a) Applications for care coordination services

1. 1) Applications for care coordination services shall include, at a minimum:

   1. A) The name, age, address and telephone number of the applicant child;
2. B) The name, address and telephone number of the LRA;

3. C) The LRA's signature; and

   1. D) Information necessary to determine medical eligibility or provide or arrange for diagnostic services as described in Sections 1200.90 and 1200.110.

4. 2) Completed Applications for Care Coordination Services

   Applications for care coordination services shall be considered completed on the business day the requirements of subsections (a)(1) and (d) are met.

b) Applications for Financial Assistance

1. 1) Applications for financial assistance shall include, at a minimum:

   1. A) The name, age, address and telephone number of the applicant child;
2. B) The name, address and telephone number of the LRA;

3. C) The LRA's signature;

   1. D) Information necessary to determine medical eligibility or provide or arrange for diagnostic services as further described in Sections 1200.90 and 1200.110; and
   2. E) Information necessary to determine financial eligibility as further described in Section 1200.80.

4. 2) Completed Application for Financial Assistance

   Applications for financial assistance shall be considered completed on the business date the requirements of subsections (b)(1) and (d) are met.

c) Diagnostic Services

No separate application is required for diagnostic services. Diagnostic services may be provided as part of the eligibility process for care coordination services or financial assistance.

d) Supplemental Information

1. 1) After an application meeting the requirements of subsection (a)(1) or (b)(1) is received by DSCC, supplemental information, including interviews and Reimbursement Agreements (for financial assistance applications), may be requested by DSCC to establish eligibility.
2. 2) The LRA shall submit the supplemental information no later than 45 days after the dated DSCC written notice or the date specified in that written notice, whichever is later.
3. 3) Failure to submit the supplemental information within the required time frame shall cause the application to be deemed incomplete under subsection (e).

e) Incomplete Applications

1. 1) Applications that do not meet the requirements of subsections (a), (b) and (d) shall be considered incomplete and will not be accepted or processed.

2. 2) Notice

   1. A) If DSCC does not accept or process an application for any reason set forth in this Section, DSCC shall use reasonable efforts to identify the LRA who initiated the application and inform the LRA of:

      1. i) The reason that DSCC did not process or did not accept the application; and
      2. ii) The action or actions required to accept or process the application.
   2. B) Notices sent pursuant to this subsection (e)(2) will not be required to comply with Section 1200.180.
   3. 3) The LRA does not have any appeal rights for notices sent under this subsection (e).

f) Good Cause Shown

DSCC may waive the requirements of this Section for good cause shown.