(spw) sas help file

STAR+PLUS WAIVER
(SPW)
SAS HELP FILE
Community Services Policy and Curriculum
Development
April 2012

Table of Contents
Initial Service Authorization / SPW ______________________________________________ 2
Authorizing Agent - SPW ____________________________________________________ 2
Enrollment - SPW __________________________________________________________ 4
Service Plan - SPW ________________________________________________________ 4
Service Authorization - SPW _________________________________________________ 5
Level of Service - SPW _____________________________________________________ 8
Medical Necessity - SPW ____________________________________________________ 9
Diagnosis – SPW _________________________________________________________ 11
Reassessment Service Authorization / SPW ___________________________________ 12
Authorizing Agent – Reassessment / SPW _____________________________________ 12
Enrollment – Reassessment / SPW ___________________________________________ 12
Service Plan – Reassessment / SPW _________________________________________ 12
Service Authorization – Reassessment / SPW __________________________________ 13
Level of Service – Reassessment / SPW _______________________________________ 19
Medical Necessity – Reassessment / SPW _____________________________________ 20
Diagnosis – Reassessment / SPW____________________________________________ 20
Transfers / SPW ___________________________________________________________ 21
Transfers from CBA services to SPW Services __________________________________ 21
Transfers from SPW to CBA Services _________________________________________ 21
Transfers From One STAR+PLUS Area To Another STAR+PLUS Area ______________ 23
Transfers From One MCO To Another MCO In The Same Service Area ______________ 25
Money Follows the Person Authorization for an SPW Applicant ___________________ 27
Authorizing Agent - SPW ___________________________________________________ 28
Enrollment - SPW _________________________________________________________ 31
Service Plan - SPW _______________________________________________________ 31
Service Authorization - SPW ________________________________________________ 32
Level of Service - SPW ____________________________________________________ 35
Medical Necessity - SPW ___________________________________________________ 35
Diagnosis – SPW _________________________________________________________ 37
Money Follows the Person Demonstration for an SPW Applicant __________________ 37
Money Follows the Person Eligibility for an Applicant Moving to CBA ______________ 39
Money Follows the Person Eligibility for an Applicant Moving from CBA to SPW _____ 39
Mutually Exclusive Services within SPW ______________________________________ 40
Terminations / SPW ________________________________________________________ 40
Terminating All Services / SPW ______________________________________________ 40
Appeal Extensions for Continued Benefits / SPW _______________________________ 41
SAS Help File
Revised: 4/23/2012 1

Initial Service Authorization / SPW
SAS Help File
These records must be completed to create an initial service authorization for SPW:
Authorizing Agent
Enrollment
Service Plan
Service Authorization
Level of Service
Medical Necessity
Diagnosis
Authorizing Agent - SPW
There will normally be one authorizing agent registered for an initial SPW member.
The STAR+PLUS Support Unit (SPSU) or Health and Human Services Commission
Managed Care Operations (HMCO) staff is registered as the authorizing agent when the
initial authorization is authorized.
To register an authorizing agent for an SPW applicant:
1. Select Authorizing Agent in the Case Worker directory.
2. Select Add and a blank Authorizing Agent record will appear.
3. Move to the Type field and select CM-Case Manager from the drop down list.
4. Move to the Group field and select 19-STAR+PLUS from the drop down list.
5. Leave the Send to TMHP field at the default selection N-NO.
6. Move to the Begin Date field and enter the date the record is being created. Leave the
End Date field at the default 00/00/0000.
7. Move to the Auth Agent field and enter STAR+PLUS.
8. Leave the Agency field at the default selection 324-DHS.
9. Move to the Name field and enter the SPSU/HMCO staff’s name.
10. Move to the Phone field and enter the telephone number of the authorizing agent.
Enter the area code, phone number and extension.
11. Move to the Mail Code field and enter the appropriate Managed Care Organization
(MCO) Plan Code from the table below.
Revised: 4/23/2012 2

12. Save the record.
SERVICE MCO PLAN NAME MCO PLAN
AREA
CODE
Bexar Amerigroup 45
Molina 46
Superior 47
Dallas Molina 9F
Superior Health Plan 9H
El Paso Amerigroup 34
Molina 33
Harris Amerigroup 7P
United Healthcare 7R
Molina 7S
Hidalgo HealthSpring (Bravo) H7
Molina H6
Superior H5
Jefferson Amerigroup 8R
United Healthcare 8S
Molina 8T
Lubbock Amerigroup 5A
Superior 5B
Nueces United Healthcare 85
Superior Health Plan 86
Tarrant Amerigroup 69
Bravo Health 6C
Travis Amerigroup 19
United Healthcare 18
SAS Help File
Revised: 4/23/2012 3

Enrollment - SPW
To register enrollment for an SPW applicant:
1. Select Enrollment in the Program and Service directory.
2. Select Add and a blank Enrollment record will appear.
SAS Help File
3. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
4. Move to the Enrolled From field and select the appropriate entry from
the drop down list.
5. Move to the Living Arrangement field, and select the appropriate
community-based living arrangement from the drop down list.
6. Move to the Begin Date field and enter the date the member is enrolled
in his MCO, which will always be the 1 st day of a month.
7. Leave the End Date field at the default.
8. Leave the Termination Code and Waiver Type at the defaults.
9. Save the record.
Service Plan - SPW
The service plan record is used to register an Individual Service Plan (ISP) for
an SPW member. The record includes the annual SPW ISP cost limit based on
the member’s Resource Utilization Group (RUG) value and the total estimated
cost of SPW services taken from the member’s ISP, Form 3671-1.
To register a service plan for an SPW applicant:
1. Select Service Plan in the Program and Service directory.
2. Select Add and a blank Service Plan record will appear.
3. Leave the Type field at the default selection AN-ANNUAL PLAN.
4. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
5. Move to the Ceiling field and enter the annual SPW ISP cost ceiling for
the RUG value entered on the Level of Service record.
Revised: 4/23/2012 4

SAS Help File
For a ventilator dependent SPW member, enter the annual SPW
ISP cost limit based on the RUG value and Ventilator use of the
consumer (6-23 hours or 24 hours continuous).
6. Move to the Begin Date field and enter the effective date of the ISP
coverage period.
7. Move to the End Date field and enter the last day of the ISP coverage
period.
8. Move to the Amount Authorized field and enter the total estimated cost
of all SPW services authorized for the current ISP coverage period, from
the Form 3671-1.
9. Leave the Amount Paid at the default setting of 0.00.
10. Leave the Units Authorized at the default of 0.00.
11. Leave the Units Paid at the default of 0.00.
12. Save the record.
Service Authorization - SPW
The STAR+PLUS Support Unit (SPSU) staff creates one service authorization
record for SPW eligibility and one service authorization record for
prescriptions.
To register a Service Authorization record for initial SPW eligibility:
1. Select Service Authorization in the Program and Service directory.
2. Select Add and a blank Service Authorization record will appear.
3. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
4. Move to the Service Code field and select SC 12 – Case Management
from the drop down list.
5. Leave the Fund and Term Code at the defaults.
6. Leave the Agency field at the default selection 324-DHS.
7. Move to the Unit Type field and select 2 – MONTH from the drop down
list.
Revised: 4/23/2012 5

8. Move to the Units field and enter 1.00.
9. Leave Amount at the default.
10. Move to the Begin Date field and enter the effective date of the ISP
coverage period.
SAS Help File
11. Move to the End Date field and enter the last day of the ISP coverage
period.
12. Move to the Contract No. field and enter the appropriate contract
number of the MCO. Use the following chart to determine the correct
contract number:
MCO Service Area
Molina Bexar 1014430
Molina Harris 1014431
Molina Jefferson 1019598
Molina Dallas 1018980
Molina El Paso 1019987
Molina Hidalgo 1019988
Superior Bexar 1014433
Superior Nueces 1014434
Superior Dallas 1018981
Superior Hidalgo 1019985
Superior Lubbock 1019986
United Healthcare Harris 1014435
United Healthcare Jefferson 1019600
United Healthcare Nueces 1014437
United Healthcare Travis 1014438
Amerigroup Bexar 1014439
Amerigroup Harris 1014440
Contract
Number
Revised: 4/23/2012 6

Amerigroup Jefferson 1019599
Amerigroup Travis 1014442
Amerigroup El Paso 1019979
Amerigroup Lubbock 1019983
Amerigroup Tarrant 1018977
Bravo Health Tarrant 1018979
HealthSpring (Bravo) Hidalgo 1019984
13. Leave NPI at the default.
14. Save the record.
SAS Help File
To register a Service Code 60, Prescriptions service authorization for an SPW
applicant:
1. Select Service Authorization in the Program and Service directory.
2. Select Add and a blank Service Authorization record will appear.
3. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
4. Move to the Service Code field and select 60-PRESCRIPTIONS from
the drop down list.
5. Leave the Fund and Term Code at the defaults.
6. Leave the Agency field at the default selection 324-DHS.
7. Move to the Unit Type field and select 2-MONTH from the drop down list.
8. Move to the Units field and enter 1.00.
9. Leave Amount at the default.
10. Move to the Begin Date field and enter the effective date of the ISP
coverage period.
11. Move to the End Date field and enter the end date of the ISP coverage
period.
12. Leave the Contract No. field at the default
13. Leave NPI at the default.
Revised: 4/23/2012 7

14. Save the record.
15. Select Submit to SAS after both records are completed.
Level of Service - SPW
SAS Help File
All SPW members must have a Resource Utilization Group (RUG) registered
on a Level of Service record. This record will be system-generated from
information received from TMHP. The MCO nurse completes the Medical
Necessity/Level of Care Assessment (MN/LOC) and submits the information
from this form to TMHP. After TMHP determines Medical Necessity and
computes the RUG value, this information is transmitted to DADS and stored in
the SAS database.
This record is system generated from the information stored in the SAS
database. This system-generated record will have an End Date that must be
extended through the last day of the month in which the ISP expires. For
example, if Medical Necessity/RUG is approved with an effective date of
5-13-11, the system-generated end date for the Level of Service record will be
5-12-12. If the ISP period is 6-01-11 to 5-31-12, the Level of Service record will
need to be extended to 5-31-12 so the member has coverage for the entire ISP
period.
To extend a Level of Service record for an SPW applicant:
1. Select Level of Service in the Medical directory.
2. An existing Level of Service record will appear. Select the record and
scroll down to click on Modify or double-click on the record to open
and modify.
3. Move to the End Date field and change the date to the last day of the ISP
period
4. Save the record.
If a Level of Service record has not been created in SAS, complete the
following steps to add the record:
1. Select Level of Service in the Medical directory.
2. Select Add and a blank Level of Service record will appear.
3. Move to the Type field and select CR – CBA RUG from the drop down
Revised: 4/23/2012 8

list.
SAS Help File
4. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
5. Move to the Level field and enter the Rug group.
6. Move to the Begin Date field and enter the first day of the ISP period.
7. Move to the End Date field and enter the last day of the ISP period
8. Save the record.
Medical Necessity - SPW
The MCO nurse completes the Medical Necessity/Level of Care Assessment
(MN/LOC) and submits the information to TMHP. After Medical Necessity is
determined and the RUG value is computed, TMHP submits the decision back
to DADS where it is stored in the SAS database.
This record is system generated from the information stored in the SAS
database. This system-generated record will have an End Date that must be
extended through the last day of the month in which the Medical Necessity
determination expires.
For example, if Medical Necessity is approved with an effective date of 5-13-
11, the system-generated end date will be 5-12-12. If the ISP period is 6-01-11
to 5-31-12, the Medical Necessity record will need to be extended to 5-31-12
so the member has coverage for the entire ISP period.
To extend a Medical Necessity record for an SPW applicant:
1. Select Medical Necessity in the Medical directory.
2. An existing Medical Necessity record will appear. Select the record and
scroll down to click on Modify or double-click on the record to open
and modify.
3. Move to the End Date field and change the date to the last day of the ISP
period
4. Save the record.
If a Medical Necessity record has not been created in SAS, complete the
following steps to add the record:
1. Select Medical Necessity in the Medical directory.
Revised: 4/23/2012 9

2. Select Add and a blank Medical Necessity record will appear.
3. Move to the MN field and select Y-Yes from the drop down list.
4. Move to the Permanent field and select N-No.
SAS Help File
5. Move to the Begin Date field and enter the first day of the ISP period.
6. Move to the End Date field and enter the last day of the ISP period
7. Save the record.
Situations in which the Medical Necessity record must be FORCED:
The Medical Necessity record must be forced in SAS to register a Medical
Necessity determination for these situations:
SPW services are not approved until 120 days after Medical
Necessity was determined.
Medical Necessity is approved on the portal but will not convert to
SAS because of a mismatch of member information between the
Medical Necessity/Level of Care Assessment (MN/LOC) and
TIERS.
An applicant who is in a Nursing Facility and receives Medicaid will
begin receiving SPW services upon discharge from the facility.
To force register Medical Necessity for an SPW applicant/member:
1. Select Medical Necessity in the Medical directory.
2. Select Add and a blank Medical Necessity record will appear.
3. Move to the MN field and select Y-Yes from the drop down list.
4. Move to the Permanent field and select N-No.
5. Move to the Begin Date field and enter the first day of the ISP period.
6. Move to the End Date field and enter the last day of the ISP period
7. Click on Force and enter the reason for the Force under Force
Comments.
8. Save the record.
Revised: 4/23/2012 10

Diagnosis – SPW
SAS Help File
The MCO nurse completes the Medical Necessity/Level of Care Assessment
(MN/LOC) and submits the information from this form to TMHP. After TMHP
determines Medical Necessity and computes the RUG value, this information
along with the diagnosis code(s) is transmitted to DADS and stored in the SAS
database.
This record is system generated from the information stored in the SAS
database. This system-generated record will have an End Date that is
extended through the last day of the month in which the determination expires.
For example, if Medical Necessity is approved with an effective date of
11-13-11, the system-generated end date will be 11-12-12. If the ISP period is
12-01-11 to 11-30-12, the diagnosis record will need to be extended to 11-30-
12 so the member has diagnosis coverage for the entire ISP period.
To extend a Diagnosis record for an SPW applicant/member:
1. Select Diagnosis in the Medical directory.
2. An existing Diagnosis record will appear. Select the record and scroll
down to click on Modify or double-click on the record to open and
modify.
3. Move to the End Date field and change the date to the last day of the ISP
period
4. Save the record.
If a Diagnosis record has not been created in SAS, complete the
following steps to add the record:
1. Select Diagnosis in the Medical directory.
2. Select Add and a blank Diagnosis record will appear.
3. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
4. Move to the Begin Date field and enter the first day of the ISP period.
5. Move to the End Date field and enter the last day of the ISP period
6. Enter up to five diagnoses.
7. Leave Version at the default.
Revised: 4/23/2012 11

8. Save the record.
Reassessment Service Authorization / SPW
When authorizing SPW services for another ISP year check or create the
following records according to the instructions for each record:
Authorizing Agent
Enrollment
Service Plan
Service Authorization
Level of Service
Medical Necessity
Diagnosis
Authorizing Agent – Reassessment / SPW
SAS Help File
Check the record for accuracy. If there are no changes leave the record openended.
Currently, although SAS will accept multiple Authorizing Agent records,
TMHP will only accept two Authorizing Agent records when a SAS file is
transmitted to TMHP. Therefore, select NO in the Send to TMHP field for all
updates.
Enrollment – Reassessment / SPW
Check the Enrollment record for accuracy and to be sure it is open-ended. If it
is open-ended, make no changes. If it has an End Date, delete the End Date or
create another record with a new Begin Date. To ensure that there is not a gap
in service, the Begin Date of the enrollment for the new ISP year is the day
after the End Date of the previous ISP year.
Service Plan – Reassessment / SPW
A new Service Plan record must be created to register the RUG cost level and
the amount of services authorized for the new ISP year.
To register a Service Plan for a new ISP year:
1. Select Service Plan in the Program and Service directory.
Revised: 4/23/2012 12

2. Select Add and a blank Service Plan record will appear.
3. Leave the Type field at the default selection AN-ANNUAL PLAN.
SAS Help File
4. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
5. Move to the Ceiling field and enter the annual SPW ISP cost limit for
the RUG value entered on the Level of Service record.
6. NOTE: For a ventilator dependent SPW member, enter the annual SPW
ISP cost limit based on the RUG value and Ventilator use of the
consumer (6-23 hours or 24 hours continuous).
7. Move to the Begin Date field and enter the effective date of the new ISP
year.
8. Move to the End Date field and enter the last day of the new ISP year.
9. Move to the Amount Authorized field and enter the total estimated cost
of all SPW services authorized for the new ISP year.
10. Leave the Amount Paid at the default setting of 0.00.
11. Leave the Units Authorized at the default of 0.00.
12. Leave the Units Paid at the default of 0.00.
13. Save the record.
Service Authorization – Reassessment / SPW
If the MCO posts a timely reassessment packet, SPSU staff creates one
service authorization record for SPW eligibility and one service authorization
record for prescriptions for the new ISP year. To ensure there is no gap in
service, the Begin Date of the authorization for the new ISP year is the day
after the End Date of the previous ISP year.
If the MCO does not post a timely reassessment packet, two service
authorization records will be required for SPW eligibility and one for
prescriptions. The first service authorization record for SPW eligibility will be
entered with SG 19/SC 13 for the month(s) for which the ISP was late. The
second service authorization record for SPW eligibility will be entered with SG
19/SC 12 for the remaining ISP period.
To enter a Service Authorization record for a timely Reassessment for
SPW:
Revised: 4/23/2012 13

1. Select Service Authorization in the Program and Service directory.
2. Select Add and a blank Service Authorization record will appear.
SAS Help File
3. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
4. Move to the Service Code field and select SC 12 – Case Management
from the drop down list.
5. Leave the Fund and Term Code at the defaults.
6. Leave the Agency field at the default selection 324-DHS.
7. Move to the Unit Type field and select 2 – MONTH from the drop down
list.
8. Move to the Units field and enter 1.00.
9. Leave Amount at the default.
10. Move to the Begin Date field and enter the effective date of the new ISP
coverage period.
11. Move to the End Date field and enter the last day of the new ISP
coverage period.
12. Move to the Contract No. field and enter the appropriate contract
number of the MCO. Use the following chart to determine the correct
contract number:
MCO Service Area
Contract
Number
Molina Bexar 1014430
Molina Harris 1014431
Molina Jefferson 1019598
Molina Dallas 1018980
Molina El Paso 1019987
Molina Hidalgo 1019988
Superior Bexar 1014433
Superior Nueces 1014434
Revised: 4/23/2012 14

Superior Dallas 1018981
Superior Hidalgo 1019985
Superior Lubbock 1019986
United Healthcare Harris 1014435
United Healthcare Jefferson 1019600
United Healthcare Nueces 1014437
United Healthcare Travis 1014438
Amerigroup Bexar 1014439
Amerigroup Harris 1014440
Amerigroup Jefferson 1019599
Amerigroup Travis 1014442
Amerigroup El Paso 1019979
Amerigroup Lubbock 1019983
Amerigroup Tarrant 1018977
Bravo Health Tarrant 1018979
HealthSpring
(Bravo)
13. Leave NPI at the default.
14. Save the record.
Hidalgo 1019984
SAS Help File
To enter a Service Authorization record for an untimely Reassessment for
SPW eligibility:
1. Select Service Authorization in the Program and Service directory.
2. Select Add and a blank Service Authorization record will appear.
3. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
Revised: 4/23/2012 15

4. Move to the Service Code field and select SC 13 – NURSING
SERVICES from the drop down list.
5. Leave the Fund and Term Code at the defaults.
6. Leave the Agency field at the default selection 324-DHS.
SAS Help File
7. Move to the Unit Type field and select 4-PER AUTHORIZATION from
the drop down list.
8. Move to the Units field and enter 1.00.
9. Leave Amount at the default.
10. Move to the Begin Date field and enter the effective date of the new ISP
coverage period.
11. Move to the End Date field and enter the last day of the month the
packet was posted.
12. Move to the Contract No. field and enter the appropriate contract
number of the MCO. Use the following chart to determine the correct
contract number:
MCO
Service Area
Molina Bexar 1014430
Molina Harris 1014431
Molina Jefferson 1019598
Molina Dallas 1018980
Molina El Paso 1019987
Molina Hidalgo 1019988
Superior Bexar 1014433
Superior Nueces 1014434
Superior Dallas 1018981
Superior Hidalgo 1019985
Superior Lubbock 1019986
Contract Number
Revised: 4/23/2012 16

United Healthcare Harris 1014435
United Healthcare Jefferson 1019600
United Healthcare Nueces 1014437
United Healthcare Travis 1014438
Amerigroup Bexar 1014439
Amerigroup Harris 1014440
Amerigroup Jefferson 1019599
Amerigroup Travis 1014442
Amerigroup El Paso 1019979
Amerigroup Lubbock 1019983
Amerigroup Tarrant 1018977
Bravo Health Tarrant 1018979
HealthSpring
(Bravo)
13. Leave NPI at the default.
14. Save the record.
Hidalgo 1019984
SAS Help File
Revised: 4/23/2012 17

To register a Service Authorization record for SPW eligibility for the
remainder of the ISP Period:
1. Select Service Authorization in the Program and Service directory.
2. Select Add and a blank Service Authorization record will appear.
SAS Help File
3. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
4. Move to the Service Code field and select SC 12 – Case Management
from the drop down list.
5. Leave the Fund and Term Code at the defaults.
6. Leave the Agency field at the default selection 324-DHS.
7. Move to the Unit Type field and select 2 – MONTH from the drop down
list.
8. Move to the Units field and enter 1.00.
9. Leave Amount at the default.
10. Move to the Begin Date field and enter the day after the end date of the
Service Code 13 record entered above. (This should be the first of the
month after the month the late reassessment packet was received.)
11. Move to the End Date field and enter the last day of the new ISP
coverage period.
12. Move to the Contract No. field and enter the appropriate contract
number of the MCO. Use the following chart to determine the correct
contract number:
MCO
Service Area
Molina Bexar 1014430
Molina Harris 1014431
Molina Jefferson 1019598
Molina Dallas 1018980
Molina El Paso 1019987
Molina Hidalgo 1019988
Contract Number
Revised: 4/23/2012 17

Superior Bexar 1014433
Superior Nueces 1014434
Superior Dallas 1018981
Superior Hidalgo 1019985
Superior Lubbock 1019986
United Healthcare Harris 1014435
United Healthcare Jefferson 1019600
United Healthcare Nueces 1014437
United Healthcare Travis 1014438
Amerigroup Bexar 1014439
Amerigroup Harris 1014440
Amerigroup Jefferson 1019599
Amerigroup Travis 1014442
Amerigroup El Paso 1019979
Amerigroup Lubbock 1019983
Amerigroup Tarrant 1018977
Bravo Health Tarrant 1018979
HealthSpring
(Bravo)
13. Leave NPI at the default.
14. Save the record.
Hidalgo 1019984
SAS Help File
To register a Service Code 60, Prescriptions service authorization for an SPW
member at Reassessment (whether timely packet submittal or untimely packet
submittal):
1. Select Service Authorization in the Program and Service directory.
2. Select Add and the Service Authorization record will appear.
Revised: 4/23/2012 18

SAS Help File
3. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
4. Move to the Service Code field and select 60-PRESCRIPTIONS from
the drop down list.
5. Leave the Fund and Term Code at the defaults.
6. Leave the Agency field at the default selection 324-DHS.
7. Move to the Unit Type field and select 2-MONTH from the drop down list.
8. Move to the Units field and enter 1.00.
9. Leave Amount at the default.
10. Move to the Begin Date field and enter the effective date of the new ISP
coverage period.
11. Move to the End Date field and enter the end date of the new ISP
coverage period.
12. Leave the Contract No. field at the default
13. Leave NPI at the default.
14. Save the record.
15. Select Submit to SAS after all the service authorization records are
completed.
Level of Service – Reassessment / SPW
All SPW members must have a RUG registered on a Level of Service record.
This record will be system-generated from information received from TMHP.
The MCO nurse completes the Medical Necessity/Level of Care Assessment
(MN/LOC) and submits the information from this form to TMHP. After TMHP
determines Medical Necessity and computes the RUG value, this information
is transmitted to DADS and stored in the SAS database.
This record is system-generated from the information stored in the SAS
database. This system-generated record will have a Begin and End Date that
matches the new ISP year.
For example, a member with an initial ISP coverage period of 12-01-11 thru
11-30-12 is re-authorized for SPW eligibility. The new ISP year will be effective
12-01-12 thru 11-30-13. These new Begin and End Dates will be systemgenerated
in the Level of Service record.
Revised: 4/23/2012 19

Medical Necessity – Reassessment / SPW
SAS Help File
The MCO nurse completes the Medical Necessity/Level of Care Assessment
(MN/LOC) for the annual reassessment and submits the information from this
form to TMHP. After Medical Necessity is determined and the RUG value is
computed, TMHP submits the decision back to the DADS where it is stored in
the SAS database.
This record is system generated from the information stored in the SAS
database. This system-generated record will have a Begin Date and an End
Date that matches the newly certified ISP year.
For example, a member with an initial ISP coverage period of 2-01-11 thru 1-
31-12 is re-authorized for SPW eligibility. The new ISP year will be effective 2-
1-12 thru 1-31-13. These new Begin and End Dates will be system generated
in the Medical Necessity record. The Medical Necessity record must be forced
in SAS to register a Medical Necessity determination for a reassessment in the
following situations:
A member files a timely appeal on a Medical Necessity denial and
the fair hearing will not be held until after the ISP expires.
Medical Necessity is approved in the portal but will not convert to
SAS because of a mismatch of member information between the
Medical Necessity/Level of Care Assessment (MN/LOC) and
TIERS.
Diagnosis – Reassessment / SPW
All SPW members must have a diagnosis registered on a Diagnosis record.
This record will be system-generated from information received from TMHP.
The MCO nurse completes the Medical Necessity/Level of Care Assessment
(MN/LOC) and submits the information from this form to TMHP. After TMHP
determines Medical Necessity and computes the RUG value, this diagnosis
information is transmitted to DADS and stored in the SAS database.
This record is system-generated from the information stored in the SAS
database. This system-generated record will have a Begin and End Date that
matches the new ISP year.
For example, a member with an initial ISP coverage period of 11-01-11 thru
10-31-12 is re-authorized for SPW eligibility. The new ISP year will be effective
11-01-12 thru 10-31-13. These new Begin and End Dates will be systemgenerated
in the Diagnosis record.
Revised: 4/23/2012 20

Transfers / SPW
SAS Help File
There are several situations that are considered transfers for SPW members,
and the procedures differ for each.
Transfers from CBA services to SPW Services
When a CBA consumer moves into a STAR+PLUS service area, he must
receive services through Managed Care. When this happens, the losing DADS
case manager closes the CBA case using the CBA Wizard and Code 034 –
Transferred to Managed Care and an end date that equals the end of the month
of move.
Once the CBA consumer has transferred to the STAR+PLUS Service Area, the
SPSU staff in the gaining STAR+PLUS service area follows the same procedures
as in the Initial Service Authorization / SPW section, with the following
exceptions:
Even though there is an existing ISP, the Begin Date for the SPW records is
the date the member is enrolled in an MCO.
The End Date for the Service Authorization (SC 12 and 60) records, the Service
Plan record and the Level of Service record remains the same date as the
current CBA ISP period.
The SPSU staff does not need to complete a Level of Service – PR for the
consumer. They only need the Level of Service – CR created.
Example: A CBA consumer with an ISP period of 11/01/11 to 10/31/12
transfers to a STAR+PLUS service area and begins receiving SPW services on
01/01/12. The Begin Date is the date he enrolled with an MCO and the End
Date for these records remains 10/31/12.
Transfers from SPW to CBA Services
When a STAR+PLUS member transfers from a STAR+PLUS service area into a
non-STAR+PLUS service area, the SPSU staff closes all Service Group 19
SPW records, with the exception of Medical Necessity, using the last day of the
month of move as the End Date.
To close the Authorizing Agent record:
1. Open the SPW member’s case in SAS.
2. Move to Authorizing Agent from the Case Worker directory and select
Authorizing Agent record.
3. Select the open record and then choose Modify or double-click on the
Revised: 4/23/2012 21

ecord to open and modify.
4. Move to the End Date field and enter the effective date of the
termination, which is the last day of the month of move.
5. Save the record.
To close the Enrollment record:
SAS Help File
1. Move to Enrollment from the Program and Service directory and select
Enrollment record.
2. Select the open record and then choose Modify or double-click on the
record to open and modify.
3. Move to the End Date field and enter the effective date of the
termination, which is the last day of the month of move.
4. Move to the Termination Code field and select the appropriate code
from the drop down list.
5. Save the record.
To close the Service Plan record:
1. Move to Service Plan from the Program and Service directory and
select Service Plan record.
2. Select the open record and then choose Modify or double-click on the
record to open and modify.
3. Move to the End Date field and enter the effective date of the
termination, which is the last day of the month of move.
4. Save the record.
To close the Service Authorization (SC 12/60) records:
1. Move to Service Authorization in the Program and Service directory.
2. Select the appropriate Service Authorization record(s) from the list.
3. Select Modify.
4. Move to the End Date field and enter the effective date of the
termination, which is the last day of the month of move.
Revised: 4/23/2012 22

5. Move to the Termination Code field and select “39 – Other” (or
appropriate code) from the drop down list.
6. Save the record.
To close the Level of Service record:
SAS Help File
1. Move to Level of Service in the Medical directory and select Level of
Service record.
2. Select the open record and then choose Modify or double-click on the
record to open and modify.
3. Move to the End Date field and enter the effective date of the
termination, which is the last day of the month of move.
4. Save the record.
To close the Diagnosis record:
1. Move to Diagnosis in the Medical directory and select the Diagnosis
record.
2. Select the open record and then choose Modify or double-click on the
record to open and modify.
3. Move to the End Date field and enter the effective date of the
termination, which is the last day of the month of move.
4. Save the record.
5. Submit the records.
Transfers From One STAR+PLUS Area To Another STAR+PLUS Area
There are two different situations that can occur when a STAR+PLUS member
transfers from one service area to another service area. The first is when a
member transfers to a new service area that his current MCO also serves, and
he wants to stay with that MCO. Even though he is staying with the same
MCO, the contract number will change and his records will need to be closed
under the previous contract number and opened under the new contract
number. The second is when the member changes MCOs in the new service
area.
To process the transfer, the losing SPSU staff closes the existing Authorizing
Revised: 4/23/2012 23

SAS Help File
Agent and Service Authorization (SC 12) records. The gaining SPSU staff
opens a new Service Authorization record (SC 12) using the MCO contract
number in the new service area.
To close the Authorizing Agent record:
1. Open the SPW member’s case in SAS.
2. Move to Authorizing Agent from the Case Worker directory and select
Authorizing Agent record.
3. Select the open record and then choose Modify or double-click on the
record to open and modify.
4. Move to the End Date field and enter the effective date of the
termination, which is the last day of the month in which the member
moved to the new service area.
5. Save the record.
To close the Service Authorization record:
1. Move to Service Authorization in the Program and Service directory.
2. Open the appropriate Service Authorization (SC 12) record.
3. Select the open record and then choose Modify or double-click on the
record to open and modify.
4. Move to the End Date field and enter the effective date of the
termination. This will be the last day of the month in which the member
moved to the new service area.
5. Move to the Termination Code field and select “39 – Other” (or the
appropriate code) from the drop down list.
6. Select Submit from the Command Menu or the Toolbar.
Once the gaining SPSU staff verifies the month in which the member moves to
the new service area, he is responsible for opening the Authorizing Agent and
Service Authorization (SC 12) records necessary to authorize SPW services
in the new service area.
The Service Authorization records are opened according to procedures
Revised: 4/23/2012 24

SAS Help File
outlined in Initial Service Authorizations for SPW members with the following
exceptions:
The Begin Date for these records is the first day of the month following the
month the member moved to the new service area.
The End Date for the Service Authorization (SC 12) record is the same as the
current ISP period.
For example, if a SPW member with an ISP period of 11/01/11 to 10/31/12
transfers to another STAR+PLUS service area on 01/15/12, the End Date for
these records remains 10/31/12.
Transfers From One MCO To Another MCO In The Same Service Area
The SPSU processes the request by closing the existing Service Authorization
record (SC 12) for the losing MCO and creating a new Service Authorization
record (SC 12) for the gaining MCO.
To close the existing Service Authorization records:
1. Move to Service Authorization in the Program and Service directory.
2. Open the appropriate Service Authorization record.
3. Click on Modify or double-click on the record to open and modify.
4. Move to the End Date field and enter the last day of the month of move
and the day before the member’s enrollment date in the new MCO.
5. Move to the Termination Code field and select “39 – Other” (or the
appropriate code) from the drop down list.
6. Save the record.
7. Select Submit from the Command Menu or the Toolbar.
To create a new Service Authorization record for the new MCO:
1. Select Service Authorization in the Program and Service directory.
2. Select Add and a blank Service Authorization record will appear.
3. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
4. Move to the Service Code field and select SC 12 – Case Management
from the drop down list.
Revised: 4/23/2012 25

5. Leave the Fund and Term Code at the defaults.
6. Leave the Agency field at the default selection 324-DHS.
SAS Help File
7. Move to the Unit Type field and select 2 – MONTH from the drop down
list.
8. Move to the Units field and enter 1.00.
9. Leave Amount at the default.
10. Move to the Begin Date field and enter the enrollment date of the new
MCO.
11. Move to the End Date field and enter the last day of the ISP coverage
period.
12. Move to the Contract No. field and enter the appropriate contract
number of the MCO. Use the following chart to determine the correct
contract number:
MCO
Service Area
Contract
Number
Molina Bexar 1014430
Molina Harris 1014431
Molina Jefferson 1019598
Molina Dallas 1018980
Molina El Paso 1019987
Molina Hidalgo 1019988
Superior Bexar 1014433
Superior Nueces 1014434
Superior Dallas 1018981
Superior Hidalgo 1019985
Superior Lubbock 1019986
United Healthcare Harris 1014435
United Healthcare Jefferson 1019600
Revised: 4/23/2012 26

United Healthcare Nueces 1014437
United Healthcare Travis 1014438
Amerigroup Bexar 1014439
Amerigroup Harris 1014440
Amerigroup Jefferson 1019599
Amerigroup Travis 1014442
Amerigroup El Paso 1019979
Amerigroup Lubbock 1019983
Amerigroup Tarrant 1018977
Bravo Health Tarrant 1018979
HealthSpring
(Bravo)
13. Leave NPI at the default.
14. Save the record.
15. Submit the record.
Hidalgo 1019984
Money Follows the Person Authorization for an SPW Applicant
SAS Help File
After SPSU verifies that the consumer left the nursing facility, they complete the
following steps listed below. SPSU does not close the Authorizing Agent, Medical
Necessity, Level of Service (RUG) records. SPSU must also insure Provider
Claims Services closes the Enrollment and Service Authorization records for
Service Codes 1 or 3, 60, and 50.
Create a one day STAR+PLUS service authorization for the first day of the
month in which a MFP consumer is discharged from a nursing facility and
begins receiving Home and Community Based Services STAR+PLUS Waiver
(SPW) services, unless the MFP applicant discharges on the first of a month.
For example: a consumer leaves the nursing facility and begins (SPW)
services on 12-25-11. The SPSU staff registers the initial ISP in SAS with an
effective date of 12-25-11 through 12-31-12. In addition to registering the initial
ISP, the SPSU staff creates all the records listed below with a Begin Date of
12-01-11 and an End Date of 12-01-11.
Revised: 4/23/2012 27

SAS Help File
Add the following records for Service Group 19 to create the one day service
authorization:
Service Authorization
Medical Necessity
Diagnosis
Level of Service
Authorizing Agent (if needed)
Enrollment
Service Plan
A one day overlap of the records listed is allowed.
Note: Members released from a nursing facility and authorized for SPW
services should be enrolled under Money Follows the Person. In the
Enrollment record, select “Rider 28/37 FAC to COMM” from the drop down list
in the Enrolled From field. Do not use “Enrolled from nursing facility” to
designate MFP members.
To Authorize SPW Eligibility for an MFP Applicant:
After creating the one-day records above, create the records needed for the
ongoing MFP SPW eligibility.
These records must be completed to create an initial service authorization for
SPW:
Authorizing Agent
Enrollment
Service Plan
Service Authorization
Level of Service
Medical Necessity
Diagnosis
Authorizing Agent - SPW
There will be one authorizing agent registered for an MFP applicant.
The STAR+PLUS support unit (SPSU) or Health and Human Services
Commission Managed Care Operations (HMCO) staff is registered as the
authorizing agent when the initial authorization is authorized.
To register an authorizing agent for an MFP applicant:
1. Select Authorizing Agent in the Case Worker directory.
Revised: 4/23/2012 28

2. Select Add and a blank Authorizing Agent record will appear.
3. Move to the Type field and select CM-Case Manager from the drop
down list.
SAS Help File
4. Move to the Group field and select 19-STAR+PLUS from the drop down
list.
5. Leave the Send to TMHP field at the default selection N-NO.
6. Move to the Begin Date field and enter the date the record is being
created. Leave the End Date field at the default 00/00/0000.
7. Move to the Auth Agent field and enter STAR+PLUS.
8. Leave the Agency field at the default selection 324-DHS.
9. Move to the Name field and enter the SPSU/HMCO staff’s name.
10. Move to the Phone field and enter the telephone number of the
authorizing agent. Enter the area code, phone number and extension.
11. Move to the Mail Code field and enter the appropriate Managed Care
Organization (MCO) Plan Code.
12. Save the record.
SERVICE
AREA
MCO PLAN NAME MCO
PLAN
CODE
Bexar Amerigroup Community Care 45
Molina 46
Superior 47
Dallas Molina 9F
Superior Health Plan 9H
El Paso Molina 33
Amerigroup 34
Harris AMERIGROUP Community Care 7P
United Healthcare 7R
Molina 7S
Hidalgo HealthSpring (Bravo) H7
Molina H6
Superior H5
Jefferson Amerigroup Community Care 8R
United Healthcare 8S
Molina 8T
Revised: 4/23/2012 29

SAS Help File
Lubbock Amerigroup Community Care 5A
Superior 5B
Nueces United Healthcare 85
Superior Health Plan 86
Tarrant Amerigroup Community Care 69
Bravo Health 6C
Travis Amerigroup Community Care 19
United Healthcare 18
Revised: 4/23/2012 30

Enrollment - SPW
To register enrollment for an MFP applicant:
1. Select Enrollment in the Program and Service directory.
2. Select Add and a blank Enrollment record will appear.
SAS Help File
3. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
4. Move to the Enrolled From field and select the appropriate entry from
the drop down list. If this is a Money Follows the Person authorization, be
sure to select 12-Rider 37/28 (FAC to Comm) from the drop-down list.
5. Move to the Living Arrangement field, and select the appropriate
community-based living arrangement from the drop down list.
6. Move to the Begin Date field and enter the date the member is enrolled
in his MCO, which will always be the 1 st day of a month. Leave the End
Date field at the default.
7. Leave the Termination Code and Waiver Type at the defaults.
8. Save the record.
Service Plan - SPW
The service plan record is used to register an Individual Service Plan (ISP) for
an SPW member. The record includes the annual SPW ISP cost limit based on
the member’s Resource Utilization Group (RUG) value and the total estimated
cost of SPW services taken from the member’s ISP, Form 3671-1.
To register a service plan for an MFP applicant:
1. Select Service Plan in the Program and Service directory.
2. Select Add and the Service Plan record will appear.
3. Leave the Type field at the default selection AN-ANNUAL PLAN.
4. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
5. Move to the Ceiling field and enter the annual SPW ISP cost ceiling for
the RUG value entered on the Level of Service record.
For a ventilator dependent SPW member, enter the annual SPW ISP
Revised: 4/23/2012 31

SAS Help File
cost limit based on the RUG value and Ventilator use of the consumer
(6-23 hours or 24 hours continuous).
6. Move to the Begin Date field and enter the effective date of the ISP
coverage period.
7. Move to the End Date field and enter the last day of the ISP coverage
period.
8. Move to the Amount Authorized field and enter the total estimated cost
of all SPW services authorized for the current ISP coverage period from
the Form 3671-1.
9. Leave the Amount Paid at the default setting of 0.00.
10. Leave the Units Authorized at the default of 0.00.
11. Leave the Units Paid at the default of 0.00.
12. Save the record.
Service Authorization - SPW
The STAR+PLUS Support Unit (SPSU) staff creates one service authorization
record for SPW eligibility and one service authorization record for
prescriptions.
To register a Service Authorization record for MFP applicant:
1. Select Service Authorization in the Program and Service directory.
2. Select Add and a blank Service Authorization record will appear.
3. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
4. Move to the Service Code field and select SC 12 – Case Management
from the drop down list.
5. Leave the Fund and Term Code at the defaults.
6. Leave the Agency field at the default selection 324-DHS.
7. Move to the Unit Type field and select 2 – MONTH from the drop down
list.
8. Move to the Units field and enter 1.00.
9. Leave Amount at the default.
Revised: 4/23/2012 32

10. Move to the Begin Date field and enter the effective date of the ISP
coverage period.
SAS Help File
11. Move to the End Date field and enter the last day of the ISP coverage
period.
12. Move to the Contract No. field and enter the appropriate contract
number of the MCO. Use the following chart to determine the correct
contract number:
MCO Service Area Contract Number
Molina Bexar 1014430
Molina Harris 1014431
Molina Jefferson 1019598
Molina Dallas 1018980
Molina El Paso 1019987
Molina Hidalgo 1019988
Superior Bexar 1014433
Superior Nueces 1014434
Superior Dallas 1018981
Superior Hidalgo 1019985
Superior Lubbock 1019986
United Healthcare Harris 1014435
United Healthcare Jefferson 1019600
United Healthcare Nueces 1014437
United Healthcare Travis 1014438
Amerigroup Bexar 1014439
Amerigroup Harris 1014440
Amerigroup Jefferson 1019599
Amerigroup Travis 1014442
Amerigroup El Paso 1019979
Revised: 4/23/2012 33

Amerigroup Lubbock 1019983
Amerigroup Tarrant 1018977
Bravo Health Tarrant 1018979
HealthSpring
(Bravo)
13. Leave NPI at the default.
14. Save the record.
Hidalgo 1019984
SAS Help File
To register a Service Code 60, Prescriptions service authorization for an MFP
applicant:
1. Select Service Authorization in the Program and Service directory.
2. Select Add and the Service Authorization record will appear.
3. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
4. Move to the Service Code field and select 60-PRESCRIPTIONS from
the drop down list.
5. Leave the Fund and Term Code at the defaults.
6. Leave the Agency field at the default selection 324-DHS.
7. Move to the Unit Type field and select 2-MONTH from the drop down list.
8. Move to the Units field and enter 1.00.
9. Leave Amount at the default.
10. Move to the Begin Date field and enter the effective date of the ISP
coverage period.
11. Move to the End Date field and enter the end date of the ISP coverage
period.
12. Leave the Contract No. field at the default
13. Leave NPI at the default.
14. Save the record.
15. Select Submit to SAS after both records are completed.
Revised: 4/23/2012 34

Level of Service - SPW
SAS Help File
There will be an existing Service Group 1 (NF) Level of Service record.
However, the SPSU will be required to create a new Level of Service record for
Service Group 19 SPW. The Service Group 1 (NF) Level of Service record can
remain open.
To add a Level of Service record, complete the following steps:
1. Select Level of Service in the Medical directory.
2. Select Add and a blank Level of Service record will appear.
3. Move to the Type field and select CR – CBA RUG from the drop down
list.
4. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
5. Move to the Level field and enter the Rug group.
6. Move to the Begin Date field and enter the first day of the ISP period.
7. Move to the End Date field and enter the last day of the ISP period
8. Save the record.
Medical Necessity - SPW
The MCO nurse completes the Medical Necessity/Level of Care Assessment
(MN/LOC) and submits the information to TMHP. After Medical Necessity is
determined and the RUG value is computed, TMHP submits the decision back
to DADS where it is stored in the SAS database.
This record is system generated from the information stored in the SAS
database. This system-generated record will have an End Date that must be
extended through the last day of the month in which the Medical Necessity
determination expires.
For example, if Medical Necessity is approved with an effective date of 5-13-
11, the system-generated end date will be 5-12-12. If the ISP period is 6-01-11
to 5-31-12, the Medical Necessity record will need to be extended to 5-31-12
so the member has coverage for the entire ISP period.
To extend a Medical Necessity record for an MFP applicant:
1. Select Medical Necessity in the Medical directory.
Revised: 4/23/2012 35

SAS Help File
2. An existing Medical Necessity record will appear. Select the record and
scroll down to click on Modify or double-click on the record to open
and modify.
3. Move to the End Date field and change the date to the last day of the ISP
period
4. Save the record.
If a Medical Necessity record has not been created in SAS, complete the
following steps to add the record:
1. Select Medical Necessity in the Medical directory.
2. Select Add and a blank Medical Necessity record will appear.
3. Move to the MN field and select Y-Yes from the drop down list.
4. Move to the Permanent field and select N-No.
5. Move to the Begin Date field and enter the first day of the ISP period.
6. Move to the End Date field and enter the last day of the ISP period
7. Save the record.
Situations in which the Medical Necessity record must be FORCED:
The Medical Necessity record must be forced in SAS to register a Medical
Necessity determination for these situations:
SPW services are not approved until 120 days after Medical
Necessity was determined.
Medical Necessity is approved on the portal but will not convert to
SAS because of a mismatch of member information between the
Medical Necessity/Level of Care Assessment (MN/LOC) and
TIERS.
An applicant who is in a Nursing Facility and receives Medicaid will
begin receiving SPW services upon discharge from the facility.
To force register Medical Necessity for an MFP applicant:
1. Select Medical Necessity in the Medical directory.
2. Select Add and a blank Medical Necessity record will appear.
Revised: 4/23/2012 36

3. Move to the MN field and select Y-Yes from the drop down list.
4. Move to the Permanent field and select N-No.
SAS Help File
5. Move to the Begin Date field and enter the first day of the ISP period.
6. Move to the End Date field and enter the last day of the ISP period
7. Click on Force and enter the reason for the Force under Force
Comments.
8. Save the record.
Diagnosis – SPW
There will be an existing Service Group 1 Diagnosis record. The SPSU must
create a new Diagnosis record for Service Group 19 SPW.
To add a Service Group 19 Diagnosis record in SAS, complete the
following steps:
1. Select Diagnosis in the Medical directory.
2. Select Add and a blank Diagnosis record will appear.
3. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
4. Move to the Begin Date field and enter the first day of the ISP period.
5. Move to the End Date field and enter the last day of the ISP period
6. Enter up to five diagnoses.
7. Leave Version at the default.
8. Save the record.
Money Follows the Person Demonstration for an SPW Applicant
Follow the instructions for an MFP Applicant above, with the Service
Authorization record completed as follows:
1. Select Service Authorization in the Program and Service directory.
2. Select Add and a blank Service Authorization record will appear.
3. Move to the Service Group field and select 19-STAR+PLUS from the
drop down list.
Revised: 4/23/2012 37

SAS Help File
4. Move to the Service Code field and select SC 12 – Case Management
from the drop down list.
5. Move to the Fund Code and select 19 MFP – Money Follows Person.
6. Leave the Term Code at the defaults.
7. Leave the Agency field at the default selection 324-DHS.
8. Move to the Unit Type field and select 2 – MONTH from the drop down
list.
9. Move to the Units field and enter 1.00.
10. Leave Amount at the default.
11. Move to the Begin Date field and enter the effective date of the ISP
coverage period.
12. Move to the End Date field and enter the last day of the ISP coverage
period.
13. Move to the Contract No. field and enter the appropriate contract
number of the MCO. Use the following chart to determine the correct
contract number:
MCO Service Area Contract Number
Molina Bexar 1014430
Molina Harris 1014431
Molina Jefferson 1019598
Molina Dallas 1018980
Molina El Paso 1019987
Molina Hidalgo 1019988
Superior Bexar 1014433
Superior Nueces 1014434
Superior Dallas 1018981
Superior Hidalgo 1019985
Superior Lubbock 1019986
United Healthcare Harris 1014435
Revised: 4/23/2012 38

United Healthcare Jefferson 1019600
United Healthcare Nueces 1014437
United Healthcare Travis 1014438
Amerigroup Bexar 1014439
Amerigroup Harris 1014440
Amerigroup Jefferson 1019599
Amerigroup Travis 1014442
Amerigroup El Paso 1019979
Amerigroup Lubbock 1019983
Amerigroup Tarrant 1018977
Bravo Health Tarrant 1018979
HealthSpring
(Bravo)
14. Leave NPI at the default.
15. Save the record.
Hidalgo 1019984
SAS Help File
Note: Once the 365-day timeframe for MFPD has been used, the fund code in
the Service Authorization record will be changed to the default.
Money Follows the Person Eligibility for an Applicant Moving to CBA
After the SPSU determines eligibility for SPW and notifies the applicant of
waiver eligibility, the consumer will discharge to the CBA region. The SPSU
will not enter any records in SAS. The gaining CBA case manager will
complete the CBA authorization in SAS using the CBA Wizard.
Money Follows the Person Eligibility for an Applicant Moving from CBA to
SPW
After the losing CBA case manager determines eligibility for CBA and notifies
the applicant of waiver eligibility, the consumer will discharge to the managed
care service area. The SPSU will enter SPW authorization into SAS after the
applicant moves to the managed care area following the MFP steps.
Revised: 4/23/2012 39

SAS Help File
Note: If the consumer is leaving the nursing facility on the first of the month
and will begin services the same day, no one-day authorization is needed. If
he is leaving on any day after the first of the month, the SPSU will complete
the one-day authorization so that services can begin upon his arrival in the
STAR+PLUS service area.
Example: The MFP consumer is determined eligible for CBA on 11/17/11. He
plans to discharge from the nursing facility 11/20/11. Upon his arrival in the
STAR+PLUS service area, the SPSU will enter a one-day authorization for
11/1/11-11/1/11. The SPSU will then enter the initial SPW eligibility into SAS
with an effective begin date of 11/20/11.
Mutually Exclusive Services within SPW
To close services that are mutually exclusive, the DADS case manager must
close the DADS’ services with an effective date one day prior to the date the
member is eligible for SPW services.
For example, if a DADS consumer receiving Family Care (FC), Emergency
Response Services (ERS) and Home Delivered Meals (HDM) becomes eligible
for SPW services on 12/01/11, he will begin receiving his services through his
MCO on that date. Therefore, the losing DADS case manager must close the
FC, ERS and HDM services with an effective date of 11/30/11.
MDCP Age Out to SPW
The SPSU will enter the initial SPW eligibility into SAS using the steps for
Initial eligibility with one exception. The Effective Begin Date for all the records
will be the 21 st birthday.
It is possible the Medical records (MN/Level of Service/Diagnosis) will have to
be extended to cover the entire ISP period.
Terminations / SPW
The Enrollment and Service Authorization records must be closed in SAS
when all services for an existing SPW member are terminated. When
Enrollment is terminated, the authorizing agent has to manually terminate each
SPW service authorization record.
Terminating All Services / SPW
To terminate all services for an existing SPW member:
Revised: 4/23/2012 40

1. Search for the member’s SPW case and open the file.
2. Move to Programs and Services directory and select Enrollment
record.
3. Open the active record and select Modify.
4. Move to the End Date field and enter the effective date of the
termination.
SAS Help File
5. Move to the Termination Code field and select the appropriate code
from the drop down list.
6. Save the record.
7. Next, open the Service Authorization (SC 12 and SC 60) records from
this directory to close any open records.
8. Select Modify.
9. Move to the End Date field of each record and enter the effective date of
the termination.
10. Move to the Termination Code field of each record and select the
appropriate code from the drop down list.
11. Save the records.
12. Submit the records.
It is not necessary to close all the existing records for a SPW service
authorization (Medical Necessity; Applied Income, if applicable; Level of
Service) unless the member will be transferred to another service group.
However, the SPSU staff can close all these records, as well, using the
effective date of termination in the End Date fields. If the SPW member will be
transferred to another service group or if he reapplies when these records are
still valid, all the existing records for SPW services must be closed using the
effective date of termination in the End Date fields.
Appeal Extensions for Continued Benefits / SPW
If a SPW member files an appeal and requests continued benefits, the SPSU
will extend all records (includes Service Authorization, Service Plan, Medical
Necessity, Level of Service and Diagnosis) by four calendar months. To
accomplish this, open each record and modify the record. Change the End
Date to the last day of the month – four months in the future. (This is
completed each time an extension is needed)
Be sure to save each modified record and to submit the records when you
have finished changing them
Revised: 4/23/2012 41