From conversation to authorization

1. 1

   The conversation

   A family member, the person themselves, or anyone close to them brings up the idea of HES with the Care Manager at a person-centered planning touchpoint.

2. 2

   Goals into the Life Plan

   The Care Manager identifies HES in the Life Plan as a service related to an assessed need, and identifies the designated HES Provider in the person's OPWDD region. HES dollars must tie to a Life Plan goal.

3. 3

   RSA or SART to DDRFO

   The Care Manager submits a Request for Service Authorization (RSA) for a new service, or a Service Amendment Request Tool (SART) to modify an existing one. The request goes to the Developmental Disabilities Regional Field Office (DDRFO) for prior authorization.

4. 4

   Notice of Decision

   DDRFO reviews and issues a Notice of Decision (NOD). Without prior authorization, HES expenses are not reimbursable.

Every acronym above — RSA, SART, DDRFO, NOD — is defined in the glossary.

Timelines

ADM 2024-02 does not set a decision deadline. Ask the Care Manager to track the request after it is submitted.

If the request is denied

A denial typically comes with information about how to respond — ask the Care Manager to walk through appeal and resubmission options for your situation. The ADM does not spell out denial-and-resubmission mechanics, so the Care Manager is the right guide for the specifics of your case.

After approval

Once the NOD approves the request, the HES provider takes over — assessment, acquisition, setup, training, and the annual review. See how HES providers work for that side of the process.