Section 16.03.10.508 - ADULT DEVELOPMENTAL DISABILITY SERVICES PRIOR AUTHORIZATION: DEFINITIONSFor the purposes of these rules the following terms are used as defined below. (3-17-22)
01. Adult. A person who is eighteen (18) years of age or older. (3-17-22)02. Assessment. A process that is described in Section 509 of these rules for program eligibility and in Section 512 of these rules for plan of service. (3-17-22)03.Clinical Review. A process of professional review that validates the need for continued services. (3-17-22)04.Community Crisis Support. Intervention for participants who are at risk of losing housing, employment or income, or who are at risk of incarceration, physical harm, family altercations or other emergencies. (3-17-22)05.Concurrent Review. A clinical review to determine the need for continued prior authorization of services. (3-17-22)06.Department-Approved Assessment Tool. Any standardized assessment tool approved by the Department for use in determining developmental disability eligibility, waiver eligibility, skill level to identify the participant's needs for the plan of service, and for determining the participant's budget. (3-17-22)07.Exception Review. A clinical review of a plan that falls outside the established standards. (3-17-22)08. Interdisciplinary Team. For purposes of these rules, the interdisciplinary team is a team of professionals, determined by the Department, that reviews requests for reconsideration. (3-17-22)09.Level of Support. An assessment score derived from a Department-approved assessment tool that indicates types and amounts of services and supports necessary to allow the individual to live independently and safely in the community. (3-17-22)10. Person-Centered Planning Process. A meeting facilitated by the participant or plan developer, comprised of family and individuals significant to the participant who collaborate with the participant to develop the plan of service. (3-17-22)11. Person-Centered Planning Team. The group who develops the plan of service. This group includes, at a minimum, the participant and the service coordinator or plan developer chosen by the participant. The person-centered planning team may include others identified by the participant or agreed upon by the participant and the Department as important to the process. (3-17-22)12.Plan Developer. A paid or non-paid person identified by the participant who is responsible for developing one (1) plan of service and subsequent addenda that cover all services and supports, based on a person-centered planning process. (3-17-22)13.Plan Monitor. A person who oversees the provision of services on a paid or non-paid basis. (3-17-22)14.Plan of Service. An initial or annual plan that identifies all services and supports based on a person-centered planning process. Plans are authorized annually every three hundred sixty-five (365) days. (3-17-22)15.Prior Authorization (PA). A process for determining a participant's eligibility for services and medical necessity prior to the delivery or payment of services as provided by these rules. (3-17-22)16.Provider Status Review. The written documentation that identifies the participant's progress toward goals defined in the plan of service. (3-17-22)17.Right Care. Accepted treatment for defined diagnosis, functional needs and abilities to achieve the desired outcome. The right care is consistent with best practice and continuous quality improvement. (3-17-22)18.Right Place. Services delivered in the most integrated setting in which they normally occur, based on the participant's choice to promote independence. (3-17-22)19. Right Price. The most integrated and least expensive services that are sufficiently intensive to address the participant's needs. The amount is based on the individual's needs for services and supports as identified in the assessment. (3-17-22)20. Right Outcomes. Services based on assessed need that ensure the health and safety of the participant and result in progress, maintenance, or delay or prevention of regression for the participant. (3-17-22)21.Service Coordination. Service coordination is an activity which assists individuals eligible for Medicaid in gaining and coordinating access to necessary care and services appropriate to the needs of an individual. (3-17-22)22.Service Coordinator. An individual who provides service coordination to a Medicaid-eligible participant, is employed by a service coordination agency, and meets the training, experience, and other requirements under Sections 729 through 732 of these rules. (3-17-22)23. Services. Services paid for by the Department that enable the individual to reside safely and effectively in the community. (3-17-22)24.Supports. Formal or informal services and activities, not paid for by the Department, that enable the individual to reside safely and effectively in the setting of their choice. (3-17-22)Idaho Admin. Code r. 16.03.10.508