(a) The applicant may be admitted to a day activity and health services DAHS facility as soon as verbal physician's orders are obtained if he appears to:
  (1) be Medicaid eligible; and
  (2) meet the medical/functional need criteria based on the information collected on DADS' Client Health Assessment/Plan of Care form.
(b) When a DAHS facility initiates a referral:
  (1) the DAHS facility interviews the applicant to determine whether he appears to be Medicaid eligible. The DAHS facility determines Medicaid eligibility by reviewing the information on the applicant's Medical Care Identification Card;
  (2) the nurse:
    (A) conducts a health assessment/plan of care to determine whether the applicant appears to have a medical need for the service. The nurse determines medical need by completing DADS' Client Health Assessment/Plan of Care form; and
    (B) obtains verbal or written physician orders, if the applicant appears to meet the medical/functional need criteria;
  (3) the DAHS facility verbally notifies the DADS caseworker or intake unit of the placement the day the applicant contacts the DAHS facility. The DAHS facility follows up the notification in writing within seven days using DADS' Case Information form. This verbal notification is a request for community services and supports.
(c) The DAHS facility must request written prior approval for the applicant from the regional nurse within 30 days after the date of the physician orders.
(d) If the DAHS facility fails to submit prior approval forms or additional documentation within required time frames, if the additional documentation is not adequate, or if the applicant is determined ineligible by the DADS caseworker, the regional nurse cancels the DAHS facility-initiated prior approval and the DAHS facility is not reimbursed for services.
(e) If DADS' Client Health Assessment/Plan of Care form or Physician's Order for Day Activity and Health Services form is missing, or if any of the critical omissions or errors stated in paragraphs (1) - (9) of this subsection have occurred in the required documentation, the DAHS facility cannot obtain prior approval.
  (1) The nurse fails to sign or date DADS' Client Health Assessment/Plan of Care form or omits the registered nurse/licensed vocational nurse credentials that should follow his signature.
  (2) Documentation on DADS' Client Health Assessment/Plan of Care form does not support the medical eligibility criteria specified in §98.201 of this title (relating to Eligibility Requirements for Participation).
  (3) Items A, B, in Sections II and III of DADS' Client Health Assessment/Plan of Care form are not completed or completed incorrectly and medical need cannot be determined.
  (4) DADS' Physician's Order for Day Activity and Health Services form does not include the MD or DO credential of the physician who signed the form.
  (5) DADS' Physician's Order for Day Activity and Health Services form does not include the license number of the physician who signed it.
  (6) The physician who signed the order is excluded from participation in Medicare or Medicaid.
  (7) The physician's signature is not on DADS' Physician's Order for Day Activity and Health Services form.
  (8) The physician's signature date is missing or illegible and the DAHS facility's stamped date is missing from DADS' Physician's Order for Day Activity and Health Services form.
  (9) The DAHS facility's stamped date used instead of the physician's date on DADS' Physician's Order for Day Activity and Health Services form does not include the provider agency's name, abbreviated name, or initials.

Source Note: The provisions of this §211.204 adopted to be effective May 1, 1999, 24 TexReg 3100 amended to be effective August 31, 2004, 29 TexReg 8382; amended to be effective April 1, 2007, 32 TexReg 1749; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4935