PURPOSE: This rule formally establishes a statewide utilization review process to: ensure individuals eligible for division services with similar needs are treated consistently and fairly throughout the state; ensure each individual’s annual plan accurately reflects the individual’s needs; ensure levels of service are defined and documented within the outcomes of each individual’s plan; prioritize need for services; and ensure accountability of public funds.

1. (1) Definitions.

   1. (A) Authorization—Approval notice to a provider that a specific amount of service at a specific rate may be provided to an individual.
   2. (B) Budget—The total cost of services and supports recommended or approved to meet an individual’s needs identified in a plan.
   3. (C) Department—Department of Mental Health.
   4. (D) Division—Division of Mental Retardation and Developmental Disabilities.

   5. (E) Emergency criteria consists of one (1) or more of the following:

      1. 1. The individual is in immediate need

of life-sustaining services (food and shelter, or protection from harm) and there is no alternative to division funding or provision of those services;

1. 2. The individual needs immediate ser-

vices in order to protect another person or persons from imminent physical harm;

1. 3. The individual is residing in a public

institution such as an intermediate care facility for persons who have mental retardation (ICF/MR) and has been assessed as able to live in a less restrictive arrangement in the community, the individual wants to live in the community, and appropriate services and supports can be arranged through the waiver;

1. 4. The individual had been receiving

significant services through division funded programs and services, is evaluated to still need the significant level of services, but is no longer eligible for the program or services due to age or other criteria;

1. 5. The individual is in the care and cus-

tody of the Department of Social Services, Children’s Division, which has a formal agreement in place with a division regional center to fund the costs of waiver services for the specific individual;

1. 6. The individual is under age eighteen

1. (18) and requires coordinated services through several agencies to avoid court action; or

   1. 7. The individual is subject to ongoing

or pending legal action that requires immediate delivery of services.

1. (F) Plan—An annual plan of care identifying all support needs an individual with a developmental disability has and how the needs shall be met.
2. (G) Prioritization of need (PON)—Process that assigns a score to the level of need for an individual for a specific service need that is wait listed so that persons with the greatest need for services and supports are served first when funding is available.
3. (H) Responsible party—The parent(s) of a minor child, spouse, court appointed guardian, public administrator or any other person who has legal authority to make decisions for a person served by the division.
4. (I) Senate Bill 40 County Developmental Disability Boards (SB40 Board)—County boards established pursuant to section 205.970, RSMo, to provide services with voter approved tax levies to residents of that county who are handicapped persons as defined in sections 178.900 and 205.968, RSMo.
5. (J) Service/Support—Informal and formal means of meeting needs identified in the plan of care.
6. (K) Utilization Review Committee (URC)—A formal committee established at each regional center to review proposed plans and budgets and make recommendations before services are approved and authorized.

1. (2) Each regional center director shall appoint a URC. URC members shall be regional center staff representing: a) quality assurance; b) community resource specialist; c) business office; d) service coordination; and/or e) administration. Membership may also include a parent or guardian representative and a SB40 Board representative. A minimum of three (3) members shall be present in order for the URC to conduct official business.

   1. (A) The URC shall meet a minimum of once per week.

   2. (B) The URC shall review the following personal plans:

      1. 1. All initial plans/budgets with funds;
      2. 2. Amended plans that increase the total

plan/budget by adding a new service or increasing the dollar amount of a specific service; and

1. 3. Plans at the discretion of the local

URC.

1. (C) To ensure documentation in the personal plan and budget supports the service need, the URC shall use the Utilization Review Checklist, included herein, to review each plan and budget.
2. (D) Other plan and budget reviews shall continue to be completed by the service coordinator and/or service coordination supervisor, as directed by the regional center director.
3. (E) The URC shall evaluate need and assign a PON score for service needs that cannot immediately be funded.

1. (3) Two (2) months prior to the proposed plan and budget implementation, the service coordinator shall meet with the individual, the individual’s family, and as appropriate the individual’s responsible party to prepare a plan and budget with justification for the individual’s support needs.

   1. (A) The initial plan and budget shall be agreed to and the plan shall be signed by the individual or responsible party. The service coordinator and the individual or responsible party shall receive a copy of the plan and 9 CSR 45-2

budget prior to submission of the plan and budget to the URC.

1. (4) One (1) month prior to the proposed plan and budget implementation, the service coordinator shall submit the signed plan to the URC.

   1. (A) If plan and budget submission to the URC shall otherwise be delayed due to the inability of the service coordinator to obtain the signature of the individual or responsible party, then the plan and budget shall be forwarded to the URC without the signature and a copy of the plan and budget shall be mailed to the individual or responsible party.

2. (5) The URC shall review the plan and budget within six (6) working days of receipt.

   1. (A) If no additional information is required, the URC shall send a recommendation to the regional center director or designee to approve or disapprove the plan and budget. If more information is needed to review the plan or changes are necessary in the budget or service authorization associated with a plan, that information shall be requested from the service coordinator, who has ten (10) working days to respond to the URC.
   2. (B) The URC shall submit the completed recommendation form, included herein, to the regional center director or designee to approve or disapprove the plan and budget no later than six (6) working days following receipt of all needed information.
3. (6) The regional center director or designee shall approve, amend, or disapprove the URC recommendation within five (5) working days of receipt.
4. (7) Upon final action by the regional center director or designee to approve, amend or disapprove a plan and budget, a copy of the final decision letter and the completed plan and budget shall be provided within ten (10) days of the decision to the individual and/or responsible party, service coordinator and provider(s) by regular mail, fax or hand delivery. If the regional center director or designee disapproves a plan and budget, the regional center director or designee shall include in the final decision letter the reasons for the disapproval or amendment.

5. (8) The individual or responsible party may appeal the final decision, in writing or verbally, to the regional center director within thirty (30) days from the date of the final decision letter.

   1. (A) If necessary, appropriate staff shall assist the individual or responsible party in making the appeal.
   2. (B) The regional center director or designee may meet with the individual or responsible party and any staff to obtain any newly discovered information relevant to the final decision and to hear any comments or objections related to the final decision.
   3. (C) Within ten (10) working days after receiving the appeal, the regional center director or designee shall notify the individual or responsible party in writing of his/her final decision.

6. (9) When the final decision, as set forth in section (8) above, results in any individual being denied service(s) based on a determination the individual is not eligible for the service(s) or adversely affects a waiver service for an individual, the individual and/or responsible party may appeal in accordance with the procedures set forth in 9 CSR 45- 2.020(3)(C) and (5).

   1. (A) An individual and/or responsible party participating in a Division Medicaid Waiver program has appeal rights through both the Department of Mental Health and the Department of Social Services. Those individuals may appeal to Department of Social Services before, during or after exhausting the Department of Mental Health appeal process. Once the appeal process through Department of Social Services begins, appeal rights through the Department of Mental Health cease. Individuals appealing to the Department of Social Services must do so in writing within ninety (90) days of written notice of the adverse action to request an appeal hearing. Requests for appeal to the Department of Social Services should be sent to: Division of Medical Services, Recipient Services Unit, PO Box 6500, Jefferson City, MO 65102- 6500, or call Recipient Services Unit at 1
7. (800) 392-2161.

8. (10) If an individual and/or responsible party timely files an appeal of a final decision, services currently being provided under an existing plan of care will not be suspended, reduced or terminated pending a hearing decision unless the individual or legal representative requests in writing that services be suspended, reduced or terminated.

   1. (A) The individual and/or responsible party may be responsible for repayment of any federal or state funds expended for services while the appeal is pending if the hearing decision upholds the director’s decision.
9. (11) The service coordinator shall provide guidance to the individual, family, and the responsible party about any alternative resources potentially available to support needs that are not approved through the URC process.
10. (12) New services/supports shall not begin before the plan and budget are approved through the URC, except in an emergency situation approved by the regional center director or designee.

11. (13) Budgets are determined by the total cost of all services and supports paid through the billing system of the department. Services and supports paid for outside of the department billing system are excluded.

    1. (A) When multiple family members are receiving division services, this shall be noted. All of the budgets shall be considered together in the utilization review process in order to have a comprehensive picture of all services/supports going into a single home so the necessary level of services can be determined. This does not require each family member’s plan be on the same plan year, but does require all of the current supports in the home be considered.
    2. (B) Applicable Medicaid State Plan services shall be accessed first when the individual is Medicaid eligible and the services will meet the individual’s needs.
12. (14) Once a budget is approved through the utilization review process, any request for additional funds shall be added to the approved budget (the total cost of all services/supports—including department, SB40 Board Waiver and non-waiver match, and Medicaid Waiver match dollars) to determine the new utilization review level. The additional request may not be considered in isolation of other services/supports the individual and family are receiving.
13. (15) A review of a single service should not delay the implementation of other services in the plan.

14. (16) The URC shall complete the priority of need form, included herein, and shall assign a score for each service request in one (1) or more of the following six (6) categories of need: emergency; health and safety; family support; daily living supports; inclusion and/or recreational supports; and long-term planning.

    1. (A) The URC shall consider a service/support for inclusion on a prioritized waiting list if the service/support meets each of the following criteria:

       1. 1. Need for the service/support is docu-

mented in the person centered plan as necesand Developmental Disabilities

sary for the individual’s health, safety, and/or independence and alternative funding or programs are not available to meet the need; and

1. 2. Need for the service/support is

specifically related to the person’s disability (i.e., not something that would be needed regardless of the person’s disability).

1. (B) Individuals evaluated with needs meeting emergency criteria receive highest priority in receiving funding for services. AUTHORITY: sections 630.050 and 633.110.2, RSMo 2000.* Original rule filed March 31, 2006, effective Nov. 30, 2006. *Original authority: 630.050, RSMo 1980, amended 1993, 1995 and 633.110, RSMo 1980, amended 1996.