SBIRT) Screening - Brief Intervention Not Provided
G. Screening Brief Intervention and Referral to Treatment
(SBIRT) Screening - Brief Intervention Provided
A3110. Additional MI Specialized Services continued
PASRR Comprehensive Service Plan (PCSP) Form, November, 2019, v2.1
Page 8 of 8
DLN Individual
PASRR Comprehensive Service Plan (PCSP) Form
A3500. LA-IDD Specialized Services and Participation Confirmation
A. I am Confirming the IDD section
B. All IDD Specialized Services selected were agreed to by the IDT
C. LA-IDD Specialized
Services Comments
D. LA-IDD Signature Date
E. LA-IDD Attendance Type
1. Yes - Attended in person
2. Yes - Attended via phone
3. No - Did not attend
F. LA-IDD Participation
Confirmation
Comments
0. No
1. Yes
Other InformationLocal Authority Confirmation
A3400. LA-MI Specialized Services and Participation Confirmation
A. I am Confirming the MI section
B. All MI Specialized Services selected were agreed to by the IDT
C. LA-MI Specialized
Services Comments
D. LA-MI Signature Date
E. LA-MI Attendance Type
1. Yes - Attended in person
2. Yes - Attended via phone
3. No - Did not attend
F. LA-MI Participation
Confirmation
Comments
0. No
1. Yes
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PASRR Comprehensive Service Plan (PCSP) Form PCSP (Texas Medicaid & Healthcare Partnership)

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Completed 20 September 2021

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