REQUEST FOR SERVICE AUTHORIZATION
Instructions for Care Managers
Care manager (CM) submits the completed/signed Request for Service Authorization form to the DDRO
Front Door
1. The Request for Service Authorization form is used to document the OPWDD services selected, the amount
(units), and the agency(ies) that agree to provide service(s), if known. The form must be signed
by the
individual/family, CM, and CM Supervisor prior to submission.
a. If the individual is requesting authorization for Fiscal Intermediary (FI) and Support Brokerage services in
order to pursue Self-Direction with Budget Authority:
i. The individual must indicate interest in one or more of the following HCBS waiver services: Respite,
Community Habilitation (CH), Supported Employment (SEMP), Individual Directed Goods and Services
(IDGS) and Community Transition Services (CTS).
ii. The services the individual is interested in must be reflected in the “Explanation of Need for Service”
sections associated with the requests for Support Brokerage and Fiscal Intermediary.
2. The CM works to secure commitment(s) from providers before submitting the Request for Service Authorization
form. However, if the CM has difficulty securing commitment(s), submission of the form should not be
unnecessarily delayed. If there is difficulty in securing provider(s) the CM indicates this by checking the box on
the form in the far-right column entitled “Service Provider Not Yet Identified.” After submitting the Request for
Service Authorization form, the CM continues to seek providers for all services the individual/family has chosen
to pursue.
3. The CM carefully reviews the previously submitted HCBS Waiver application elements to ensure that all
required elements are provided. This includes: confirmation of OPWDD Eligibility, LCED and Medicaid
eligibility, Application of Participation form and Documentation of Choices form. If all required elements are not
provided, the Waiver application cannot be processed and there will be a delay in service authorization.
4. As part of the process, the care manager submits the Request for Service Authorization form (RSA). The RSA
form, supporting documents, and the HCBS Waiver application should be submitted in CHOICES using the
Documentation Submission Form.
• The reason chosen for submission on the Documentation Submission should be “Service
Authorization.”
• If uploading the RSA supporting documents and HCBS Waiver forms, they must adhere to the naming
convention:
Naming Convention: Last name_first name_TABS ID_YYYY_MM_DD_Document Name
Example: Peterman_Jacopo_201249_2018_02_28_Requestforserviceauthorization
Peterman_Jacopo_201249_2018_02_28_Applicationforparticipation
• When submitting documents in CHOICES, the CM must notify the Front Door via CCO Alert email that
the document has been submitted electronically and is ready for review.
5. Once the Front Door Team receives the completed Request for Service Authorization form and HCBS Waiver
elements, the materials are reviewed and services authorized. The individual and CM will then receive a
Service Authorization Letter and Waiver Notice of Decision (NOD). Service provider agencies identified on
the Request for Service Authorization form will also receive a copy of the Service Authorization letter.
6. It’s important for the CM to follow up with identified providers to ensure that necessary enrollment materials
are submitted to the DDRO, including the Developmental Disabilities Profile 1 (and DDP1 Supplement, when
required). The DDP1 and DDP1 Supplement can be found on the OPWDD webpage under forms.
7. Note:
Requests for authorization of a new service or additional units of service for an individual already receiving
services should be requested using the Service Amendment form located on the OPWDD webpage under forms.
Revised 1/23/19
